Thomas McCaffery, Defense Department assistant secretary for health affairs, and Army Lt. Gen. Ronald Place, director of the Defense Health Agency, testify about military health system reform before the House Armed Services Committee’s subcommittee on military personnel, December 5, 2019.
Transcript
Hearing on the Military Personnel Subcommittee on Military Health System Reform to order. Today this hearing is focused on the status of military health reforms Congress enacted in the 2017 NDAA, and whether the department and the military services are working towards achieving congressional intent. The reform that most impacts service members and their families is the transition of management of the military treatment facilities from services to the Defense Health Agency, which is the focal point of this hearing. The last time we had a briefing on this issue was in December of 2017. I recall there was some disagreement among the military departments and DOD on how to implement these changes. I understand this transition began, at least in part, as of October 1st this year, but it was painful getting to that point and it was a very small step towards accomplishing the overall goal of a single military health system instead of three separate service health systems. There also are many important reforms critical to making the MTF transition successful that are lagging behind, such as implementation of the new electronic health records, Genesis, the proper analysis of what medical skills and the number of medical providers are needed to support the warfighters and beneficiaries, the appropriate number and sizes of medical facilities, and reforms that could create economies of scale and effective efficiencies within the MHS. To be clear, budget cuts are not the same thing as efficiencies in MHS. And many rumored cuts to the military medical workforce, whether primary care physicians or ophthalmologist, lack rationale or evidence that they would actually save taxpayers money. One of the top concerns many of my colleagues have heard over the past eight months was about the military medical manpower cuts in the president’s FY 2020 budget. This was done to repurpose 17,944 military department officer and enlisted health specialty medical billets and transition them to other manning needs in the military departments. I was baffled as to why this request was submitted when the services and the Joint Staff had not completed the analysis of the operational requirements for supporting combatant commanders in time of conflict of war. It appeared to me that this proposal prioritized cost cutting over operational needs and common sense. In February 2019, the GAO confirmed our concerns when they reported that the DOD has not determined the required size and composition of its operational medical and dental personnel who support the wartime mission or submitted a complete report to Congress, as required under the NDAA for fiscal year 2017. We have also heard that there is a defense-wide review underway that is considering a wide variety of cost-cutting proposals, including shuttering major military medical centers, a restructured Tricare benefit that could significantly increase copays, closure of the Uniformed Service University of the Health Sciences and the potential destruction of some reforms that we’ve made into law over the past three years. The goal of military health reform is not to reduce the military’s ability to deliver healthcare in times of peace or war. The goal is to find ways to be more efficient so that we can save taxpayers money while providing better quality healthcare for our service members and their families. Private insurance and private providers may serve these goals for some types of services in some communities, but privatization can also threaten worse outcomes and higher costs if done without care and consideration. The ranking member and I recently visited Madigan Army Medical Center, Naval Hospital Bremerton and the David Grant Air Force Medical Center, where we spoke with military spouses about quality of life issues. Access to military healthcare came up at every discussion. At each installation, we heard about challenges with the lack of mental health resources in the local community. We heard about civilian healthcare networks that either lack the capacity or are unwilling to admit Tricare beneficiaries. And we’ve heard about challenges accessing appointments at military treatment facilities. The larger problem we heard is not that local providers think Tricare reimbursement rates are low, it’s that the healthcare market is already oversaturated, even in large metropolitan areas like Seattle and San Francisco. It’s not all bad news. At Travis Air Force Base, we saw a busy military treatment facility working hand in hand with the VA in collaboration that could, along with civilian providers, create an integrated delivery system. The 2017 NDAA encouraged these types of relationships with local healthcare facilities. We need to see more of this kind of cooperation and hear more from these programs in order to replicate their successes. Instead, DOD seems intent on gutting our Military Health System and calling it an efficiency. The system is costing less. It has saved billions of dollars, at least $1 billion in just the last year, but there remains urgent coverage needs that should be addressed by reinvesting any savings in the military healthcare system, not continuing to squeeze every last penny out of the system in order to fund other priorities. Healthcare is a need and right we must continue to provide for our military families. Weakening the delivery system will only cost us and our service members more down the road. The department must do better. Today, we will hear from a panel of senior leaders from across the Department of Defense that are responsible for implementing the Military Health System Reform. We are seeking to better understand how DOD is implementing major Military Health System Reforms, how they are determining Tricare success in meeting the needs of its beneficiaries, and how DOD plans to repurpose roughly 18,000 medical positions and how that will affect health services. We will also hear how DOD is balancing readiness with efficiency, and how the Joint Staff and the service surgeon general are approaching readiness to ensure that we have the right personnel and the right capabilities at the right time. I now would like to have Ranking Member Mr. Kelly offer us any opening remarks.
Thank you, Chairwoman Speier. And that’s as long as I’ve heard our chairwoman talk on any subject, and mine’s gonna be lengthier than usual, too. And that’s because we’re very passionate about it and getting this right. This is one of the most important things I think we do on this subcommittee. I wanna welcome our witnesses today’s hearing and thank you for your service to our service members and their families. The Military Health System is one of the largest healthcare systems in the world, and you all have the critical mission of providing care to one of the most venerated segments of the United States population, our service members, veterans and their families. We hold the Military Health System to a higher standard than civilian healthcare given your important mission, and I know that you share that commitment. That is why this committee has worked continuously with the Department of Defense to ensure that our Military Health System has the resources and systems in place to provide exceptional healthcare. The 2017 Military Health System Reforms are an integral part of improving healthcare delivery. The primary goal of that reform effort was to improve medical readiness, standardize patient experience in military medical treatment facilities and, where possible, improve efficiency. I am encouraged by the progress that DOD and the services have made in implementing these reforms, but there remain several areas of concern. In particular, I’m very concerned with the department’s current efforts to restructure and realign military treatment facilities, commonly known as Section 703 implementation. I believe that the department may be viewing this as a cost-saving exercise, when the actual purpose is to improve efficiency and healthcare quality. It is crucial that prior to any reductions in MTF services that DOD fully understand the civilian network capability to absorb those patients. In our visit to military installations around the country, I can tell you that many civilian healthcare networks are oversaturated and will not be able to absorb more patients. I look forward to hearing what analysis has been done regarding network adequacy in preparation for any MTF realignment. I’m also very concerned about the planned reduction in military healthcare billets. The services identified over 17,000 healthcare billets for elimination. While some of these positions are purely administrative in nature, many of them are medical professional billets. At nearly every military installation I visited, one of the chief complaints regarding healthcare is that patients must wait weeks in order to get an appointment. That is unacceptable. And I’m concerned that further personnel reductions will make the problem worse. I would like to hear more about what analysis was done to support these reductions. Finally, I’m concerned about the state of behavioral healthcare in the military. I’ve repeatedly heard from medical providers, service members and their families about chronic staffing shortages and long wait times for appointments. Meanwhile, the rates of suicide in our military continue to increase. I understand that this is a national problem, but I wanna know what the services and the Defense Health Agency are doing to fix this program in the military. In a recent report, each of the services said that the number one recruiting challenge for behavioral health providers is low pay and a lengthy hiring process. So now that you have identified the problem, what specific authorities do you need in order to fix it? I wanna thank our witnesses for their considerable efforts to improve healthcare and institute the Military Health System Reforms. I look forward to a robust discussion that is focused on readiness and quality care. Thank you, and I yield back, Chairwoman.
Thank you, Ranking Member. As you can see from both of our statements, they’re fairly consistent, which is a recognition, I think, that we here in Congress are very concerned about what’s happening. We now welcome our distinguished panelists. Mr. Thomas McCaffery is the assistant secretary of defense for Health Affairs. Lieutenant General Ronald Place, director of the Defense Health Agency. Lieutenant General Dorothy Hogg, surgeon general of the Air Force. Lieutenant General Scott Dingle, surgeon general of the Army. Rear Admiral Bruce Gillingham, surgeon general of the Navy. Brigadier General Paul Friedrichs, Joint Staff surgeon. I will ask unanimous consent to allow any members not on the subcommittee to participate in today’s hearing and be allowed to ask questions after all subcommittee members have been recognized. Without objection?
[Trent] Without objection.
That is granted. Let us then ask each of you to summarize your testimony in five minutes or less. Your written comments and statements will be made part of the hearing record, and each member has the opportunity to question the witnesses for five minutes. We will start with Mr. McCaffery, and you may offer your opening statement.
Thank you, Chairwoman Speier and Ranking Member Kelly, members of the committee. Thank you for the opportunity today to discuss our combined efforts to maintain and strengthen our Military Health System. The men and women of the MHS are justifiably proud of what they do. They provide the platform to train our uniformed medical force and they ensure our active duty service members have access to the healthcare they need in order to do their jobs anywhere, anytime. They support one of the largest and most successful medical research enterprises in the country. They operate a global health surveillance network that monitors for infectious threats to our forces and our homeland. They manage of the country’s largest networks of hospitals and clinics. They do all that will unfailing professionalism, and I might add with incredible passion. They, and we, are grateful for the committee’s support of this work. Our primary mission, as you had indicated, is readiness. The readiness of the medical personnel to support our forces in battle, and the medical readiness of combat forces to complete their missions. And that readiness mission also entails caring for the families of our troops and our retirees. After all, while service members who deploy must be medically ready to do their jobs, they also need to know that their families back home are cared for, and that in retirement, they will receive a health benefit that recognizes the value of their service. Meeting this obligation to our beneficiaries is vital to recruiting and retaining a high-quality force. In order to advance these goals, we believe the MHS, like the rest of the Department of Defense, must adapt and change in order to carry out our mission in an ever-evolving security environment, and very importantly for us, a consistently dynamic medical landscape. And we know that Congress shares this belief. In the past three National Defense Authorization Acts, Congress has given the department very clear direction on the fundamental reforms it expects us to implement. Building off that direction, we are changing to ensure that the system can most effectively meet our mission. Some of the things that the reforms that we are partnering with Congress on are aimed at ensuring that the uniformed medical force is properly sized and has the skills to respond to operational requirements. Ensuring that our system of hospitals and clinics is optimally sized and shaped to support the readiness of our medical forces, the medical readiness of combat forces and our obligations to our beneficiaries. Better organizing and integrating our direct-care system to form a true unified medical enterprise that can improve our effectiveness and efficiency and provide a more standardized, dependable, high-quality experience for our active duty, their families and our retirees. And finally, most effectively managing private sector care through Tricare’s managed care networks. General Place and I outlined in more detail in our written testimony each of these reform efforts, but the point we’d like to emphasize is that all of these efforts are aimed at ensuring that the Military Health System provides maximum support to the department as it executes the National Defense Strategy. It’s our privilege to testify before you today on this critical mission of the health system and to provide you information on the status of the numerous reforms Congress has directed us to pursue. Thank you to the members of this committee for their support of that mission and the men and women who carry it out. And we look forward to answering your questions.
Thank you. Lieutenant General Place.
Chairman Speier, Ranking Member Kelly, members of the committee. I’ll add a few comments to Mr. McCaffery’s opening comments. As he made clear, our principal mission is enabling readiness. And within that mission are two distinct responsibilities. First, to ensure every person in uniform is, in fact, medically ready to perform their job anywhere in the world. And then secondarily, to ensure our military medical personnel are individually and collectively prepared to support the full range of military medical operations. The Defense Health Agency serves as the supporting agency in this readiness mission to the combatant commands and to the military departments, the Military Health System. Performance on the battlefield is exemplifying historically high survival rates from combat wounds, and historically low rates of disease and non-battle injuries. These successes reflect the processes in which joint solutions contributed to these outcomes. Now, the DHA was established to strengthen our health system in both the deployed settings and in the fixed healthcare facilities around the world. Our combat support responsibilities include a broad range of military health support. They include management of the Armed Services blood program, the Joint Trauma System, public health, Armed Forces medical examiners, medical logistics in the operational environment, health information and technology in the operational environment, and really a whole lot more. But as the DHA assumes responsibility for managing all the military’s hospitals and clinics, we continue to view these medical facilities as readiness platforms where medical professionals from the Army, from the Navy and from the Air Force obtain and sustain their knowledge and skills, and for which these professionals deploy in support of our military missions. The DHA approach better enables the MHS to optimize the care we can deliver, along with clinical skill sustainment experiences for our medical staff within and across geographic markets. As DOD leadership evaluates the size of the medical force and makes determinations about the configurations of hospitals and clinics, the DHA is also prepared to ensure our beneficiaries have access to care they need through the management of the Tricare program. Now, the department has long relied on civilian healthcare to provide and deliver care to our beneficiaries in locations where we don’t operate medical facilities or when the needs of our patients exceed the capabilities that we have locally. Over the past three decades, with changes in military basing, reductions in the military force strength, we’ve successfully increased specific civilian healthcare networks. We’re performing those assessments again today, and will do so continuously. And we’re working with the military departments to ensure military families and retirees continue to enjoy access to high-quality care if military medical capabilities are exceeded. I’m grateful for the opportunity to share our detailed plans to further improve military medical support to combatant commands and to the military departments. Thank you, again, to the members of this committee for your time and your continuing service to the men and women of our Armed Forces and the families who support them.
Thank you. Lieutenant General Hogg.
Chairwoman Speier, Ranking Member Kelly and distinguished members of the subcommittee, thank you for the opportunity to provide an update on Air Force Medical Service reform. This committee is well aware of the reemergence of great power competition, such as China and Russia, and the Air Force’s need to increase lethality, strengthen alliances and realign resources in preparation of these potential threats. The Air Force Medical Service is evolving in support of these overarching national defense objectives. Air Force medics continue to answer the call across a broad spectrum of operational, humanitarian and disaster response missions. We specialize in aerospace and operational medicine, most notably, aeromedical evacuation, while ensuring the readiness and deployability of our warfighters. Our charge is crystal clear, and I am confident that these reforms will maximize our ability to meet combatant commander requirements and support line of the Air Force operations across the enterprise. With this renewed focus on operational readiness, we restructured our headquarters by deactivating the Air Force Medical Support Agency and re-designating the Air Force Medical Operations Agency as the Air Force Medical Readiness Agency. This new organization directly supports readiness, aerospace and operational medicine activities, and provides oversight of strategic medical readiness initiatives at Air Force installations. We are also realigning medical resources at our base installations in order to improve airmen deployability and overall wellness. This initiative reorganizes medical groups into two squadrons, an Operational Medical Readiness Squadron, which serves active duty guard and reserves, and a Health Care Operations Squadron, which serves non-uniformed members and dependents. While these squadrons are interconnected, they have a singular focus which allows each of the squadrons to optimize care for its designated population. We continue to enhance our ability to save lives both on and off the battlefield by investing in our most vital pacing units, our critical care air transport teams and our ground surgical teams. Complementing these efforts is one of my strategic initiatives called Medic X. This goal is to develop multifunctional medics who can perform duties beyond their primary specialty, which will have exponentially expanded clinical capabilities. Our partnerships with military, educational and civilian medical institutions will remain a critical component to maintaining medical airmen’s clinical skills and currency. Collectively, these efforts increase our ability and agility to support homeland defense, deployed requirements and operate in tomorrow’s highly contested environment. I would like to highlight the progress and the collaboration with the Defense Health Agency in transitioning authority, direction and control of military treatment facilities to the Defense Health Agency. The Air Force Medical Service will continue to provide direct support to the Defense Health Agency until it can establish its headquarters, markets and functional capabilities. We are committed to a successful transition that will continue delivering high-quality readiness and beneficiary care. My testimony gives the committee a clear picture of the Air Force Medical Service and how we are aligning our efforts with Defense Department and Air Force priorities. As our nation faces new challenges, preparing for an uncertain future requires bold and innovative thinking. I have no doubt we are moving in the right direction, and our medics throughout the Military Health System will rise to the occasion. Thank you, again, for your time, and I look forward to your questions.
Thank you. Lieutenant General Dingle.
Chairwoman Speier, Ranking Member Kelly, distinguished members of the subcommittee, it is an honor to speak before you today as the 45th Army surgeon general representing over 130,000 soldiers and civilians in Army medicine. I also would like to thank my Military Health System and my sister service colleagues here today. We all share a common commitment to ensuring our Military Health System is manned, recognized, trained and equipped to meet the needs of our services and the Joint Force. The chief of staff of the Army states winning matters and people are our number one priority. As the Army modernizes and prepares for large-scale combat operations, it is imperative that our medical force remains ready, responsive and relevant in order to conserve their fighting strength in the multi-domain battlespace because in combat, winning not only matters, but there is no second place. As required by law, the Army transitioned authority, direction and the control of our medical treatment facilities to the Defense Health Agency. The transfer has been transparent to our soldiers, civilians and our beneficiaries. Partnering with the Defense Health Agency, we will continue to deliver high-quality and safe care. The Army is continually assessing the risks with changes to medical and strength. Personnel changes currently under review are a necessary part of our modernization and our force shaping. We will ensure that adjustments are informed and support the operational force, as well as the healthcare delivery mission. As we reform and reorganize, we are committed to providing ready and responsive health services and force health protection. I have established my priorities to ensure that we remain ready, reformed, reorganized, responsive and relevant. Ready to deploy, fight and win when called upon. Reformed in accordance with the law. Reorganized to support Army modernization. Responsive to the demands of the multi-domain operations, and relevant to the rapid changes in modern warfare. Finally, Army medicine must change at the speed of relevance. This includes modernization of key capabilities, innovation of organizational concepts, advancement of technology and integration with the joint and inter-agency community. In closing, I am committed to meeting the congressional intent and sustaining the readiness of Army medicine. Further, I am committed to my statutory responsibilities in support of the secretary of the Army and as the chief advisor to the Defense Health Agency for the Army. I will inform the committee as we make strides in Military Health System Reform and Army medicine. I want to thank the committee for your longstanding support to Army and military medicine. For the service and sacrifice of our soldiers and their families, we must get this right. This is our solemn obligation to our nation. Thank you for the opportunity to come before this committee, and I look forward to answering your questions. Thank you.
Thank you. Rear Admiral Gillingham.
Chairwoman Speier, Ranking Member Kelly, distinguished members of the subcommittee, on behalf of the mission-ready Navy medicine team, I’m pleased to be here today with my colleagues to provide you an update on an important issue for us all: Military Health System Reform. As we move forward with systemic changes in the MHS, I want to assure you that the foundation of Navy medicine is readiness. Our highest priority is keeping sailors and Marines healthy and ready to deploy, and ensuring they get the best care possible from trained and confident providers when they are wounded or injured. The nation depends upon Navy medicine’s unique expeditionary medical expertise to prepare and support our naval forces. To this end, our priorities of people, platforms, performance and power are aligned to this commitment. Well-trained people working as cohesive teams on optimized platforms, demonstrating high-velocity performance that will project medical power in support of maritime superiority. On any given day, Navy medicine personnel are deployed and operating forward in a full range of diverse missions, including austere damage control, resuscitation and surgery teams in Central Command and Africa Command. Trauma care at the NATO Role 3 Multinational Medical Unit in Kandahar. Humanitarian assistance aboard hospital ship USNS Comfort. And expeditionary health service support with joint, fleet and fleet Marine forces around the world. A week ago, I had the honor of celebrating Thanksgiving with our Navy medicine personnel forward deployed at Camp Lemonnier, Djibouti, as part of the Combined Joint Task Force- Horn of Africa. I saw firsthand the important work they continue to do to ensure the health and readiness of our service members and multinational partners. All of us can be justifiably proud of the great work that they do. Collectively, the substantive reform legislation contained in the fiscal years 2017 and 2019 National Defense Authorization Acts represents an important inflection point for military medicine, and catalyzed our efforts to strengthen our integrated system of readiness and health. Navy and Marine Corps leadership recognized the tremendous opportunity we have to refocus our efforts on medical readiness while transitioning healthcare benefit administration to the Defense Health Agency. I want to emphasize that while significant organizational change in healthcare is inherently complex, all of us testifying before you today know we have a shared responsibility to ensure that both the services and the Defense Health Agency are successful. Our efforts will continue to reflect this imperative moving forward. Integral to the MHS-wide transformation is the transition of our military treatment facilities to the DHA. In October, as you know, the DHA assumed authority, direction and control of all MTFs in the continental United States, including Alaska and Hawaii. As a component of this significant transition, we are continuing to provide defined support to the DHA as it progresses to full operating capability. In addition, Navy medicine is making important changes at all levels to support our refocus on readiness. We are streamlining activities that directly impact our capabilities to support operational requirements and ensure we have a trained and ready medical force. We must have the agility to rapidly deploy anytime, anywhere to support fleet and fleet Marine force missions and platforms, including expeditionary medical facilities and units, hospital ships, as well as casualty receiving and treatment ships. The success of Navy medicine is inextricably linked to a dedicated and well-trained workforce. We continue to emphasize recruiting and retaining personnel with the proper skillsets to care for sailors and Marines, particularly those with critical wartime specialties. Thank you for your support, both in resources and authorities, to help us maintain our most important asset, the Navy medicine team. In summary, we continue to make progress in our tranformation efforts. However, all of us recognize there is much hard work ahead as we continue to build an efficient and sustainable integrated system of readiness and health. Once again, thank you, and I look forward to your questions.
Thank you. Brigadier General Friedrichs.
Thank you, Chairwoman Speier, Ranking Member Kelly and distinguished members of the Military Personnel Subcommittee. On behalf of Chairman Milley it’s truly an honor and a privilege to be here this afternoon to provide the Joint Staff perspective on health system transformation and its impacts on the operational readiness of the Joint Force. As the 15th Joint Staff surgeon, I also want to thank you for the strong support you’ve continuously provided to military personnel, including to me. This support’s impacted more personnel than we can acknowledge this afternoon. But I’d like to tell ya a little bit, (clears throat) excuse me, about my father, who grew up in Southern Louisiana on a farm during the Depression. Served at the end of World War II, and through the GI Bill, received his college education. Went on to help design aircraft carriers at the Brooklyn Navy Shipyard. He inspired me. Later, he met my mother, who was born in Hungary, fought in the ’56 Revolution, was tortured by the KGB, eventually came to this country to teach, married. And the two of them taught me the value of freedom and the price that must be paid to preserve it. They’ve inspired me to become a military physician, and I’m honored to be here in that role. I also want to thank you for your continued support of the Reserve Officer Training Program, which allowed me to attend the Louisiana State University and then Tulane, and your support for the Uniformed Services University, which provided a phenomenal medical education and alllowed me to be a competent, and more than competent, surgeon in Iraq when people relied on me to care for them. And they relied on many of us to care for them, whether it was in Iraq or Afghanistan, the North Pole, the South Pole and all the other places where military service members receive care from military medics. I’m grateful for your commitment to Joint Medical Operations. I met my wife, an Army physician, in the back stairs of the old Beach Pavilion at Brooke Army Medical Center. We have a much better facility today, thanks to you, but we’ve always had great facilities in which we provided great care for our service members. As the son of a Navy service member, the husband of a former Army service member, the father of two young men who hope to serve in the Navy, I am fiercely committed to continuing to ensure we provide great care. My wife now works for the Veterans Health Administration and is a constant reminder to me of the importance not only of getting it right while people are serving, but also as Americans transition from the Department of Defense to the VA, we must continue to improve that inter-agency collaboration. As Chairman Milley recently noted, we’re in a period of great power competition within a complex and dynamic security environment. The fundamental character of war is changing rapidly, the threats are worsening, and we must evolve to meet them. And thanks to your continued help, we are doing so. You asked us in Section 732 of the 2019 National Defense Authorization Act to develop a joint medical estimate, and our office is leading that effort. We will put the initial draft in coordination next month, and plan to publish it in May. That will be an annual report in which, as other functional communities have done, we will describe requirements, gaps and the risks that those gaps create to the mission and to the force based on the National Defense Strategy, co com inputs, the inputs from the services, our inter-agency partners and our allies. After the JME is published, if helpful, it would be a privilege to return and brief you on its contents. The National Defense Strategy describes significant challenges, and the 2019 capstone concept of Joint Operations begins to describe how the department integrates those requirements across the force in order to reshape the force. In addition, we know our nation continues to face natural disasters and other events which require a whole of government response, and we continue to partner with the Department of Health and Human Services, Department of Veterans Affairs, other federal, state, regional, tribal and local stakeholders to ensure we are ready when our nation requires us to respond. But regardless of the technology employed by our warfighters, there’s always a human being in that process, and our job as military medics is to maintain that human weapon system. Our job is to ensure that human is ready to deploy and that we are there and ready to care for them when they need us. I’m grateful for your support for our mission and for our service members, grateful for the opportunity to serve as a military medic and grateful for the opportunity to answer your questions this afternoon. Thank you.
Thank you all for your testimony. Let me begin by asking the question that probably is on the minds of a lot of people. Are there going to be 18,000 billets that are going to be reduced as part of this defense-wide review? Is that a question for you, Mr. McCaffery?
Yes, I will start the initial response. The proposal that you’re referring to, in terms of the proposed reduction of around 18,000 medical billets, is something that was put forward in the president’s 2020 budget, so last year. That is distinct and separate from your reference to the defense-wide review, which is something that just started within the last three months by Secretary Esper, so the two are separate. To get to your question about the plans for the 18,000, I will let each of the military departments kinda weigh in in more specifics, but the bottom line, last year, each of the military departments determined that their current medical force exceeded the operational requirements they needed, and each military department made a decision to look at a subset of their medical billets and repurpose them for other high priorities tied to the military department’s needs in meeting national defense goals. That is the basis for the proposed reductions. I will defer to the military departments in terms of giving a little more detail, in terms of the numbers and the timing. The initial planning here is in, I think with some exceptions, in 2020, the plan would be to only make changes to vacant billets, so billets that don’t have somebody currently occupying, doing a job. And right now, our focus, working with the military departments, the Defense Health Agency, is really around what would be the scheduled reductions coming in FY ’21 and what would our plans be to implement that in a way that we maintain the capability in our system, be it through contractors, the Tricare network, hiring civilians to restore that capability that could be removed based upon the medical billet reduction.
[Jackie] All right. Do you have numbers for each of the services?
I think I will let each of the services get into their particular numbers.
Yes, ma’am. So every year in the Air Force Medical Service, we go through a process to identify what our operational medical requirement is. And that process is called the Critical Operational Readiness Requirement. And in that process, it identifies what I need in uniform to do my operational mission. Last year’s review of that indicated that I had a little over 4,000 medics that were over my uniformed requirement.
Okay, I’m gonna have to, we’re gonna have to move quickly ’cause I have a number of other question I wanna ask. Lieutenant General Dingle. So 4,000 in the Air Force, is that right?
[Dorothy] Yes, ma’am.
Ma’am, in the Army, we have 6,935 billets that we have identified for conversion. In our analysis, these do not impact any services or any risk to mission, and we continue to do analysis with the DHA and the other service to ensure that it’s not impacting the multi-service markets.
[Jackie] All right, Admiral.
Chairwoman Speier, the number for the Navy is 5,386. This was based on a careful analysis of the National Defense Strategy. But as General Dingle stated, we continue to assess this against the DHA requirement.
All right. I think we’re gonna need to have you provide us something a little more detailed. So if you would, make a point of providing us the specific specialties that you are extracting these billets from, and then we’ll go from there. We may have to do a deeper dive than that. But Ranking Member Kelly, do you have any other thoughts about that?
Just any adds that they got ’cause you know the OBGYN shortage that we talked about with our female combat (mumbles). So I see the subtractions, but would ya have any adds, we’d like to know those, too.
Okay, very good. Now, my time has expired, but I’m gonna take the privilege of asking just one more question. Mental health was an issue we heard about over and over again when we visited the various bases. That initial assessment may be made within 72 hours, but then they wait upwards of three months. Now, that’s an unacceptable length of time to wait for mental health services. So I don’t know that you could speak to that today, but I think I would like for you to be on notice that I am not confident that we are providing the level of mental health services we need. And I would like for you to each go back and look at the length of time between initial assessment and the ability to actually get the regular services. And then, the oversaturation, I think it’s a, we heard it loud and clear in Seattle, in particular, when we were there. People are, families are not able to access the services in Tricare. And there’s some speculation that Tricare is paying at a lower rate, which doesn’t make sense to me because, ostensibly, it’s linked to Medicare, and, therefore, should meet the needs. But if it’s not, that needs to be assessed, as well. And with that, I will turn it over to Ranking Member Kelly.
Thank you, Chairwoman Speier. And I’m glad you, we’re pretty much locked up on this. And I just want you guys to know that’s a lotta billets that are going away. And you talk about near peer and future threats, let me tell you what. Civilians don’t go downrange when we hit ’em downrange. It takes guys and girls in uniform to get our soldiers to the right level of care in that magic hour. And if they’re not there, we have soldiers, sailors, airmen and Marines that die. And so we need to make sure that we’re looking at each and every one. We need to scrutinize every single medical professional we can. And then going back to my point with Chairwoman Speier, we talked to female combat soldiers and there is a lack of medical professionals that are able to provide specific, whether it be medics or OB-GYNs or things that can apply specific medical procedures for women, and we need to make sure we’re addressing that. So we shouldn’t just be subtracting, we should be adding in some areas and saying, “Hey, we can get rid of these folks, “but we need more in this area.” So I ask that ya do a comprehensive review. As I mentioned in my opening statement, I’m extremely concerned about the lengthy delays for routine behavioral health appointments and the shortage of mental health professionals. The services have told us for years that low pay and complex hiring processes are to blame. What are the services and DHA doing to fix this issue? And I think if either Mr. McCaffery or Lieutenant General Place can answer this, I’ll just stick with you so I can get more questions in.
Sir, we agree with you. The challenges, some of it are within the regulations, the requirements that we have of hiring civilians into any part of our programs. Certainly in high-yield areas like mental health, it’s even more of a problem. We do have a wide range of incentives and bonus pays that we apply to them. In some areas, they’re relatively effective, in other areas, they’re just not. The reality is across the systems, I can give you examples. I prefer not to, but rural America in particular, it’s very difficult to find these sorts of things, irrespective of the incentives that we put against it. So for a worldwide organization, that’s the challenge that we face.
We’ve heard from several families in veterans service organizations that increased copays for specialty care visits, like care for autism, have made this care unaffordable for many military families. In a recent report to Congress, DOD stated that approximately 1/4 of military beneficiaries with household incomes below 50,000 reported postponing primary care sometimes, often or usually. This is unacceptable. What has the department done to fix this?
I’m not aware that, you mentioned with regard to increasing cost shares for certain services, that that has been identified as a barrier in terms of seeking primary care appointments, other appointments. I know one of the things that we have done at DHA last year, we’re continuing to look at it, is, indeed, have there been a difference in terms of utilization of services based upon some of the increased co-shares? I don’t believe we have finished that analysis, but that would, I think, inform what would be the next steps to—
And I won’t interrupt you, but you guys always have an answer on the record. That is definitely, that is exactly and specifically. And if you need me to give you the question again after so we can get specific replies, but we can’t afford. Our families of our soldiers and our soldiers or our airmen or our sailors are the most important things that we have, and we’ve gotta make sure that we don’t put any impediments to primary care for those folks. And for Mr. McCaffery or Lieutenant General Place, I wanna ask you about MTF realignment process. Can you explain what you’re doing to ensure the civilian healthcare network can absorb the patients that would be displaced from the MTFs? Because I know in as early as 2017, I was in Italy and we were talking about shutting down in Naples, where there was no primary care available on the local economy. So tell me how you’re gonna address that, please.
So what you’re referring to is, as you mentioned in your opening statement, one of the things that Congress directed the department to do in NDA 2017 was, for lack of a better word, was they asked us to optimize our direct-care system. And what I mean by that is to look back and say the essential purpose of our medical treatment facilities is to serve as training platforms for our providers and to provide access to care to active duty so that they can do their jobs. And so the ask was looking at a particular MTF and the services, the capabilities they have, how does it tie to that? How does it tie to supporting that mission? And part of that is there may be areas where there is no civilian network, and so ya need to have an MTF there. But there may be places, not everywhere, but there may be places where the civilian network is robust. We can provide care to non-active duty at less cost. And that helps optimize the use of that MTF.
We’re over time, Mr. McCaffery, but I do wanna make one final point. We were just at Joint Base Lewis-McChord, and we’ve oversaturated that, based on civilian capability that was there. And so we’ve sent all our people with problems, with the identical problems there because they had it, and now we’ve oversaturated the civilian market. We have to pay attention to second and third-order effect. And then I have to yield back, Chairwoman.
Thank you. Congresswoman Davis.
Thank you. Thank you, Madam Chair and thank you to all of you for being here, for your dedication. We know this is really complex. When any large organization tries to integrate in a different way, it’s gonna be very difficult. But I wonder if you could, for a moment. I think, actually, Mr. McCaffery, you sort of just summed up, I think, what the goals, what the expectations were, to a certain extent, but what I’m hearing, and I think what we’re concerned about, is that perhaps the push for cost savings is, could overshadow not just efficiencies, but services to beneficiaries. And my understanding is that there’s some difference in the way the different services see this. And could you talk, maybe just going down the line a little bit, was there a difference in what we were, you were trying to accomplish through this? And how are, what were those differences expressed?
Sure. And Congresswoman Davis, I appreciate your opening statement about this being hard. My background is in private sector and public sector healthcare. And what we’ve talked about, in terms of this MTF transition, is really, in essence, like a merger, a merger of separate healthcare systems. It is a big, heavy lift. And anyone that would think, whether it’s the military or any other organization, that wouldn’t have challenges, wouldn’t have contention about that change, they’re not speaking realistically. Have we had those? Yes, we have. But that being said, I believe we are in an excellent spot in terms of how we manage this. We’ve already started it. A year ago, we moved 31 facilities under the DHA, and as you heard from the panel, we are actually working in direct support relationship with each of the military departments to manage this transition in a way that we don’t let it affect our active duty or our beneficiaries. Number two, the issue you mentioned about is this about cost savings or efficiency, I’d say it’s about effectiveness. I think Congress recognized in 2017 that we could be more effective as a military medical enterprise if we didn’t have four separate systems, but we had a consolidated system that could respond to the mission requirements as an enterprise, that we could have more standardization across the system not just for our beneficiaries and their experience of care, but most importantly for how it affects operational missions. Meaning the fact that you could have the same equipment or devices that our uniformed providers are using in the MTFs are the same ones they’re using downrange. So this is, to me, more about effectiveness, of making the Military Health System even more successful in meeting the mission, as opposed to. Do I think there’s gonna be savings out of it? Yes. I think you get that out of that consolidation and standardization. But the focus is on effectiveness.
Mm-hm. If anybody else wants to comment on that. I think the difficult thing is what we’re dealing with people, (laughs) right? Employees who have to sort of work through what this is gonna mean to them. And so I’m wondering a little bit, too, about how you’re messaging for them because if you’re losing that many billets, that’s having an effect on people. And I think it does translate into beneficiary services. And I know, as well, I mean, having served on the Mil Pers committee at the height of our wars, I mean, from 2001 until today, there were so many families that were ready to walk because, initially, they were not getting the support that they needed. And so talk a little bit more about, I mean, what comes together is that there are needs that are difficult and difficult to work through in a very short period of time. What is it today that you would like to share with us that’s going to get this job done perhaps a little faster?
To get the transition done faster?
Well, I think to help with the transition, while at the same time respecting the men and women not just who serve, but all the people who are part of this system. How are they gonna be part of it?
So right now, General Place and each of the surgeons general are actively part of this transition of moving administration of the MTFs to DHA is about, well, how do we make sure that that knowledge and the resources that are now in the services get moved over to the DHA? And we’re talking about people. It’s easier for us to move uniformed people around, but the civilians are different. And so what we’re doing is we are working together to, as much as possible, allow a clean transfer of folks doing certain responsibilities in the service medical headquarters, bring them over to DHA. And where we’re not being able to do that, look at different tools that we can do management directive transfers so that we ensure not only the DHA get that people resource that we need, but that’s also the same time ensuring that those employees that are doing that mission continue to do that mission, but under a different management.
Yeah, I appreciate that. My time is up. I’m gonna turn it back to the chairwoman, but I, just sort of hearing from all of you, as well, and in terms of, like, so what do you have to do to make sure that that happens, and we’re not just saying we’re gonna do it, but we’re gonna act on what we say?
Thank you. Dr. Abraham.
Thank you, Madam Chair. Dr. Friedrichs, I listened to your resume and I know where you went to medical school. And I know in your heart of hearts, you do understand that LSU will be the national champion this year.
Absolutely, sir. I strongly endorse that.
On a sad note, we were discussing with you, ladies and gentlemen, that our veterans are being moved to the civilian population. And I still practice pro bono in a medical practice. That certainly takes those wonderful people. But we still have problems with Tricare West and others not being accepted in the civilian. I’ve taken this up with with the Veterans Affairs Committee, where, of course, jurisdiction lies. But you need to be aware that when we move these veterans from an active military situation to a civilian situation, it becomes problematic that if that particular insurance is not taken by civilians, those patients, those veterans are denied, unfortunately, care in some places. We, of course, take ’em regardless, but some practices can’t afford to do that. And toward General Kelly’s point, there is a barrier, Mr. Secretary, when that copayment is higher for certain specialties. As to those families that may not can afford if it goes from 10 to 25 to 50, whatever. So that is something that we have to continue to address. My question, and I’ll start with all the surgeon generals here, just please explain any inefficiencies or structural difficulties that you have with DHA at this time. And General Place, I’ll start with you, sir.
I don’t think there’s any structural problems with DHA. I see a collaborative process that enables us to come together to have overlap. Now, one of the problems with overlap, overlap takes more time. And it’s crucial to not have gaps and drop a solider, drop a family member, drop a retiree. So to Miss Davis’ point before, ma’am, I get that we wanna go fast, but not at the expense of one of our service members or their family. So that’s, if anything, I see that as the problem. That is the challenge, is the timeliness of, but it’s based on not wanting to drop anyone through the system. I think we’re set up well.
[Ralph] Yeah, General Hogg.
Yes, sir. So I believe we are working well together in trying to address some of the difficulties. This is hard.
I understand.
It’s very challenging to bring all us together at one time. And we are working well together. I would articulate that, I like to say I would like to transition before I transform. So let’s get the Defense Health Agency on its feet with 702 to where they can truly take over authority, direction and control of the military treatment facilities. And then we can start finding those efficiencies that I know we can find. But if we try to do both at the same time, I do have concern that we might miss some very important things.
[Ralph] General Dingle.
And I would echo the same comment. I believe that it has to be focused and deliberate. That we must focus on the medical treatment facilities transferring and the electronic health record, get that correct before we do anything else, and that’s my decision.
The EHRs are problematic, as we know. That’s why about 1/2 of the gray hair I have on my head is there now, dealing with that. Admiral.
Yes, Congressman. I would say as the new kid on the block, having been in this position for about five weeks, I’m incredibly impressed by the collaboration that exists with my partners. I would say in terms of the structure, I think the establishment of the direct support agreements has been a very important step to ease that transition, rather than just a complete turn the switch in October. So I would say that continuing that work, but having a clear roadmap for hand-off of those functions is a critical step going forward.
[Ralph] General.
Thank you, sir, and I would echo that from the Joint Staff perspective, one of the great strengths of DHA has been how they have helped us to better collaborate in the combat support arena, things like the Joint Trauma System. We recently hosted a meeting with the combatant command surgeons in which they highlighted the significant progress that we’ve made in what was already a world-class Joint Trauma System, making it even better as we continue to work more closely together. So I think there’s great progress. Obviously, much more work to be done. There will always be opportunities for improvement.
Well, I’m glad to hear the cohesion. Madam Chair, I just request that we enter into the record this article on Military Times, the military needs for a unified command. And that’s from Brad—
[Jackie] No objection.
Thank you. I yield back, I’m out of time.
General Friedrichs, one of the articles that our good friend Dr. Wenstrup had brought to our attention that was put out by the U.S. News & World Report spoke about how surgeons in the military are not getting the kind of experience that they should be getting in order to be more proficient. That they’re getting about 20% of what a surgeon in civilian workforce would be getting, in terms of the number of cases they handle a year. And you just spoke about the trauma care issue. So I’m curious how we’re going to address the fact that they are lacking in the opportunities to handle enough surgeries and be prepared, then, in terms of readiness when they’re out on—
So thank you, ma’am. And I would say from the Joint Staff perspective, we define the requirement, we describe what the combatant command requirements are, and rely on the services and the Defense Health Agency to organize, train and equip to meet that requirement. I believe as a surgeon that the article captured a number of points on which we’re already working. One of our responsibilities in the Joint Staff is joint capability development. And we’ve been working on improving through the Joint Trauma System a number of areas, whether it’s expanding opportunities for currency or expanding equipment, improving equipment availability, for several years now. Those articles capture very valid concerns that are expressed by some surgeons. I can tell you, I was in San Antonio two weeks ago at the Committee on Trauma, which is the assemblage of our senior leaders. And I heard a much more optimistic story of progress being made across the services. And so I would respectfully ask if my colleagues from the services could also talk about what they’re doing on that.
All right, I wanna give Congresswoman Trahan her opportunity first. We’ll come back to this issue, thank you.
Thank you. Thank you, Madam Chairwoman. I’m gonna switch gears. I’m not sure this is going to really fall with the five minutes, but I’m going to give it a shot, given that I’ve got so many surgeon generals and military healthcare professionals in front of me. I wanted to talk about suicide for our active duty members. Data shows that there are approximately 60% of military personnel who are experiencing mental health problems, and they’re not seeking help. And when I reviewed the medical standards for appointment, enlistment and induction, it precludes things like sleep disorders, ADHD, depressive disorder, anxiety disorders, so I don’t think it’s any surprise that there are studies that suggest that many are skirting the rules to enlist. And I’m wondering can you briefly touch upon maybe the cognitive assessments taken on service members as they join? And also, what is preventing service men and women to self-report potential risk factors, like sleeplessness and depression?
[Jackie] It’s not a good sign that none of you are responding here.
The reason is just in terms of some of the questions that you’re asking with regard to military department processes, in terms of accession, standards. I think one of the surgeons would be most able to kind of respond to some of those specifics.
Okay, I’ll start. Yes, ma’am, it definitely is a very important aspect. So at the point of accessions, behavior health screening, physical screenings are very important, and you are absolutely correct that we can improve it to make sure that we’re not missing it and then taking it on when they come on to active duty. In reference to why are they not reporting, it has been a challenge in removing the stigma. It is improve imperative that we educate and that we change the climate and cultures of commands and organizations so that soldiers, sailors and airmen are not afraid to report because of retribution or impact on their career. And so that is the bottom line why service members do not report. They do not want it to impact their careers. However, one of the greatest things that I saw at the DOD VA Suicide Prevention Conference this summer was that we have to move to prevention, getting ahead of the act, by changing the culture. And we change that culture by removing the stigma and education and the holistic approach from the command itself.
Yes, ma’am. So in the Air Force, we’re actually seeing an increase in people coming to mental health because of the outreach that we’re doing. We’re embedding our mental health into units where they can build a relationship with those providers and they feel more comfortable coming in to get care. The other thing that we’re doing is we are, a lot of this is really giving people the capability to handle stress without crisis. And so in our basic training military capacity, we are actually providing classes to our new recruits in how to handle stress and what are the ways to seek care if needed and reach out and touch people.
[Lori] Mm-hm.
And Congresswoman Trahan, I would just say from the Navy perspective, we very much endorse embedding mental health personnel at the deckplate and in stressful training commands. So 1/4 of our mental health professionals are actually in the operational force. And so we have seen a commensurate increase in access, and decrease in stigma. The other benefit is that those mental health professionals do tremendous training for the senior officers in those, for example, submarine squadrons, so that they’re extenders, in terms of identifying those at risk. And similar to the Air Force, we are piloting teaching meditation to new recruits at bootcamp as a way to help deal with stressful situations.
Congresswoman, was your question actually answered? I thought what you were asking was when recruits are reluctant to identify these conditions, how are you able to assess that as they are going through the training process? Is that what your question was?
Yeah. So, one, I think it’s great to sort of diagnose and help embed and to treat people who are suffering from mental illness. And culture is, some organizations do it better than others when it’s time to change culture. My question is, I mean, certainly we’ve got generations of young people who are taking medication to prevent sleep disorder, to prevent ADHD. They’re working. Is there any discussion around? My fear is that people are going off their medication when they enlist because that’s a requirement. And that can cause great mental, that can, obviously, cause harm and mental disorders to flare up in non-traumatic situations, even. So I’m wondering if there’s been any discussion around revisiting some of these protocols, or if there’s been any sort of study or discussion around that being a root cause for some of the mental health problems and suicide rates that we’re seeing in our non-deployed activity duty service men and women?
So not to my knowledge, but is certainly something that we can take back and take a view and see if we have something that we can improve upon.
You know, Miss Trahan, I think that you’ve touched on an issue that probably deserves having a briefing on because there is an ability for people to be very functional on drugs to combat ADHD.
[Lori] Yeah.
And yet, I’m sure that if that was identified in an application before a recruiter, that person would be declined the opportunity to serve. So maybe we need to just have a generalized discussion on whether or not the basis on which individuals are allowed to enlist meets the medical technology and advancements we’ve made relative to drugs and other things.
[Lori] I would love to attend that hearing. Thank you, Madam Chairwoman.
Thank you. Congressman Bacon.
Thank you, Madam Chair. I wanna thank all the witnesses for being here tody and for your commitment to the health, the readiness of America’s most important weapons system. That’s our warriors and their families. I’d like to focus for a moment on a medical readiness challenge that concerns me, and perhaps an opportunity, as well. And most Americans would be surprised to learn that in World War I, more soldiers actually died due to disease than to enemy action, largely as a result of the 1918 influenza epidemic, or pandemic. Today we know that our enemies are relentlessly pursuing ways to kill Americans in large numbers. We also know that naturally occurring infectious diseases in our increasingly interconnected world have the ability to spread faster than ever. The risk to infectious diseases is significant and growing, not only for our general population, but also for our defenders in the Armed Forces and our first responders. So as these threats grow, I’m concerned that our capacity to prepare, detect and respond with specialized care for chemical, radiological, biological and infectious disease is far less than we need, and may actually be declining. So my question is to General Friedrichs, and if we have time, we’ll come back to others, but my question to you, General Friedrichs, is as you contemplate the 21st-century force health protection threats facing our military and the shrinking of our uniformed medical service, how do we better position the military and our civilian health systems to work together to address this mission?
Sir, thank you very much, and I would offer several observations. First, absolutely agree with your points about the rapidly evolving threats. There’s no question that the threats that we faced in previous conflicts are not the threats we will face in the future, and we must continue to evolve our detection capability, our attribution capability, our ability to prevent the effects of those agents that are being used, and then to treat those once they’re exposed. All of that is work that must continue, and it will require a robust whole of government cooperation, partnering across the Department of Health and Human Services, the Department of Homeland Security and the Department of Defense. But more importantly, we’re grateful that we have partners at the state level who have recognized these threats and have joined in those partnerships to develop new capabilities. That sort of partnership is imperative because the threat is not just somewhere else. It’s not just in another continent. It can just as easily happen here. It can be a pandemic that occurs on our own soil or an attack on our own soil. To your specific comment about the capabilities that we need, as these threats evolve, we must develop new detection capabilities, we must develop new training capabilities for our medics, we must develop the ability to have better treatments that allow us to function wherever that new agent is used as we go forward. And that’s important work which is gonna require partnership, as I said, across the whole of government and with key state partners. Thank you, sir.
So, look, we have facilities in Omaha, like the University of Nebraska Medical Center, that is the world’s center of excellence for Ebola, as an example. So let me just follow up and ask ya, how do you take advantage of civilian centers of medical excellence, like UNMC, in developing solutions? Do you see a role for more creative public/private partnerships, like we now are doing in communities like Omaha with the new VA Medical Center? So I appreciate your insights on that.
Sir, first, thank you for the question, and more importantly, thank you for the community support across the state of Nebraska. That was not just an Omaha initiative, that was a statewide initiative that, in many respects, is a model public/private partnership. The work that has occurred across the agencies in order to work with the Nebraska community does set a model that we can use in the future going forward because this is not solely a military problem. We are part of our nation’s response, but we cannot be the only response. It begins with local capabilities, local leaders who recognize the threat, and then partner with state and federal experts to develop those capabilities that we can use, whether it’s a local event or a national event or, unfortunately, as may occur in the future, an international event. I think that the capability that’s been developed for Ebola, the partnership for the VA hospital, some of the cutting-edge research that’s being done there at Nebraska is exactly the sort of work and collaboration that we need to move forward in the future.
Thank you, and, Madam Chair, I see an opportunity for public/private partnerships working together for the whole country and beyond just the military. I have a follow-up for General Hogg, if I may. Don Bacon’s gonna ask our question here. We’ve been working off and on together for a long time. So have we already had cuts made at the bases at the medical centers? Have those cuts already occurred?
No, sir, they have not.
‘Cause I’ve been getting more and more reports from concerned constituents, retirees, primarily, that feel like they’re being pushed out, made to go to the VA and not allowed to do the Tricare. So these phone calls I’m getting are not related to the proposal that’s going on here? Is that what I’m hearing?
Right, yes.
Okay, thank you.
All right, we’re gonna do a second round for those that are interested in staying to ask more questions. I’d like to go back to that question that I asked about surgeons and their ability to have enough experience with cases and what we’re doing to try and. If, in fact, the average surgeon has 500 cases a year, and the average surgeon in the military has only 20% of that, that’s a real vacuum, I think. So let’s start with you, Lieutenant General Hogg.
Yes, ma’am. In the Air Force, we have, for a long time, had what we call training affiliation agreements where we send out our medics to civilian or other federal institutions to get those touches, the what I like to call volume, acuity and diversity of cases because we know in our direct-case system, we won’t have that. And so for a long time, we have been sending our specialized medics, trauma surgeons, orthopedic surgeons, nurses, out into civilian facilities to get that. Nellis is a good, UMC is a good example of that, Baltimore Shock Trauma is a good example of that, and many others. We are also now having some success in getting our enlisted medics into those treatment facilities in order to have the touches that they need. One of the difficulties that we have is gathering the data on exactly how—
All right, so I’d like to get to the other services. Could you just provide that data to us? Because, in part, General Friedrichs, I think what I would like to see is a response to those articles, as to where we are falling short and where we have actually made some advances. General Dingle.
And, ma’am, we are coming on the critical point because what we’ve also done as a collective joint workgroup, we’ve identified what’s called those knowledge skills and attributes that are required for surgical proficiency. And not just surgical proficiency, but all of our specialties across the militaries. Within the Army, we then build on top of that with what we call ICTLs, individual critical task lists. So for that trauma surgeon, how many procedures do you need, as you mentioned? And then we, for the first time in our history, are tracking and documenting those as it goes towards readiness. And we’ll continue to build upon those internally with the—
So you recognize that there is-
Yes, ma’am.
An issue and you’re attempting—
Yes, ma’am.
To address it. Admiral.
Chairwoman Speier, I would agree. Yes, we do. We are approaching this in two different directions. Internally, within the direct-care system, you may be aware that Naval Medical Center Camp Lejeune was designated a trauma center, and we’re seeing tremendous value, both within Lejeune and also to the local community. And then externally, we also have existing partnerships, which also include our corpsmen, which we all recognize at the tip of the spear are some of the most important part of the trauma response.
Okay, thank you. What we have seen since the budget year 2015 is an actual reduction in the cost of providing military health by about at least a billion dollars. So I guess to you, Mr. McCaffery, where is that money going?
So is the question with regard to change from fiscal year ’19 to what the president’s budget proposed for ’20 or?
No, I think the staff has looked back at the Defense Health Program spending since 2015. And the program has had a decrease in funding, and it appears that it’s costing less money and that the savings, whether it’s a billion or three billion, we’ve seen different figures, there’s a savings of about a billion to three billion. And I wanna know where that money is going.
So in some of the data I’m looking at right now, and I’m looking at the Defense Health Program appropriation, so that is what is funding our direct-care system, the purchase care system, some of the R and D, what I am looking at for FY 2015 shows that DHP plus military construction for health facilities is about 33 billion. It dipped a little bit in ’16. 33 billion in ’17. 34 in 2018. And just under 35 in 2019. So I’m not sure if we’re looking at different numbers or?
[Jackie] Why don’t you respond? We’ll have our resident expert.
Mr. McCaffery, we’re actually, the question is really the unified medical budget, the DHP.
Okay. So I’m looking at that now for the same figure. The unified medical budget, in ’15, I have 48 billion. It then dipped a little under 48 billion. Then 49 billion in FY 2017, and 50 billion in 2018. And a little over 50 billion at least enacted for FY ’19. So, now, I know in the FY ’20 proposed budget, the president’s proposed budget has it down at 49 billion, but my understanding, and I could be wrong, is every year, Congress adds in roughly a billion, between, I think, 800 million and a billion in additional R and D dollars. That’s not in the base budget proposal in the president’s budget. And so that probably is one explanation for a delta between what was actually enacted in FY ’19 versus what the president proposed in ’20. But we can, I can go back and double check and confirm that.
So the question becomes if it’s basically stagnant, is that actually savings? ‘Cause we’re not seeing the cost of living increase. I don’t wanna take any more time. Maybe we can have a subsequent conversation on that. Ranking Member Kelly.
Thank you, Chairwoman Speier. And just real quick, and I think you answered this, Admiral Gillingham, but the embeds you were talking about on behavioral health, you’re also doing that with your corpsmen with the Marines that are forward, is that correct?
Yes, sir, that is across—
Okay, very good. I’m satisfied with your answer. I just wanna make sure we’re taking care of our Marines.
[Bruce] Yes, sir.
And then, Lieutenant General Dingle, I didn’t hear the Army talk about embeds at all. And I would argue that the people who are the hardest and need that the most are the Army and the Marine Corps, based on the duties and the unit types that they have. So what are we doing?
Mr. Kelly, you are spot on. We did embeds many years ago, and we continue to champion that as part of our behavioral health system of care. Embeds are a very important part of our brigade combat teams forward.
So we are doing that?
[Scott] Absolutely, yes, sir.
But is there a shortage there of behavioral health because my experience in the Army, and especially in the Guard and Reserve, is that there is an extreme shortage of professional behavioral health specialists that are in the Army units that are filling those MTO slots. We got the slots, but we don’t have the docs.
What we’re doing, again, improving the recruitment to try to get those specialties in there. In addition to that, within the Army, we did a bottom-up review where we looked at the mental health requirement and identified even more. So as we’re looking at H2F, Holistic Health and Fitness, it’s from a mental health perspective, as well as a physical therapist and occupational therapist, also, augmenting our brigade combat teams and our divisions forward.
Have you been down to Bragg lately and seen what they’re doing down there with our special operators at Bragg, as far as psychological health and just total package?
[Scott] Yes, sir.
We need to do that across the services ’cause that’s all services, and we need to figure out how we can do that better across the entire services. And I’m sure you’ve been down there, too, General, but I just wanna make sure that we’re doing that. Second, real quickly, what authorities do you guys need to help you assess behavioral health experts? ‘Cause we’ve asked you, and you guys need to give us what authorities or what things do you need in order to get this to where we need to be. For accessions of behavioral health specialists.
Right. I don’t believe there’s authorities, in terms of statute or policy direction. I believe that you’ve kind of heard a common theme from everybody, and it’s also common in the private sector, is resources, resources to be able to hire. And even if you have resources, there are gonna be certain areas that you’re gonna have a hard time recruiting, even if you can pay them, recruiting mental health providers. But I would say it’s probably more around resources and what else we can do to entice folks to join and provide that services.
[Jackie] Will the gentleman yield?
[Trent] Yes.
When you say mental health providers, I mean, are we also talking about marriage and family counselors? I mean, we’re talking about the whole gamut, it’s not just psychiatrists and psychologists?
Correct, correct. And I can’t speak to kinda each service in particular, but I know in certain classification of mental health providers, we are pretty good. I think it’s hit and miss based upon the classification of provider.
And then the final thing I want all you guys to look at is we are a total force, but docs can make a lot more money on the civilian world than they can in the Army, Navy, Air Force, okay? I mean, there’s a lot more money to be made. It’s kinda like being in Congress. There’s a lot better ways to make money than to do this job, okay? So you guys do it because you love it. But there’s an opportunity out there in our Guard and Reserves for the Air Force and Navy and Army, there’s an opportunity ’cause these guys wanna serve. I mean, the reason people are doctors is ’cause they wanna help people. It’s not about money, okay? But there’s a point where they have other obligations. So let’s make sure that each of our services are looking at our Reserves and our National Guards, and saying, “Do we pay ’em better?” How do we get them in the rotation so that they fill behavioral health specialties? Maybe we have those seeing soldiers or airmen at Joint Base Lewis-McChord on the weekends, or maybe they do their two-week AT there and we schedule ’em in. So as a whole, as an Air Force or as an Army or as a DHA, how are we integrating especially behavioral health specialists into the Guard? I mean, into the total force so that we’re using that to our benefit? And maybe we need to pay them a little more. Maybe we need to make their incentives a little better so that when a guy comes off active duty, or a doctor who wants to serve, man, everybody likes to wear a uniform. ‘Cause, I mean, they do. I mean, ’cause it’s the same thing that makes people wanna be doctors that make ’em wanna be soldiers. They wanna serve. So how do we get those guys so they can serve in a capacity and help our total force? And with that, Chairwoman, I yield back.
[Jackie] Thank you. Congresswoman Davis.
Thank you. Again, I think what I know I’m hearing and what I really wanted to ask you about, as well, is was what’s the strategy, what’s the plan? How do we make certain that as we move further into Tricare for our beneficiaries that there’s some, (laughs) there’s a there there for them, and they’re not going to lose in of the benefits that they’ve already had? I know that it’s a great source of anxiety for our families. And certainly, and when we go on a full op tempo and deployment, all the pediatricians go to war, right? So we don’t have them. And it’s important that we figure that out. So for mental health, I mean, one of the questions that I was interested in is we talked a lot, while a number of our troops and our corpsmen were coming home from the war, some of them had developed a real aptitude for being able to help one another in the mental health field. And I hope, and, again, part of this really thinking ahead about it is how do we make sure and identify those people, and I think the ranking chair mentioned this, that are coming out of the service, that, perhaps at another time, they woulda never thought about going into the behavioral health field, but they are now? We talked a lot about social workers a number of years ago. How does the military identify those people who, with proper training and with loan forgiveness, that they can do that? And so I’m hoping that perhaps we think a little bit more about the future because there’s no way in the world that we’re gonna be able to rely on the civilian world to satisfy the needs that we’re gonna have. And the other thing is, just quickly, finding a better way, and we have some wonderful folks in San Diego that have really looked into this because of a family suicide, how do we, within our system of privacy, HIPAA, whatever, make certain that families can be more involved in the mental healths of their loved ones? It’s a deep, dark secret sometimes that somebody needs help, and it shouldn’t be that way. As a parent, you feel like I wanna be a partner here, but I don’t know how. And there’s some men and women in the services who are not gonna call their families and tell ’em they’re struggling, but maybe there’s a better way of doing that. And I know the VA’s been working on that. So thinking about how do we do a better job. That certainly our spouses, and I remember talking to so many spouses about this. Yeah, they were afraid to share the fact that their husbands were screaming in the night because they were afraid that they would be kicked out of the service. And they need to be involved, as well. And certainly having good practitioners to help them out, as well. So I hope that all those issues will be looked at. And we were talking about that, the issue that I think, Admiral Gillingham, you would be aware, too, in San Diego, we really did not have the patients for our (laughs) surgeons to be able to help there. And so they go to L.A. County Hospital. That’s where they go for their gunshot wounds, honestly. And that’s what we have to do sometimes in partnering. But just as it’s been difficult for you all to work together (laughs) to have this change, it’s not so easy for them, as well, although our military has often been trained in the civilian world, and back and forth, and we train them very well. But, sorry. I think my time is almost up? Maybe you gave me more time.
[Jackie] You have another minute. (group laughs) You can actually have them answer you.
Yes, please, please. So is there that kind of planning, that we’re really looking at all the parameters possible to be able to serve our men and women?
So let me start with one of the first questions you asked in terms of where does the Tricare program, where does our partnership with the civilian sector fit into where we’re going in terms of reforming the whole system because that is a key, it’s a linchpin. And even though the current Tricare contract is only, well, a little less than two years onboard, we are already starting the effort in terms of the next generation, the next procurement, because just for what you said. It has to be critical to support the change in the system. So if we’re gonna be consolidating all of our MTFs under one management, under the same roof that manages the Tricare program, we need to make sure that we have that, that we are requiring more from our contractors, both to make sure we get the, what I would call the readiness-related caseload we need into our system, for all the reasons we’ve talked about, in terms of keeping our surgeons, our providers current. So we need to be able to do more of that. We need to make sure that we do have the adequate networks to support our families and our beneficiaries if, when, indeed, we are making changes to the system, and we realign services in certain areas in terms of what MTFs are providing, we need to make sure that we have that partnership with those contractors to make sure that the capability doesn’t go away. You may not get something from a uninformed provider, but we have to make sure you get it from a provider. So I think those are some key things that we are looking at, as to how, what we need to do to support this, the reform, going forward.
Yeah, and looking at increased pay, obviously, is gonna be an issue.
[Jackie] All right, Dr. Abraham.
General Friedrichs, educate me, sir, please. You said Lejeune has been designated a trauma center. Oh, I’m sorry, Admiral. Is that true? Is it a level I?
Level III, sir.
[Ralph] Okay, a level III.
But there are aspirations for a level II.
[Ralph] Okay, and so you are seeing civilians in that capacity?
Yes, sir, that’s correct.
[Ralph] You’ve worked out getting the ambulance through the gate, insurance, all that stuff? Okay.
Yes, sir.
So the reason I ask is I know that the Armed Services surgeons are not getting enough cases, or as many as they desire. And I know that in some cases, you’re meeting some headwinds from the civilian docs taking their cases. And so we understand the dynamics there of there is just a set number of trauma patients, and everybody wants to have their gloves on and hands in fixing that patient. So I think it’s a wonderful concept, of designating as many camps as we can as trauma centers so we can get that expertise that you people need with your doctors in play, so it’s a good concept. Mr. Secretary, just one question for you. Do you see value in placing the DHA under a unified operational command?
I mean, I think one of the things that Congress has asked us to do, and we’re in the kind of final stages, was actually to look at is it feasible to morph DHA into a unified health command, a defense health command? And we are putting together what we think could be feasible options. The key thing is what would we wanna get out of that? I mean, it could be, is it because we wanna have more clear command authority over all medical forces across the services? Is it efficiency? And that’s the thing that I think ya have to determine first before you can assess whether that’s the right direction. But the one thing I think there’s unanimity within the department is we don’t believe this is the time for us to go down that path, only in that you’ve heard us all talk about the enormous change we’ve already launched. And our feeling is it’s better to see how does DHA function with their new responsibilities before we were to talk about would you convert that or change the Defense Health Agency into an even larger command across the departments. So we do think it’s worthwhile looking at, but we wanna revisit that in probably the next three to four years, once we have some more stability in the system.
[Ralph] Okay, thank you. Madam Chair, I yield back.
Thank you.
I think it was you, Lieutenant General Hogg, who said. Is it Hoag or Hogg? I’m sorry, Hogg. Who said that it’s really important for us to bring all of these services together under one roof before we start moving forward on some of these other aspects. I’m presuming you mean these billets, as well. Is that correct? Or is that something that you’re going to implement while this process is going on?
So the billets are from the Air Force, higher Air Force level, right? And the plan right now is while they’re there, we will not reduce the faces until the system can handle the workload.
All right. And how about you, General Dingle?
Yes, ma’am. We, likewise, the billets have been identified and we are coming together, working with the DHA, to see impacts of billets. However, we also have a large number of unfilled billets that we are looking at this fiscal year.
Well, are you going to hold off reducing the billets, or are you going to reduce the billets, is what I’m asking.
Our unfilled billets, ma’am, have already been converted over. There will be no further reductions until we do the complete analysis with the DHA.
But what happens if those billets are mental health professionals? I mean, one of the issues that we’ve talked about a lot today is the fact that we need more mental health providers. So arbitrarily, if you’re just going to not fill these unfilled billets, don’t you have to make an assessment as to whether or not they’re important to be filled?
Yes, ma’am. And one thing, a little more details, as we have done conversion of billets, some of the billets we have converted are, in fact, those towards Holistic Health and Fitness, mental health providers, but on the operational force side of the house. The empty billets that are in the MTF side of the house, again, are unfilled. And as we move them to the operational force, we have done bottoms-up review in which we have, in fact, identified more medical requirements for our operational force that we will move to recruit to fill those billets in.
All right. Admiral.
Yes, ma’am. For the Navy, the faces remain in the billets, and looking very carefully at the impact on DHA. I will say, to your point about mental health, very few of the planned reductions were in mental health billets.
All right.
[Trent] Would the gentlewoman—
Of course.
I just wanna make sure. I get the unfilled billets, but from a lotta years of experience, the unfilled billets are generally the low-density, hard to get billets. And I just wanna make sure that those aren’t the behavioral health and the OB-GYNs and all the areas we have difficulty getting enough people, that we’re not, just because those billets aren’t full, that those are the slots where the people that we’re going, so we’re not going out and recruiting those, if that makes sense. We’ve gotta make sure that we’re not, just because we don’t have a filled billet with a behavioral health specialist, that we don’t do away with that slot. We gotta fill that slot. We gotta do away with another slot when it goes away. And I yield back.
Let me also make note of the fact that when we were visiting the bases, it was astonishing to both of us that there was such a high incidence of autism among the families of service members, many of whom were officers, as well. In the military system and the health system to provide the services to these families. And finally, there’s a lotta talk today about effectiveness and readiness and efficiency. And what was left out of all of those terms is the fact that it’s not just for that. The families are a huge component of the healthcare system within the military. And if we don’t have a robust system that provides the services, I think we’re gonna have a problem with retention. And so it’s really important that we have the quality of healthcare that each of these families deserves. And if we’re falling short there, we’re falling short in many other areas, as well. So with that, if there’s not any further comments to be made, thank you very much for your service and for your participation here tonight. And we stand adjourned. (gavel banging) I guess it is night, isn’t it?