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"We recruit individuals, but we retain families.” This profound statement by a senior military leader during a conversation at Air University in August 2021 astutely observes both the familial bonds that characterize the profession of arms and the challenge of maintaining those bonds while in the active defense of the Nation. The “we” is the Department of Defense (DOD), which appropriately frames the level of responsibility. Likewise, the “retain families” mindset adroitly frames the scope of accountability.

The preeminent program whose purpose is to serve and care for the special needs of eligible families of Servicemembers is DOD’s Exceptional Family Member Program (EFMP). Concisely, the core of EFMP is the advocacy and facilitation of services to support the needs of Servicemembers and their dependents who require more acute or specialized care than may be available at military base ecosystems, and EFMP’s goal includes connecting people to these services. In execution, however, EFMP has foundational issues. For example, one military member commented that he and his spouse “wish that it wasn’t such an arduous process to get her the required healthcare” and that communication of program processes was poor. Another military member commented that EFMP was central to their decades-long career and involved processes “that had too much bureaucracy in it.”1 To realize the scale of the impact that EFMP has on the force, realize that the first speaker is a staff sergeant, and the latter is the current Chief of Staff of the Air Force.

The strategic impact of such a program on the viability and sustainability of a military force and the families who support them is seminal. According to DOD’s Fiscal Year (FY) 2020 EFMP report to Congress, an estimated 248,500 Active-duty Servicemembers and family members are enrolled in the program (roughly 9 percent of the force and dependents, not including Guard, Reserve, or DOD civilians).2 That number is equivalent to every living person in either Orlando, FL, Pittsburgh, PA, Lincoln, NE, or Santa Ana, CA, being enrolled in the program, and this fact demands attention. Inarguably, this level of U.S. force projection capability affected by a singular program is strategically significant.

Accordingly, EFMP has congressional attention. As it has done with other serious issues plaguing the force, such as sexual assault and suicide prevention, Congress established improvement requirements for DOD and the military departments through its main resourcing tool, the National Defense Authorization Act (NDAA). The foundational obstacles plaguing the program arise from DOD’s lack of centralized command, control, and communications, leading to nonstandardization, disparate program implementation and communication across the departments, uneven service availability at installations, and inefficient and ineffective insurance processes. These foundational obstacles, in turn, have a cumulative effect on the Servicemember, which negatively affects DOD’s collective human capital.

EFMP Nonstandardization

EFMP’s lack of centralized command, control, and communications results in inconsistent standards, policies, practices, and services across DOD. The FY21 NDAA objectively addresses the issue of standardization within DOD, highlighting the disparately applied program across the departments.3 Specifically, the NDAA requires the Secretary of Defense, in coordination with the department secretaries, to standardize EFMP within 6 months of the enactment of the NDAA.4 Furthermore, the NDAA requires the Secretary of Defense to submit a standardization and implementation plan to the Armed Services Committees in the Senate and House of Representatives within 180 days of the enactment of the NDAA.5 Admittedly, this revelation of the nonstandardization of EFMP is not revelatory at all. Neither the FY21 NDAA nor this article is the first to shed light on a foundational flaw in the program. For example, the Government Accountability Office (GAO) published a study in 2018 providing a critical finding that DOD had not standardized the program or had any measures by which to measure program efficacy.6 In 2020, GAO congressional testimony stated that DOD had yet to implement recommendations from the 2018 report.7 Furthermore, RAND’s review in 2021 highlighted the significant level of differences in the program’s application as a critical finding.8

Despite these studies, it is apparent that problems persist in the EFMP, requiring congressional oversight. As evidence of this issue, the FY20 DOD EFMP report to Congress in May 2021 listed standardization as the top priority in righting the ship, highlighting the efforts of DOD and the Services in doing so.9 While not arguing the efforts made, the results are noticeably absent. DOD’s EFMP policy, as discussed below, is currently the guidepost for the program. The reliance on this policy and subordinate departmental policies do not inspire confidence that the program is evenly distributed and applied. The 2018 GAO report on EFMP issues prompted Congress to act, as it has done in the past when the military has failed to address an issue.10 Four years have gone by since the GAO report with little to show in the way of standardization and efficacy improvements at the DOD level. So why did Congress address EFMP so decisively?

The congressional intent is clear: the accountability for developing and implementing a clear EFMP plan for the departments to implement rests with DOD. The manifestation of this centripetal requirement rests in a published and legally reviewed directive. Absent any unpublished updates, the most recent directive concerning EFMP at the DOD level is DOD Instruction (DODI) 1315.19, The Exceptional Family Member Program, dated June 23, 2023.11 The document goes into detail as to the bureaucracy required to execute EFMP. However, it lacks the proper focus on the Servicemember and his or her dependents who require special needs by not explicitly opening the directive with why EFMP is so critical to the mission and the military family. While this tone is not in and of itself indicative of a directive written for the directive’s sake, it does not inspire confidence that the program builds around the Servicemember and his or her dependent’s needs. Finally, DODI places too much onus for program development, execution, and feedback on the departments. Specifically, the directive is more about reporting procedures and less about program purpose.12 In this regard, the directive meets the intent of “up and out” congressional communication but not “down and in” leadership of the departments or facilitation for program beneficiaries. Failing to meet the design principle of form following function reveals itself in dated, unsynchronized, and non-integrated department regulations.

Uneven Service Availability

Not only does DOD’s lack of centralized command, control, and communications engender disparate program implementation and communications across the departments, it is also complicit in uneven service availability at installations. For example, the RAND EFMP study in 2021 highlighted a decided difference in services available to Servicemembers and their families from installation to installation.13 Service availability at the installation level has two facets that are illustrative: lack of services and the appearance of service availability when the reality is otherwise.

Lack of Services. A lack of service availability, or cumbersome access to care, is an issue that plagues EFMP. Additionally, it speaks to a lack of personnel in the military to provide EFMP services at the installation level, further straining a lack of resources outside the installation. Both indicate a capacity and capability gap, severely affecting the Servicemember and family.

In response to congressional requirements as listed in the FY17 and FY20 NDAAs, DOD announced the planned reduction of 12,801 medical billets across all departments to transition these positions to operational needs.14 One-third of these reductions would be absorbed by personnel in addition to their current duties or by not training students for attritional purposes, with the remaining two-thirds being adjudicated by other means.15 DOD’s report maintains one crucial concern: medical care is nonnegotiable, and the reductions in military medical positions must be covered elsewhere, primarily by off-base providers.16 Of the 122 medical community networks evaluated by DOD, as a determinant in the reduction study, 68 networks were identified as “high risk” or “extreme risk” in absorbing additional workloads, meaning major impacts would occur or the network was incapable of supporting additional stress.17 While the reduction of military medical staff will affect all beneficiaries, EFMP families will face compounding issues due to a lack of specialty care both on and off base, either restricting assignment availability or sending families to a location where the community healthcare system is overly strained. An inadequately resourced care team for EFMP beneficiaries shifts the burden to the community, imposing an additional hurdle to quality care and creating the appearance of services when the facts on the ground are quite different.

Appearance of Service Availability. The appearance of, but not actual, service availability at a particular location arrests a Servicemember’s and his or her family’s critical care. One area of concern is medical capability and capacity. As DOD expands the requirements for an off-installation provider to be considered “trusted and accountable,” a program the FY23 NDAA seeks to proliferate further to “shift risk from the DOD to civilian healthcare providers,” the capability issue may resolve itself, but capacity is sure to be decremented.18 The risk may prove too heavy a burden for off-base providers to shoulder.

Another area of concern is public education capability and capacity, specifically special education related to EFMP. A 2019 Army survey and a 2010 Marine Corps survey shed light on the problems their respective EFMP families face in terms of transitioning special education services during an assignment change or ensuring that services are supported by the school system.19 Furthermore, in testimony to Congress in 2020, advocates conveyed Servicemembers’ ordeals in dealing with both inadequate access to health care and inadequate support to individual education plans.20 Far from localized either geographically or organizationally, the vignettes represented each Service and each region of the country.21 As the burden shifts to communities to support services such as health care and education, the strain on EFMP families increases, as many networks are ill equipped to fill the gap.

Worrisome Insurance Processes

TRICARE is the Defense Health Agency (DHA)–managed healthcare program charged with serving DOD Servicemembers, dependents, and retirees. TRICARE suffers from one major ineffective procedure and one significant inefficient process in executing this charge specific to those requiring specialized care through EFMP.

Insurance Ineffectiveness. In terms of ineffectiveness, one procedure bedevils TRICARE and causes inordinate harm to Servicemembers and their dependents: the curtailment of services, specifically the Autism Care Demonstration (ACD). According to TRICARE’s Web site, ACD began in 2014, is authorized to operate through 2023, and covers Applied Behavior Analysis (ABA) services meant to target core symptoms of autism spectrum disorder (ASD).22 In 2020, the Assistant Secretary of Defense for Health Affairs (ASDHA) directed the Defense Health Board (DHB) to provide recommendations in modernizing TRICARE to position the program as a values-based healthcare provider.23 The recommendations from the working group were unanimously accepted by the DHB and presented to the ASDHA in November 2020.24 A consequential recommendation is that the nexus of care should revolve around an Accountable Care Organization (ACO).25

Regarding autism and ABA, the recommendation is that TRICARE should evaluate ACOs based on outcome and precise patient-reported outcomes and ensure that providers have processes in place to care for complex conditions such as autism.26 The result of such recommendations is a constriction of available providers and services based on the stricter rules governing TRICARE coverage. In early 2021, TRICARE released the changes to the ACD. Of note, there are no longer authorizations for Registered Behavior Technicians (RBT) in the school setting, and the authorization for ABA services is more restrictive than in the past.27

The appearance of non-objectivity in reaching these decisions is of concern. Congress agrees, and the FY22 NDAA contains a provision for an independent review of ACD to judge its efficacy and provide recommendations to the Secretary of Defense.28 Representative Bill Posey (R-FL), a member of the Congressional Autism Caucus, echoed this in an October 2021 letter to Secretary of Defense Lloyd J. Austin III urging an independent review of the ACD and rolling back the curtailments until an independent review is completed.29

Insurance Inefficiency. One inefficient process plagues TRICARE and causes inordinate harm to Servicemembers and their dependents: the requirement for Servicemembers and their families changing assignments across TRICARE regional boundaries to recomplete the referral process for services. Admittedly, this requirement is not the sole province of EFMP families; however, while all military families experience referral issues on an assignment change, EFMP families experience compounding issues due to a break in specialty services. Fortunately, the FY23 NDAA contains language requiring DOD to report the impediments to removing this requirement.30 One such impediment will be the lesser known link between TRICARE and Medicaid. EFMP beneficiaries, if they qualify, are often dependent on Medicaid to supplement healthcare costs when TRICARE will not cover the expense.31 Unfortunately, Medicaid benefits vary from state to state, meaning that what Medicaid might cover for an EFMP family in one state might not be covered in another.32 Out-of-pocket costs to EFMP families are an additional stressor in an already fraught scenario.

Impact on People

The strategic significance of the issues negatively affecting EFMP is palpable, specifically the effect these issues have on a sizable portion of the Nation’s combat capability as it affects Servicemembers and their families. For example, according to a 2019 Army-sponsored survey of EFMP families, half of the respondents indicated they did not receive information about the program.33 Additionally, the same percentage of respondents reported experiencing moderate, heavy, or severe impacts due to a military move, with the percentage increasing for those with multiple moves.34 Last, one-third of the respondents reported not receiving services at the gaining installation in addition to experiencing service unavailability or barriers to service.35

According to a 2020 survey conducted by Partners in Promise, a nonprofit organization advocating for EFMP families, 40 percent of respondents were unfamiliar with the process, and 20 percent did not enroll for fear of negative impacts to career progression.36 Moreover, 40 percent of respondents with EFMP students experienced issues, such as Individualized Education Program implementation, and 79 percent reported going more than a month at the new installation without receiving services.37 According to a 2021 Partners in Promise survey, 39 percent of respondents reported going without special education services for their children after a military move, with an average wait time of nearly 6 months before receiving support.38 While only 20 percent of respondents reported filing a claim due to a lack of legally required support, 74 percent reported the desire to do so.39 Of note, this most recent survey found no delineation between the Services according to beneficiary experience.40

According to a 2010 Marine Corps–sponsored survey, respondents noted challenges in accessing care, paying out of pocket, restrictive coverage, insurance processes, and teaming with the local school system, likening the preceding issues to “a continual struggle for parents.”41 The Navy (2020) and Air Force (2016) each surveyed their respective forces, ostensibly with similar findings regarding EFMP inadequacies, based on congressional testimony.42 EFMP is a DOD responsibility and a community imperative to fulfill both Navy and Air Force mandates to the EFMP beneficiaries. However, the program has benefited from the attention of key stakeholders.

Senior Leader Perspective. General Charles Q. Brown, Jr., is the current Air Force Chief of Staff, and he and his wife, Mrs. Sharene Brown, are an EFMP family. During an interview to follow up on the Browns’ Air Force Association Air, Space, and Cyber Conference Town Hall, they shared why they care so deeply about EFMP, where the program is currently, where it needs to be, how the military has improved, and how it should improve to close the gap.43 The Browns have dealt with EFMP throughout their time in service. As parents to a son diagnosed with autism, they have navigated the system as many military families have had to do, with both positive and not-so-positive experiences.44 As “regular people” with life experiences and struggles relatable to EFMP families across the force, the Browns have been able to combine a passion for program improvement with a position by which to advocate for beneficiaries strategically.45 General Brown also agrees that there should be increased national awareness concerning diagnoses such as autism and mental health needs, providing a fertile ground that furthers EFMP’s efficacy.46 National awareness has spurred tremendous support through nonprofit organizations and local agencies to support EFMP needs. However, Mrs. Brown identified a need to synchronize and integrate these virtuous yet disparate efforts into streamlined care.47 She also offered that a troubling issue for EFMP was something that the military has been perennially poor at executing: marketing, especially when it comes to support programs internal to the military.48 The Browns created and champion the Five and Thrive initiative, a program addressing top concerns of military families such as child care, education, health care, housing, and spouse employment.49 Seminal to this initiative is active advertisement through multiple modes and mediums, creating local and national awareness.

The Browns see additional avenues for EFMP improvements, such as program standardization among the Services, program support for special needs adolescents transitioning into adulthood, feedback mechanisms to validate program efficacy, and right-sizing resources in concert with TRICARE and DHA.50 Moreover, the Browns discussed the need for the military community to speak in a “collective voice,” engendering advocacy at the highest government levels and continuing the momentum of EFMP improvement required to place the program among the pantheon of military-provided support viewed by beneficiaries as superlative to benefits provided by corporate America.51 Moving the needle in this direction is a crucial factor in retention. Through this keen insight and advocacy at the strategic level, EFMP now touts significant improvements.

Recent Success of Improvements

General Brown highlighted improvements that simplify, centralize, and standardize EFMP across the Air Force, and these efforts are led by the Air Force Personnel Center EFMP Central Cell.52 Since May 2020, the Central Cell has provided Servicemembers and their dependents with bimonthly updates on ongoing improvements, gaps yet to be addressed, and the plan moving forward. The updates include a Department of the Air Force Family Vector Web site that provides families access to plentiful EFMP resources any time and near-real-time information on what installations can and cannot support, as well as acceptance rates based on a specific condition or diagnosis.53 Additionally, the updates include staff additions at the Central Cell, including a specialized attorney, a special education specialist, four registered nurses, a health benefits analyst, a respite care liaison, and a plan to hire four physicians soon.54 Last, an update was made to the assignment change procedure, fully automating the Family Member Travel Screening process with no requirements for medical appointments and providing an entirely online experience for submitting forms and documents throughout the assignment process.55 This update is ubiquitous in its usefulness to Servicemembers and their dependents. It promises to drastically reduce time and effort in navigating the change of assignment consideration process: acceptance or denial, appeal, and completion. The Army, Marine Corps, and Navy have likewise launched similar initiatives aimed at facilitating “smooth moves” and services for their EFMP families. That said, General Brown acknowledges the challenges of nascent processes endeavoring to accomplish a complex mission.56 However, given the organizational learning of the past year, he is confident that the teams facilitating EFMP improvement are on the right track in terms of capacity and capability to provide sustainable, repeatable, and timely support to EFMP families.57

Recommendations

In addition to the possibility of scaling EFMP improvements across the force, there are effective ways to continue to steer the program in the spirit of its noble cause.

First, DOD must codify, coordinate, and communicate a comprehensive EFMP policy. An effective strategy for implementing EFMP at the DOD level prioritizes specialized care for beneficiaries in a principled way by matching actions with words. A coherent strategy signals to Congress how resources will be allocated to implement congressional mandates and gaps between current funding and required funding. A clear strategy communicates to beneficiaries what to expect from EFMP. An articulate strategy provides each department with the necessary details to develop their respective policies and the mechanisms to adjudicate program implementation issues. Currently, DOD’s Office of Special Needs (OSN) and the Services are in the process of standardizing EFMP, which is a crucial first step, but it is certainly not the desired endstate. An active strategic narrative to market the program is essential to the success of a standardized program. OSN and the Services should consider writing EFMP regulations with the beneficiary in mind rather than the bureaucracy. Building trust with special needs families begins with a communications strategy that seeks shared understanding and creates a sense of appreciation by the beneficiary that program administration places them at the nexus of care. Information is the new key terrain and decisive point in any current environment. EFMP is no different. Akin to an application developer, there must be a collective mindset that EFMP is iterative and attuned to customer requirements at the speed of need.

Second, the Services should emulate and supplement the DOD Advisory Panel described in the House-approved version of the FY22 NDAA.58 The President’s signed version includes a requirement for DOD to establish an advisory panel comprising stakeholders in the leadership, administrative, and, most important, beneficiary realms of EFMP.59 While this provision is a significant step forward in highlighting, devising, and recommending program updates to OSN for implementation across the departments, the House-approved version contains much more substance. In it, the Service Vice Chiefs of Staff nominate the panel members, and members must represent the force’s diversity and serve a 2-year term, except for one member who serves for 3 years.60 These stipulations help to ensure that a broader range of perspectives, experiences, and proposed solutions are presented by an inclusive team to OSN for consideration. In addition, the term limit ensures that new perspectives are considered, and the 3-year term for one member establishes a process of continuity from term to term. This type of council at the Service level could put a more refined take on the Service-specific issues facing special needs families, function as conduits up and down levels of command, and better inform the DOD Advisory Council.

Third, DOD must make entry into the Services more attractive for trained providers in fields such as, but not limited to, pediatrics, mental health, and counseling. Generalists cover gaps in care, but this does not correlate to an even exchange of expertise. Along with a fully staffed EFMP office, military providers trained in the fields of medicine of greatest need for special needs families allow for a superb quality of service and quality of life and provide the departments greater flexibility in personnel moves. This buoyed staffing would better support all Servicemembers, not just those with special needs. For example, the Department of the Air Force launched a Developmental and Behavioral Health Family Readiness Center pilot program in 2020 to address this provider shortfall.61 In essence, the program sought to provide a “hub and spoke” model of care to small or remote locations that do not have adequate services.62 Through teleconsultation, virtual health, and provider travel, the department looks to address inefficient and ineffective care at some locations that affect EFMP services and personnel mobility.63 The pilot program has shown positive results at two locations, and the plan is to resource and scale the program across the department.64 While this program tempers the symptoms—and DOD should look at projecting a similar model across the Services—it does not cure the lack of qualified providers in the Air Force. In addition to qualitative measures, Congress and DOD should refrain from reducing medical billets pending a review of the effects such reductions will cause to the Military Health System. While there may be efficiencies gained by reducing overhead and combining efforts, quantity has a value all its own. Given no decrease in demand, quantitative measures are critically important.

Fourth, DOD must engage with civic leaders who partner with the installation to broaden and deepen the services provided in the community, specifically in the fields of medicine, therapy, and education. For special needs families who desire the use of, or must use, off-base services for various reasons (including insurance necessity), a range of options to support special needs requirements enhances the installation and its mission. This synergy affords the departments greater flexibility in managing the force through assignment changes. Furthermore, it provides Servicemembers and their dependents peace of mind during the stressful assignment change process. This provides a linking mechanism between the installation and the community, furthering the cohesion of a critical civil-military relationship. One example of partnership is the DOD pilot program for allowing off-base military dependents to access education on base (currently reserved for on-base residents) to shore up lacking services in an area. As military medical positions are reduced, synergistic efforts between the installation and the surrounding community are crucial.

Fifth, DHA must allow Servicemembers and their dependents to transfer active referrals across TRICARE boundaries prior to, not after, permanently changing assignments to a new TRICARE region. This flexibility would remove the cumbersome process of starting the referral process again at a new installation. Furthermore, it removes costly wait times, which preclude critical special needs care for Servicemembers and their dependents when they could have been added to a waitlist while at their previous duty location. Referrals for ABA already accomplish this through the Environmental Influences on Child Health Outcomes program, but other special needs services have long wait times, which could be minimized. At a new installation in a new TRICARE region, the primary care manager should not need to see the patient to aid in the referral transition process. The whole point of EFMP is to ascertain capability and capacity of care at the new installation. Once the change of assignment order is in hand, the Servicemember should be able to move referrals across TRICARE borders while also using services under that referral at the present location. The ability to remove arbitrary borders and the bureaucracy that comes with it substantially and more seamlessly enhances the continuation of care.

Sixth, DOD should roll back the curtailment of ABA services and exclusion of RBTs in the school setting. The FY22 NDAA contains a provision requiring an independent review of the efficacy of DOD’s ACD program and ABA services.65 While autism is just a subset of EFMP, it is a microcosm of the issues beleaguering the program—more precisely, the impression that EFMP is limiting services to or making the process more laborious for the most vulnerable population. An independent review might arrive at the same conclusion as DHA, but it might not. Nevertheless, an independent review would lend credibility and legitimacy to a decision that drastically affects Servicemembers and their families who depend on ABA services.

Lastly, DOD, much like it does regarding innovation efforts across the departments, should formulate a sustainable, repeatable, and measurable process for capturing best EFMP practices from across the force and push these to all Services for review and implementation as appropriate. As the sage advice posits, “Many hands make light work.”

Conclusion

The preceding recommendations are not all-encompassing, nor is the goal to perfect the program sensible. However, improvement is a realistic goal. The 2018 National Defense Strategy codifies the importance of the men and women who serve in the Armed Forces either in uniform or in a civilian capacity by saying the “talent of the American warfighter is our greatest enduring strength, and one we do not take for granted.”66 Unfortunately, the Cultivate Workforce Talent section does not mention the criticality of supporting Servicemembers or their families through initiatives such as EFMP.67 Much like DOD policy regarding EFMP and the trickledown effect on Service-specific EFMP guidance, the lack of specificity on how DOD prioritizes quality of life calls into question the “not taken for granted” approach while also not setting the standard and expectation for the departments.

Engaged senior leaders such as General Brown, who laid out his people-first vision in his Chief of Staff of the Air Force Action Orders, are critical to creating a principled plan of action for improving EFMP.68 As Simon Sinek offers, “For values or guiding principles to be truly effective, they have to be verbs . . . articulating our values as verbs gives us a clear idea.”69

However, the program falls short of its guiding principle of Servicemember and dependent–centered special needs care. Suppose people are indeed DOD’s competitive advantage. In that case, the strategic imperative of ensuring the support systems meant to care for Servicemembers and their families demands that EFMP does not exist as a bureaucracy solely for the bureaucracy’s sake and that it is the most responsive, agile, and relevant program feasible. Providing sustainable resources of qualitative and quantitative substance will always be DOD’s and the Services’ sacred charge in caring for the military community.

Increasing the efficacy of the program is the right thing to do. It is also a prudent thing to do. The past three administrations have posited a world in which the character of war will shift in various degrees, one of which portends the return to a global struggle with peer competitors. While nonhuman resources, such as next-generation weaponry and cutting-edge Joint All-Domain Command and Control capabilities, capture the headlines, people will be the deciding factor in the next conflict. EFMP is a strategic fulcrum with retention or separation hanging in the balance. As a strategic interest, EFMP is complex and requires deliberate development and resources over the next decade to produce lasting effects, capability, and capacity. Although complex, DOD cannot afford to lose talent due to the continued inadequacies of a program it administers. Therefore, EFMP must be a strategic priority as the geopolitical landscape shifts. Strategic competition with China and Russia requires it. Congress and its constituents demand it. Most important, the hundreds of thousands of Servicemembers and their families depending on EFMP, including my two sons diagnosed with autism, deserve it. JFQ

Notes

1 Amanda Miller, “Caring for Their Son Gave the Browns a Window Into the Needs of Exceptional Families,” Air and Space Forces Magazine, September 27, 2021, https://www.airforcemag.com/air-force-chief-of-staff-browns-son-autism-exceptional-families.

2 Annual Report to the Congressional Defense Committees on the Activities of the Office of Special Needs—2020, Pursuant to 10 U.S.C., § 1781c(h) (Washington, DC: Department of Defense [DOD], May 2021), 5, https://download.militaryonesource.mil/12038/MOS/Reports/osn-report-to-congress-2020.pdf.

3 William M. (Mac) Thornberry National Defense Authorization Act for Fiscal Year 2021, H. Res. 6395, 116th Cong., 2nd sess., Congressional Record 116, December 7, 2020, 652, https://docs.house.gov/billsthisweek/20201207/CRPT-116hrpt617.pdf.

4 Ibid., 654.

5 Ibid., 657.

6 Government Accountability Office (GAO), Military Personnel: DOD Should Improve Its Oversight of the Exceptional Family Member Program, GAO-18-348 (Washington, DC: GAO, May 8, 2018), https://www.gao.gov/products/gao-18-348.

7 GAO, DOD Has Made Limited Progress Toward Improving Oversight of the Exceptional Family Member Program, GAO-20-400T (Washington, DC: GAO, February 5, 2020), https://www.gao.gov/products/gao-20-400t.

8 Sarah O. Meadows et al., The Exceptional Family Member Program (EFMP): Policy Alignment Between the Department of Defense and the Services (Santa Monica, CA: RAND, 2021), https://www.rand.org/pubs/research_reports/RRA742-1.html.

9 Annual Report to the Congressional Defense Committees on the Activities of the Office of Special Needs, 2.

10 William M. (Mac) Thornberry National Defense Authorization Act for Fiscal Year 2021, 686.

11 DOD Instruction 1315.19, The Exceptional Family Member Program (EFMP) (Washington, DC: DOD, June 23, 2023), 1, https://www.esd.whs.mil/Portals/54/Documents/DD/issuances/dodi/131519.pdf.

12 Ibid., 6.

13 Meadows et al., The Exceptional Family Member Program.

14 Report to the Congressional Armed Services Committees: Section 719 of the National Defense Authorization Act for Fiscal Year 2020, Public Law 116-92 (Washington, DC: Under Secretary of Defense for Personnel and Readiness, July–August 2021), 1.

15 Ibid., 2.

16 Ibid., 28.

17 Ibid., 30–31.

18 James M. Inhofe National Defense Authorization Act for Fiscal Year 2023, Public Law 117-70, 117th Cong., 2nd sess., December 6, 2022, 649–651, https://www.congress.gov/bill/117th-congress/house-bill/7776/text.

19 Health of the Army Family: What We Know, What We Don’t Know, and What’s Next (Washington, DC: Headquarters Department of the Army, December 2021), 67, https://api.army.mil/e2/c/downloads/2022/06/15/04d8667e/haf-2021-report.pdf; United States Marine Corps Exceptional Family Members: How to Improve Access to Health Care, Special Education, and Long-Term Supports and Services for Family Members With Disabilities (Washington, DC: National Council on Disability, November 2011), 3.1, https://ncd.gov/publications/2011/Nov282011#toc40.

20 Exceptional Family Member Program—Are the Military Services Really Taking Care of Business? Hearing Before the Subcommittee on Military Personnel, House Armed Services Committee, 116th Cong., 2nd sess., February 5, 2020, 120–142, https://www.govinfo.gov/content/pkg/CHRG-116hhrg43664/pdf/CHRG-116hhrg43664.pdf.

21 Ibid.

22 “Autism Care Demonstration,” Plans and Eligibility, TRICARE, July 14, 2022, https://tricare.mil/ACD.

23 Modernization of the TRICARE Benefit (Washington, DC: Defense Health Board, November 5, 2020), 3, https://apps.dtic.mil/sti/pdfs/AD1116727.pdf.

24 Ibid.

25 Ibid., 25.

26 Ibid., 19.

27 “Autism Care Demonstration.”

28 National Defense Authorization Act for Fiscal Year 2022, Public Law 117-81, 117th Cong., 1st sess., December 7, 2021, 634, https://www.congress.gov/bill/117th-congress/senate-bill/1605/text/eah.

29 Representative Bill Posey (R-FL), letter to Secretary of Defense Lloyd J. Austin III, October 1, 2021, letter in author’s possession.

30 James M. Inhofe National Defense Authorization Act for Fiscal Year 2023, 604.

31 “Medicaid for Family Members With Special Needs,” Military OneSource, March 22, 2022, https://www.militaryonesource.mil/special-needs/medical-needs/medicaid-for-family-members-with-special-needs.

32 Ibid.

33 Jill A. Brown et al., Exceptional Family Member Program Survey: Assessing the Needs of Exceptional Army Families, Public Health Assessment Report No. S.0065576-19 (Washington, DC: Headquarters Department of the Army, Health Promotion and Wellness, Public Health Assessment Division, July 2019), ii, https://apps.dtic.mil/sti/pdfs/AD1095007.pdf.

34 Ibid., 9.

35 Ibid., ii.

36 Rebecca Alwine, “Survey Says Families Aren’t Using EFMP Because They Don’t Know How,” Military.com, February 2, 2021, https://www.military.com/2021/02/02/survey-says-families-arent-using-efmp-because-they-dont-know-how.html.

37 Ibid.

38 Karen Jowers, “Military Kids Face Delays, Inequities in Getting Special Education Services,” Air Force Times, February 3, 2022, https://www.airforcetimes.com/pay-benefits/2022/02/03/military-kids-face-delays-inequities-in-getting-special-education-services.

39 Ibid.

40 Ibid.

41 United States Marine Corps Exceptional Family Members, 3.1.

42 Amanda Dolasinski, “Navy Launches Survey to Hear From Special Needs Families,” Military Officers Association of America, June 3, 2020, https://www.moaa.org/content/publications-and-media/news-articles/2020-news-articles/navy-launches-survey-to-hear-from-special-needs-families; “Exceptional Family Member Program—Are the Military Services Really Taking Care of Business?” 179.

43 Miller, “Caring for Their Son Gave the Browns a Window Into the Needs of Exceptional Families.”

44 General Charles Q. Brown, Jr., and Sharene Brown, interview by author, Washington, DC, March 2, 2022.

45 Ibid.

46 Ibid.

47 Ibid.

48 Ibid.

49 Ibid.

50 Ibid.

51 Ibid.

52 Ibid.

53 Tammy Hern and Tami Nelson, “Update on the EFMP Central Cell Special Education Program and Special Education Legal Services,” Facebook video, October 28, 2021, https://m.facebook.com/AirForceEFMP.

54 Ibid.

55 Ibid.

56 Author interview with General and Mrs. Brown.

57 Ibid.

58 National Defense Authorization Act for Fiscal Year 2022, H. Res. 4350, 117th Cong., 1st sess., October 18, 2021, 530, https://www.congress.gov/117/bills/hr4350/BILLS-117hr4350pcs.pdf.

59 National Defense Authorization Act for Fiscal Year 2022, December 7, 2021, 496.

60 National Defense Authorization Act for Fiscal Year 2022, October 18, 2021, 532–533.

61 Colonel Kristine M. Hackett, “Talking Paper on Developmental and Behavioral Health Family Readiness Centers (DBFRCs),” Air Force Surgeon General email in author’s possession, 2021, 1.

62 Ibid.

63 Ibid.

64 Ibid.

65 National Defense Authorization Act for Fiscal Year 2022, December 7, 2021, 634.

66 Summary of the 2018 National Defense Strategy of the United States of America: Sharpening the American Military’s Competitive Edge (Washington, DC: DOD, 2018), 8, https://dod.defense.gov/Portals/1/Documents/pubs/2018-National-Defense-Strategy-Summary.pdf.

67 Ibid., 7–8.

68 General Charles Q. Brown, Jr., CSAF Action Orders: To Accelerate Change Across the Air Force (Washington, DC: Headquarters Department of the Air Force, 2020), 3, https://www.af.mil/Portals/1/documents/csaf/CSAF_Action_Orders_Letter_to_the_Force.pdf.

69 Simon Sinek, Start With Why: How Great Leaders Inspire Everyone to Take Action (New York: Portfolio, 2009), 67.