[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]


                                     

                         [H.A.S.C. No. 110-69]
 
   FINDINGS OF THE DEPARTMENT OF DEFENSE TASK FORCE ON MENTAL HEALTH

                               __________

                                HEARING

                               BEFORE THE

                    MILITARY PERSONNEL SUBCOMMITTEE

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                              HEARING HELD

                             JULY 12, 2007

                                     
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                    MILITARY PERSONNEL SUBCOMMITTEE

                 SUSAN A. DAVIS, California, Chairwoman
VIC SNYDER, Arkansas                 JOHN M. McHUGH, New York
LORETTA SANCHEZ, California          JOHN KLINE, Minnesota
NANCY BOYDA, Kansas                  THELMA DRAKE, Virginia
PATRICK J. MURPHY, Pennsylvania      WALTER B. JONES, North Carolina
CAROL SHEA-PORTER, New Hampshire     JOE WILSON, South Carolina
                David Kildee, Professional Staff Member
               Jeanette James, Professional Staff Member
                      Joe Hicken, Staff Assistant
















                            C O N T E N T S

                              ----------                              

                     CHRONOLOGICAL LIST OF HEARINGS
                                  2007

                                                                   Page

Hearing:

Thursday, July 12, 2007, Findings of the Department of Defense 
  Task Force on Mental Health....................................     1

Appendix:

Thursday, July 12, 2007..........................................    31
                              ----------                              

                        THURSDAY, JULY 12, 2007
   FINDINGS OF THE DEPARTMENT OF DEFENSE TASK FORCE ON MENTAL HEALTH
              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Davis, Hon. Susan A., a Representative from California, 
  Chairwoman, Military Personnel Subcommittee....................     1
McHugh, Hon. John M., a Representative from New York, Ranking 
  Member, Military Personnel Subcommittee........................     2

                               WITNESSES

Arthur, Vice Adm. Donald C., Co-Chair, Defense Health Board Task 
  Force on Mental Health, Surgeon General of the Navy, U.S. Navy.     3
Casscells, Hon. S. Ward, M.D., Assistant Secretary of Defense for 
  Health Affairs.................................................     9
MacDermid, Shelley, Co-Chair, Defense Health Board Task Force on 
  Mental Health, Director, the Center for Families at Purdue 
  University, Co-Director, Military Family Research Institute....     6

                                APPENDIX

Prepared Statements:

    Arthur, Vice Adm. Donald C...................................    48
    Casscells, Hon. S. Ward......................................    40
    Davis, Hon. Susan A..........................................    35
    McHugh, Hon. John M..........................................    37

Documents Submitted for the Record:
    Task Force Report on Mental Health submitted by Dr. Shelley 
      MacDermid..................................................    59

Questions and Answers Submitted for the Record:

    Mrs. Boyda...................................................   162
    Mrs. Davis of California.....................................   161
    Mr. McHugh...................................................   161
   FINDINGS OF THE DEPARTMENT OF DEFENSE TASK FORCE ON MENTAL HEALTH

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
                           Military Personnel Subcommittee,
                           Washington, DC, Thursday, July 12, 2007.
    The subcommittee met, pursuant to call, at 10:01 a.m. in 
room 2118, Rayburn House Office Building, Hon. Susan A. Davis 
(chairwoman of the subcommittee) presiding.

OPENING STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM 
    CALIFORNIA, CHAIRWOMAN, MILITARY PERSONNEL SUBCOMMITTEE

    Mrs. Davis of California. Good morning, everybody. It is my 
pleasure today to convene this meeting of the Military 
Personnel Subcommittee. I just want to acknowledge my 
colleagues, and thank them very much for their support. I am 
really honored to be chairing the committee, and particularly 
to be having this very important hearing this morning. We also 
asked that members come down a little closer to our witnesses 
today. When we have these subcommittee meetings, this is a very 
big room, and we want very much to enjoy a conversation with 
you to the best extent that we can so we can look at the report 
and have a chance for a really good exchange.
    I appreciate the time and effort that you all have put into 
it. And I know that it is going to be a good meeting. The 
purpose of the hearing today is to receive the findings of the 
Department of Defense (DOD) Task Force on Mental Health. The 
Task Force was mandated by Congress in the 2006 National 
Defense Authorization Act, and which charged to, both assess 
the military mental health care system, and to make 
recommendations on how to improve it. We are so fortunate today 
to have both the co-chairs of the Task Force with us, Vice 
Admiral Donald Arthur, who is also the Surgeon General of the 
Navy, and Dr. Shelley MacDermid, the Director of the Center For 
Families at Purdue University, and also the Co-Director of the 
Military Family Research Institute.
    We are also fortunate to have the new Assistant Secretary 
of Defense for Health Affairs, Dr. Ward Casscells, in his first 
appearance before the Military Personnel Subcommittee. Admiral 
Arthur and Dr. MacDermid will speak to the findings and 
recommendations of the Task Force, while Dr. Casscells will be 
able to tell us how the Department of Defense plans to improve 
the provision of mental health care.
    Again, we welcome all of you to the hearing. My 
understanding is that our panel will make brief opening 
statements so that we may quickly get to our members' 
questions. All the members of the subcommittee are unanimous in 
their support for our service members and their families. With 
multiple, long-term deployments now the norm for our military, 
mental health is more important than ever. Whether on the 
battlefield or back at home, the psychological resilience of 
our troops and their families plays a central role in the 
effectiveness of our armed forces.
    The final report of the Task Force on Mental Health makes 
it clear that substantial changes need to be made to the 
military health care system to provide the proper care at the 
proper time and the proper place. So let's be clear that this 
will be a long process. It will take a sustained effort for the 
foreseeable future to make the required changes to the Defense 
Health Program. We will, indeed, face challenges in recruiting 
or training additional mental health providers. We will 
encounter institutional resistance from those who think the 
current system is adequate.
    And finally, we will face fiscal challenges. These 
structural and cultural changes will require significant and 
continuing financial outlays. Improving and sustaining the 
mental health care system will be expensive, but we simply 
cannot afford not to do it. So finally, let me also mention 
that this may be Admiral Arthur's final hearing before the 
committee. He is retiring next month I know. And I am welcoming 
him, I hope, to San Diego after 33 years in uniform. Thank you, 
Admiral, for your many, many contributions and your faithful 
service to our Nation. Thank you very much, sir. And I am very 
delighted to turn the microphone over to my colleague, Mr. 
McHugh, for his opening remarks.
    [The prepared statement of Mrs. Davis can be found in the 
Appendix on page 35.]

  STATEMENT OF HON. JOHN M. MCHUGH, A REPRESENTATIVE FROM NEW 
     YORK, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE

    Mr. McHugh. Thank you very much, Madam Chair. Let me, 
again, congratulate you on your new position. I look forward to 
working with you. I know with your years of service on this 
subcommittee, you have a passion and a compassion that will 
lead us in very exciting directions. And if we get off track, 
we have still got the former chair, Dr. Snyder, watching over 
us very carefully, so I feel comforted. Also you made me feel 
14 years younger. I don't look it. But moving back down here is 
kind of a different experience. And the acoustics are different 
as well. So thank you for that innovative approach. Let me add 
my words, too, of thanks and appreciation, best wishes to 
Admiral Arthur. And as you said, Madam Chair, he has been a 
tremendous leader, a leader of heroes really in his 
contributions over a great career. It cannot be adequately 
described.
    But I know, Admiral, you take with you our deepest thanks 
for all that you have done. And I know that the men and women 
in uniform that you served for these many years feel very 
similarly. And thank you, too, to both of you as co-chairs of 
this Task Force that has put together the report that has 
gathered us here together.
    We are looking forward to your comments. And of course to 
Dr. Casscells, welcome, your first appearance, to the new and 
friendlier Personnel Subcommittee. We wish you all the best, 
and am looking forward to meeting with you. And I know you 
follow too in the footsteps of a gentleman who did good work, 
Dr. Winkenwerder, who brought with him a real devotion and 
dedication. So we wish you the best.
    Madam Chair, rather than just to keep rambling and read 
what I wrote, the statement that we have prepared here, I would 
ask for unanimous consent it be entered in its entirety into 
the record. And without that objection, I would just say in 
brief, as you said, mental health is an ongoing problem. It is 
not a new one. This subcommittee just two years ago held a 
hearing to talk about what kinds of services were available to 
our military personnel, to their families.
    And we find ourselves here again today recognizing, as the 
Task Force report I think shows, that there are many challenges 
and unmet needs that we must pursue to a successful end. And I 
am certain that we all carry with us that devotion and that 
dedication. So without delaying any more, let me yield back to 
you, and I look forward to today's hearing.
    [The prepared statement of Mr. McHugh can be found in the 
Appendix on page 37.]
    Mrs. Davis of California. Thank you, Mr. McHugh. And thank 
you for your encouraging words.
    Admiral Arthur, would you like to start?

  STATEMENT OF VICE ADM. DONALD C. ARTHUR, CO-CHAIR, DEFENSE 
 HEALTH BOARD TASK FORCE ON MENTAL HEALTH, SURGEON GENERAL OF 
                      THE NAVY, U.S. NAVY

    Admiral Arthur. Yes. Good morning, Madam Chair, and 
distinguished members of the subcommittee. Thank you very much, 
first, for your great and undying support for all of our 
military services. It is greatly appreciated. I am honored to 
be one of the co-chairs, along with Dr. Shelley MacDermid. I 
would like to say, though, that for the first ten months of the 
Task Force, Kevin Kiley, the former Surgeon General of the 
Army, was the military co-chair. And I would like to recognize 
his contributions over those many months. They were phenomenal.
    Mrs. Davis of California. Excuse me, Admiral, could you 
move your microphone just a little bit closer? Thank you.
    Admiral Arthur. Is that better? Can you hear me now?
    Mrs. Davis of California. Yes. Thank you very much.
    Admiral Arthur. You are welcome. Well, thank you again for 
having us here. We have, I think, given you a very honest 
appraisal of where we are and some frank talk about what needs 
to be done in the future in ways different than we have thought 
about mental health in the past. We have organized the report 
into four sections. The first talks about building a culture of 
support for psychological health within the military. The 
second talks about ensuring the full continuum of care for 
service members, their families, and those retirees who are 
affected by psychological issues. Third is the issue of 
providing sufficient resources, both financial and personnel, 
for these mental health services. And fifth--I am sorry, fourth 
is to empower the leaderships of the military to take on these 
issues and be proactive, not just keeping psychological health 
in the realm of our physicians, doctors, nurses, social workers 
and others, but to take it as a call for line leadership. We 
present many innovative topics in the report. But I would tell 
you if you were to ask me what needs to be done today, what are 
the most pressing issues, I would say it is to identify and 
treat those who are currently affected.
    There are many people who have difficulty getting access, 
who have issues with stigma that prevent them from seeking 
psychological health. And I think the thrust of our activities 
should be aimed immediately at identification and treatment of 
those who are encountering psychological stresses and are 
significantly affected by them. I would say parenthetically 
that having been in combat, I know that no one goes into combat 
and comes out without being significantly affected by the 
experience.
    There is nothing like it anywhere else in the world. We see 
combat often in the movie theatres, 90 minutes of combat 
followed by parades and victory by our heroes. That is not how 
it happens in real life. In real life, there are challenges, 
there are frightening times day after day, and they profoundly 
affect those who are in combat. But there is more to military 
life than just combat. There are routine deployments, such as 
on the USS Frank Cable, several months ago, where a steam pipe 
broke, seven people were severely burned, two died. And those 
people are as significantly affected by their military 
experience as anyone in Iraq and Afghanistan.
    Families, likewise throughout the history of their military 
career, spend times when their spouses are deployed, their 
fathers, their mothers are deployed. And those are 
significantly challenging times that have no similar experience 
in the civilian sector.
    We feel that families are a very, very important part of 
the psychological health of the service members, and that they 
need to have the unfettered access to help and resources that 
will support their military service member. Two very important 
concepts that have come out of our research were the concept of 
resilience and the concept of vulnerability to post-traumatic 
stress disorder (PTSD). Let me talk about resilience for just a 
moment. We have not--not just in the military, but in 
psychological circles worldwide--we have not paid much 
attention to what is resilience? How does one person become 
affected less than another in similar circumstances? How is it 
that someone like General Chesty Puller can get five Navy 
Crosses and continue to go into battle with great courage and 
great leadership skills while others would be so severely 
affected that they would be unable to pick up the task?
    We have not identified resilience factors. We have not 
identified which of our service members are more or less 
resilient. We think that if we can measure resilience in some 
way and discover those factors which would help us to train our 
service members to be more resilient we would have better 
service members, we would have better mothers and fathers, we 
would have better parents. We would also be able to identify 
people who have the least resilience, and perhaps ask them to 
undergo more training than others in how to adapt to the 
stresses of military life.
    Currently, we enter boot camps and officer indoctrination 
schools and we make everybody a sailor, a Marine, a soldier, or 
an airman without regard to their particular needs. This is 
also applicable to post-traumatic stress. There are men and 
women who come into the military who have had very, very 
difficult childhoods. We don't assess their prior experiences 
or their current vulnerability to stress. And I think the 
second thing we need to do is identify those who either, 
because of their prior experiences or their psychological 
makeup, are more susceptible to post-traumatic stress than 
others. And if we can find those who are more susceptible, then 
we would like to not put them into situations--I think it is 
our duty to not put them into situations--where they would be 
severely affected. We could say to someone, ``We would like you 
to be a jet mechanic,'' a perfectly acceptable military 
occupational specialty, but we may not want them to carry a 
rifle down the streets of Fallujah, where they would be 
psychologically affected.
    I think we have the capability, and we should identify 
those people. We should also be very, very aware that the 
individual's response to psychological stress is largely 
inborn. I think that there can be training that will affect it, 
but we don't fault people who break legs. We don't fault people 
who get cancer. We don't fault people who get sore throats. But 
we tend to blame people who have post-traumatic stress 
disorder. It is not your fault if you get cancer. It is not 
your fault if you are severely affected by post-traumatic 
stress of having been in combat.
    It is an extraordinary stressor. And that is the kind of 
psychological framework that we need to imbue in our 
leadership. One of the other important concepts in the report 
is the concept that psychological health is as important as 
physical health. We currently measure pushups and pullups and 
how fast can you do a mile run. And they are great markers of 
our fitness for combat. And we don't often consider, in fact, 
seldom consider the psychological health of our service members 
because we don't have good markers.
    We would like to imbue in the leadership, the trainers of 
our officers and enlisted leaders, that psychological health is 
just as important and should be exercised and trained just as 
much as physical health, because it will endure one in combat 
situations. We also focus on access. And that is not just at 
our military treatment facilities, but it is also in the 
Department of Veterans Affairs (VA) facilities, it is 
facilities for our Reserves, who don't have access to military 
treatment facilities, as well as those who get out of the 
military and need to come back to us for care, or at least 
access to the VA system.
    One of our recommendations is to ask all of our recruit 
centers, which you can find at many shopping malls around the 
country, to be a point of information access and a point of 
contact so that they--a service member, former service member, 
can walk into a recruit training center or recruiting depot and 
say I need some help. Can you guide me? And they will have the 
literature and they will be able to make some phone calls to 
properly guide that former service member.
    There are some programs which we currently do in the 
military--we have--I don't mean to give the impression that the 
military is not way ahead of many of the civilian sector 
programs in mental health. They certainly are. But I would 
frame this in a context of the last 30 years, where we have not 
been in combat. Not since Vietnam have we had a sustained 
military combat operation where we have required this extent of 
psychological services. We have through that 30 years, which is 
essentially my entire career, we have shaped our system to be 
exactly what it needed to be each year. And each year of that 
30 years between major combat operations we have needed less 
and less psychological services. Now we need them in times of 
great stress on our combat arms. And now is the time when we 
need to take a full assessment of what we can do and beef up 
our system that has been allowed to atrophy because it hasn't 
been needed. There are some programs that we do now that are 
voluntary programs, the Key Wives, the Voluntary Ombudsmen, and 
other organizations that voluntarily support the military 
services.
    One of our recommendations is that we codify those 
programs, that we make those programs not volunteer programs 
that are non-funded by the services, but that they are 
mandatory programs that families need to be supported by the 
services when their spouses, their husbands, their wives, their 
fathers, their mothers go oversees. It shouldn't be something 
that is left to volunteers to be done on an ad hoc basis. And 
last, we have asked for an infrastructure within the Assistant 
Secretary of Defense's for Health Affairs purview that 
specifically addresses the psychological needs of our forces. 
That is someone in his office who will be tasked with 
overseeing the mental health of our forces, and each of the 
services having a greater infrastructure for looking at those. 
When we briefed this report, the Department of the Defense I 
think embraced it, as evidenced by Secretary Gates' statement 
that he wanted action plans within 60 to 90 days.
    We have also had many meetings with Dr. Casscells and Ms. 
Embrey, who works with him as a principal deputy. And their 
response has been nothing short of extraordinary. They want to 
know not just what is in the report, but what can we do now? 
What more can we do? Where are the gaps that we need to fill? 
We have seen great compassion from our civilian leadership, for 
which I am very, very grateful. Let me stop there, and we will 
be happy to take further questions. I know Dr. MacDermid has 
some opening remarks as well. And thank you again.
    Mrs. Davis of California. Thank you very much, Admiral 
Arthur.
    [The prepared statement of Admiral Arthur can be found in 
the Appendix on page 48.]
    Mrs. Davis of California. Dr. MacDermid.

STATEMENT OF SHELLEY MACDERMID, CO-CHAIR, DEFENSE HEALTH BOARD 
TASK FORCE ON MENTAL HEALTH, DIRECTOR, THE CENTER FOR FAMILIES 
  AT PURDUE UNIVERSITY, CO-DIRECTOR, MILITARY FAMILY RESEARCH 
                           INSTITUTE

    Dr. MacDermid. Thank you. Chairwoman Davis, Mr. McHugh, 
distinguished members of the subcommittee, ladies and 
gentlemen, good morning. I am honored to join Dr. Casscells and 
Admiral Arthur in discussing with you the work of the Task 
Force. As you know, this group of professionals included 
distinguished experts from both military and civilian 
organizations. For the record, I would like to commend to you 
the outstanding efforts extended by each Task Force member. I 
submitted for the record the report of the Task Force, and now 
would like to draw your attention to four areas of concern that 
Task Force members believe require legislative attention. First 
and foremost, additional funding is needed if adequate care for 
psychological health is to be provided. Task Force members 
would want me to emphasize to you that the shortcomings we 
observed in the military mental health system were exposed, but 
not caused by the protracted conflicts in which the United 
States is now engaged, and that these shortfalls are unlikely 
to disappear when the conflicts end. Thus, nonrecurring funds, 
while helpful, do not allow the fundamental challenges to be 
addressed.
    I also must emphasize that the mental health landscape has 
many parts. Those parts do not all reside within the Health 
Affairs arm of DOD. There are many players, and funding 
attention needs to be distributed across the continuum of 
psychological health if all of the recommendations of the Task 
Force are to be carried out. Second, the Task Force found 
significant gaps in the mental health services provided to both 
service members and family members that cannot be fully 
remedied without increasing the numbers of military mental 
health professionals, including a critical mass of providers in 
uniform.
    This conclusion is based on almost six months of site 
visits, briefings from military and civilian experts, and 
review of thousands of pages of evidence. An expanded supply 
would make it possible to more aggressively prevent mental 
illnesses and intervene early when they occur by embedding 
mental health professionals in military units and primary care 
settings, as well as conducting annual mental health checkups. 
Additional personnel would allow for professionals to be fully 
trained in the newest evidence-based treatments and prevention 
information, and to train military leaders and personnel how to 
maximize the psychological health and readiness of the force.
    Finally, increased numbers would curtail potentially 
harmful delays and denials of service by reducing waiting times 
and giving family members the same access as service members to 
treatment by military mental health professionals who 
understand the demands of military life. The Task Force notes 
the necessity of your help in ensuring that aggressive efforts 
receive funding and are implemented to recruit and retain 
mental health professionals. Reimbursement programs need 
sufficient predictability to allow offers to be made to 
candidates for military mental health training programs and 
time to compete with other training programs. Realistic access 
to career advancement must be assured. And compensation 
packages must be competitive with other employers, especially 
today the VA.
    The third set of issues I would like to bring to your 
attention pertains to the TRICARE network, the cornerstone of 
the military health system for service members and family 
members who cannot access military facilities. It is not 
without difficulties, however, and some solutions require 
legislative redress. Patients who receive mental health care 
via TRICARE have significantly less access to treatment than 
patients treated at military facilities. One reason is that 
TRICARE cannot now reimburse for the treatment of bereavement, 
marriage difficulties, parenting problems or domestic abuse. 
TRICARE benefit coverage, and thus reimbursement, needs to be 
expanded to cover conditions labeled as V codes.
    We found that TRICARE reimbursement rates for mental health 
diagnoses in particular may be systematically lower than those 
for other diagnoses. Providers told us this at every site 
visit. The limited hospital data we were able to examine 
revealed startlingly large gaps. TRICARE officials who 
testified before the Task Force in December 2006, told us that 
the average reimbursement for residential drug rehabilitation 
in the Health Net system is $380 per day, while the TRICARE 
rate is $80 per day, below the Medicaid standard in some 
states. Current quality assurance and reporting procedures do 
not appear to contain sufficient detail about mental health to 
regularly reveal the severity of the these problems.
    TRICARE regulations currently prohibit adoption of some 
validated therapeutic best practices that are already well 
accepted in the civilian community. And they also impose the 
burden of extra certifications on providers who wish to join 
the network. TRICARE access standards also allow too many 
delays in treatment and should be revised. For some disorders, 
these restrictions create a hall of mirrors that effectively 
eliminates access to treatment.
    Let me give you an example. Imagine the family of a soldier 
deployed to Iraq whose teenage child has developed a substance 
abuse problem. There is an accepted continuum of progressively 
more intensive and expensive care for substance abuse treatment 
that includes outpatient counseling, intensive outpatient 
programs which provide about 12 hours of care per week, partial 
hospitalization when a patient sleeps at home and spends the 
day in treatment, residential care in a special treatment 
facility, and inpatient care in a medical facility. TRICARE 
regulations require that outpatient counseling be provided only 
by counselors working at TRICARE-accredited partial or 
residential programs, but most people in the United States live 
too far from one of these to drive to counseling sessions. So 
the family would need to go up the continuum to intensive 
outpatient treatment. But TRICARE regulations do not permit 
coverage of any inpatient--sorry, intensive outpatient 
treatment at all, so they would need to go up the continuum 
again to partial hospitalization.
    But TRICARE requires an extra certification, which 
providers find so burdensome that accredited programs exist in 
only 18 states, none near this family. So they would need to go 
up the continuum again to residential treatment. Unfortunately, 
the same problem applies. There are only 17 states with 
TRICARE-accredited programs, even though facilities offering 
each of these forms of treatment and accredited by national 
respected organizations are numerous in every state. For 
example, there is no TRICARE-certified mental health or 
substance abuse treatment facility in New York State or in 
Kansas. So the only service available to this family is 
inpatient detoxification, the most expensive form of care, and 
one which has been shown to be ineffective when not followed by 
other care. While all this is going on, the soldier sits in 
Iraq, worried and increasingly frustrated about her family.
    Finally, I would like to draw your attention to the 
National Guard and the Reserves, who today are called to serve 
at levels not previously seen by anyone now in the military. 
There is no doubt that the challenges of providing health care 
for such a widely dispersed population are daunting, but there 
was also no doubt in the minds of Task Force members that the 
Guard and Reserve members deserve higher priority in both 
resources and infrastructure for the care of their 
psychological health. Too often, members of the National Guard 
and Reserves seek mental health care in their communities, only 
to find that providers are neither familiar with nor aware of 
best practices for dealing with the sequela of deployment. 
Across the country, no one seems to have the explicit ongoing 
responsibility for monitoring the psychological health status 
of service members in the National Guard and Reserves, for 
following up to ensure competent treatment is provided, and for 
advocating at senior departmental and service levels for 
resources to provide adequate care. The Department of Defense 
has made enormous progress in administering and following up on 
post-deployment health reassessments, but this does not address 
the ongoing infrastructure challenges.
    We made several specific recommendations to address these 
challenges with new leadership positions, but legislative 
action is required to implement them.
    In conclusion, chairwoman and distinguished members, Task 
Force members came away from their task with a strong sense of 
urgency about the challenges that military members and their 
families are facing today. They are waiting and watching for 
your response. That concludes my opening remarks. At your 
convenience, I would be delighted to respond to questions. 
Thank you.
    [The information referred to can be found in the Appendix 
on page 59.]
    Mrs. Davis of California. Thank you very much.
    Secretary Casscells.

STATEMENT OF HON. S. WARD CASSCELLS, M.D., ASSISTANT SECRETARY 
                 OF DEFENSE FOR HEALTH AFFAIRS

    Dr. Casscells. Thank you, Madam Chairwoman, distinguished 
members of the committee. I will be very brief. I am very 
grateful to you for taking an interest in this issue and to 
this committee, which has a track record in supporting the 
military, and particularly supporting enlisted personnel and 
their issues. And for taking the broad view. I think as Admiral 
Arthur alluded to, this is not just a medical issue, it is an 
issue about communities, families, and a whole culture. And so 
we know you have got a bunch of work to do here. The Task Force 
has given us a great start. And on behalf of Secretary Gates, 
who takes this problem very, very seriously, and has tasked us 
with getting a response to him by September 12th, I can just 
say that our pressing need now is to get some surveys done to 
put numbers on the shortfalls that you just heard about, and 
then to gather all the ideas we can. And we are tiger teaming 
this now.
    We have had a number of summits on this. We are reaching 
out to expert help from the National Institutes of Health, 
Institute of Medicine, and particularly working closely with 
the Veterans Administration to be innovative, to do all we can 
through leadership, in addition to working with you on what 
things need legislative redress, what things may need funding. 
A lot of the data that we need will not be available for some 
months. But there is no doubt that there are shortages of 
access to care in some areas. We do have lots of authority to 
regionalize those reimbursements, but we know we have got to 
do--this is a tough recruiting climate. And it is tough to 
retain nurses, psychiatric social workers, psychologists, and 
psychiatrists. Having said all that, what is doable?
    The stigma issue is a really tough nut throughout 
behavioral health worldwide. It is particularly difficult in 
the military because of the traditions and the special issues 
regarding security clearances, weapons clearances, and the 
absolute importance of being able to rely on the stability of 
the person next to you. Having said that, we are working 
closely with the lines, because they do know that we are 
talking about human beings here, and that we have to have a 
culture where being able to ask for help is a sign of 
integrity. It is your duty. It takes courage.
    And to overcome the challenge is a sign of your success, 
and should mark you for leadership, not for, you know, 
sidelining of your career. And so the line has got to balance 
this. They have got to figure out, you know--they have got to 
recognize that having people in the--in service, whether it is 
as Admiral Arthur says, walking the streets of Fallujah with a 
rifle, or in some other capacity, having people who have dealt 
with mental challenges, who have demonstrated their own 
resilience is a tremendous asset. And Admiral Arthur and Dr. 
MacDermid have done the service members great favor by talking 
not just about the stigma and the access to services, but about 
incorporating psychological health from the beginning of one's 
military career through deployment, post-deployment, care and 
rehab if necessary in retirement, and making the continuum.
    And the classic sound mind sound body, you know, tradition, 
which has not been the military tradition per se. But they are 
really being patientcentric and service membercentric here. And 
I think--I am happy to say the line commanders are listening. 
And the soldiers and sailors and airmen and Marines are 
responding to this. This concept that when your battle buddy is 
stressed it is your opportunity to grab that person before they 
do something rash. It is your opportunity to reorient their 
thinking before they turn inward.
    Before I deployed to Iraq last summer, I was myself quite 
anxious. I woke up one night with a panic attack basically. I 
had never had a panic attack, but as a doctor, I knew what a 
panic attack was. And I turned to my wife and said, you know, 
we have got three young kids, a teenager, maybe I am more 
needed here. She said we have sent out the invitations for the 
good-bye party, you are going. Well, that helped me laugh. And 
then at Fort Bliss I met a psychologist, Colonel Carl Castro, 
an Army guy, and I mentioned to him I was a little bit nervous.
    And he told me that he was a lot nervous. And then he 
started talking to me about experiences he had had with 
previous deployments. Well, these kinds of things are 
relatively easy for mature, middle aged doctors to share. But 
it is harder for young guys and young gals. You know, my career 
is at a plateau. They are trying to make their mark. They 
really need encouragement to help each other. So you can help 
us help them in that way.
    We appreciate any ideas you have. I wish I had more data. 
We are in the process of gathering the data to address these 
issues. But I just want to say we are absolutely committed to 
this. It is our top priority right now in our office. And in 
the military health care system mental health is now job one 
because of the people we lose from the force, because of the 
pain for the families, because of the long term financial 
obligations. This is something we have to put at the top of our 
priorities. I don't expect we will have a perfect solution 
because we are dealing with, you know, systems that have 
trouble recognizing that everyone is different. And not 
everyone is cut out to be a warfighter. But I always tell the 
soldiers in talking to them, and I start with this quiz. You 
know, what did Martin Luther, Gandhi, Churchill, Lincoln, van 
Gogh, Mozart, and a number of athletes, Bradshaw and others 
have in common? And they go, I don't know. I said depression. 
They struggled with depression all their life, but they 
overcame it and they went on to greatness.
    So one of our jobs in the military is not to be a cookie 
cutter, but to find a position in the military where you can 
shine depending upon your background, your skills, your 
interests. And we will work with you on that. So there is a lot 
going on. And I want to take your questions and not belabor you 
with all our pilot studies and surveys, but please know that we 
are in this, you know, neck deep right now wading through it. 
Thank you.
    [The prepared statement of Dr. Casscells can be found in 
the Appendix on page 40.]
    Mrs. Davis of California. Thank you. Thank you very much. I 
just want to say I am sure my colleagues would agree, I think 
the sensitivity with which you have approached this issue is 
quite remarkable. And we are very fortunate to have the 
application of your sensitivities here today, and I really 
appreciate that. You know, you talked about it is really a 
shift of thinking in the services, and even to the civilian 
sector a little bit. I think that while we have certainly seen 
great gains in the way we think about mental health care today, 
at the same time, there are a lot of things that we don't know 
or that we try and put under the carpet all the time as well in 
the way we approach it in terms of insuring people who have 
mental health problems.
    And so I think that what we learned over the course of time 
here should be very helpful. I appreciate the issue of 
resiliency as well. I know as a former school board member, we 
used to marvel at the fact that some kids could come out of the 
just an unbelievable situation and do very well. And you have 
to ask, you know, what is different here? Who are the mentors, 
who are the people that made such a difference in these kids' 
lives? And the same is true when we look at the military, and 
those who command young men and women in the services, and the 
tremendous role that they play. We need to try and capture 
that, you know, bottle it if we can, and to use it in the best 
way possible.
    I wanted to turn for a minute, though, to some of the 
questions we have, because while the report makes a number of 
recommendations, excellent recommendations about increasing the 
number of practitioners, ensuring an adequate supply of 
military providers, embedding additional uniform providers in 
military units, and making mental health professionals easily 
accessible, I think that begs the question for all of us.
    And Secretary, you mentioned this, is trying to get a 
handle on what are we talking about here in terms of numbers, 
certainly in terms of cost, in terms of training, in terms of a 
pipeline of people who are going to be available?
    So as you went about your discussions, could you share that 
with us? Do you have some ballpark figure, I guess, really 
about how many military providers you are talking about? Is it 
in the hundreds or the thousands? And how many of those might 
be new providers, too, that are not necessarily in the services 
today? But again, how many do we have that are in the services? 
And that is a matter of tapping some of the talent that is 
already there. Admiral, would you like to try and address that?
    Admiral Arthur. You were about to say benchmark, and I 
think I would rather take the benchmark, Madam Chair. We have 
recommended that there be a risk-adjusted population-based 
model approach. Each of the services, in fact each of the units 
within services will have different requirements. And I think 
it is up to the services to assess their requirements for their 
operational units, how they operate, what kind of operations 
they have, what kind of support they will need. There are some 
common factors. Embedding providers in operational units I 
think has been shown by the Navy, Army, and Marine Corps to be 
very, very good ways of caring for service members in their 
units.
    It is very different when you are in a combat situation or 
deployed situation and you can go to another member of your 
unit who happens to be a psychologist or social worker or 
psychiatrist and express that you have a problem than having to 
go up to a hospital to access that care. It is a very different 
flavor. We also have recommended putting psychologists in 
primary care clinics. Because most of the depression, most of 
the prescriptions for antidepressant medication in this country 
are not written by mental health professionals, they are 
written by primary care providers. And we would like to embed 
psychologists into those clinics to give them easy access to 
the environment, to have the patients immediately receive 
access to psychological support when they present to the 
primary care provider for depression.
    We also tried to introduce into the report the concept that 
psychological services should be provided wherever the patient 
and his or her family needs them. And it could be a 
psychiatrist in a clinic in a military treatment facility, but 
it could also be the school nurse or the teacher in the grade 
schools who needs to be better, more adept at identifying the 
psychological needs of the children of deployed service 
members. I think wherever our families and service members can 
get the access to care is where we should provide it. We have 
downsized our military providers over time because the needs 
weren't there during times of relative peace. Now we have 
identified greater needs because there have been greater 
stress, and we are going to need more active duty providers, 
more contract providers, more access to TRICARE providers. They 
should be--yes, ma'am.
    Mrs. Davis of California. Did the panel identify the 
challenges in terms of recruitment? Because we know that just 
bringing people into the services in the professions is 
difficult to do today.
    Admiral Arthur. It is.
    Mrs. Davis of California. How do they feel that that can be 
addressed?
    Admiral Arthur. Well, we would like to be able to contract 
enough of our services in the TRICARE network and in other 
areas so that we don't have a large number of active duty 
people that we need currently but may not need in five years. 
That said, we feel strongly that the active duty providers, 
whether they are psychiatrists, psychologists, social workers 
or mental health technicians, nurse practitioners, many of them 
should be active duty to treat the active duty service member. 
And the reason is that active duty providers will have been in 
the military, they will likely have been in combat or close to 
combat situations, and understand the milieu, understand the 
challenges of service members and their families, and can be 
better prepared than a civilian provider who has had limited 
access to a military experience and never been in any combat. 
So we feel that military providers are the best for service 
members.
    But the family members should be able to receive care 
wherever they feel they would like the access, especially when 
service members deploy and their spouses and children may go 
back home to Kansas or home to a grandparent. We feel that 
there needs to be access within the system, and that would be 
our TRICARE system for those needs.
    Mrs. Davis of California. Thank you. Mr. Secretary, does 
that seem reasonable to you? To try and, I think, develop 
within the services perhaps more people that are going into the 
behavioral health fields who may not have been thinking about 
that right now or may be doing something else?
    Dr. Casscells. Madam Chair, it does. And we are looking 
right now at this in a new light. One of the issues is 
whether--is how we can improve recruiting of psychologists, 
psychiatrists, for example. But equally important is our 
recruitment of psychiatric social workers, and the use of other 
caregivers, other stakeholders, the chaplains, the family 
practitioners, the internists, the nurses, the first sergeants, 
platoon leader, lieutenants, for example, and incorporating 
this kind of approach just as Admiral Arthur has recommended, 
where everyone is looking after the welfare of other people. We 
have done it with combat casualty care.
    Everyone gets the basic combat lifesaver course before they 
go over there. Now we must go back and get people to recognize 
that if your buddy is staring off into space and picking at his 
food or her food and not laughing at the dumb jokes, maybe that 
is a sign that that person needs to get back to base and get, 
you know, three hot meals and a couple of good nights sleep and 
then a chance to talk to someone confidentially and so forth.
    So this kind of thinking has got to be incorporated very 
quickly, because the recruiting, it is not easy to get people 
in the military. It seems like every person I am able to help 
recruit--and we want everyone to be a recruiter these days--
there are nine who get part way through the process and it 
stalls, they get frustrated or something. So this is a tough 
issue. We cannot hire 200 Army psychologists, which is the 
number that General Pollack wants to do, we can't get those 
overnight. So right now we need everyone to be thinking about 
this issue and watching out for our service members.
    Mrs. Davis of California. Thank you. If I could turn now to 
my colleague, Mr. McHugh. And again, thank you for your 
leadership on this committee, Mr. McHugh.
    Mr. McHugh. Thank you, Madam Chair. I tried to play close 
attention. I may have missed the batting of the ball, if you 
will, but I believe the Chair asked about estimates on funding 
as such. You have all talked about dollars. This has got to be 
significant dollars. Were you able to quantify any of the 
recommendations with respect to numbers of professionals and 
such, expansion of TRICARE, all of those things? Because at the 
end of the day, it is our responsibility, and I think a very 
important one, that we start talking about authorization 
appropriation.
    Admiral Arthur. Yes, sir. The committee members didn't 
specifically have the expertise in financial management. And it 
was a huge challenge with just the year we had to do this job 
to collate all of these recommendations. And the committee felt 
that we would be best to provide a clear vision of where we 
needed to go, and use that population base risk-adjusted model 
to allow the services to quantify their requirements and allow 
the services latitude to vet that through their chains of 
command.
    We didn't feel that we were necessarily qualified to do 
that. There was so much of the vision that we wanted to 
project. And I think all of these have to be taken in the 
context of service requirements and current funding and all of 
the decision-making that goes on in balancing the funding. So 
we did not quantify that, but I think that is one of the things 
that the services, especially through the coordination of the 
Assistant Secretary of Defense (ASD) Health Affairs Office, 
will need to be doing in the short term.
    Mr. McHugh. Fair enough. You have got a seven-page list of 
recommendations here, and they are broken out into three 
different categories. Some do require legislation, others are 
policy and action. I think they all require money, or certainly 
most of them require money. So let me ask you, and you did 
define, and Dr. MacDermid defined what she felt were some of 
the most important things that the Congress do.
    Let me ask you to tick off, if you can, if you agree, three 
or four of the more important off of this list, because my 
understanding is this is not really prioritized in any 
particular way, so that we can get a focus in an area and think 
about translating policy into dollars, which is the ultimate 
challenge for us, frankly. Would that be possible today?
    Admiral Arthur. Yes, sir.
    Mr. McHugh. Okay.
    Admiral Arthur. Maybe not today, but certainly we can get 
back to you very quickly. I constructed that list. And that is 
just a list as the recommendations are in the report. They are 
just a collation. And we attempted to make--put the X's in the 
boxes of the things that we can do right now that don't require 
legislation or policy--and Dr. Casscells has taken many of 
those things for action immediately--and to give people an idea 
of where their responsibilities lie.
    [The information referred to can be found in the Appendix 
beginning on page 161.]
    Mr. McHugh. Okay. And I agree with that. However, when you 
can, and you certainly feel free to take this for the record, I 
think it would be helpful for us to hear amongst this collation 
of proposals which you feel are the most important so that we 
can begin to focus on it. They are all important, don't 
misunderstand me. But out of seven pages, Congress has a tough 
time focusing that broad a vision, quite honestly. And I would 
like, at least for my own use, to have a list of some sort of 
top ten, for example, that you feel are of the greatest urgency 
for the greatest good. I know over time, all of these are 
integral to an effective mental health policy, and I am not 
trying to minimize any. I am just trying to help focus at least 
my attention.
    Admiral Arthur. Sure. The things that we will choose are 
undoubtedly those things that immediately improve access to 
care for service members and their families, both in the 
Medical Treatment Facilities (MTF) and in the TRICARE network 
system.
    Mr. McHugh. I don't want to prejudice your answer, but that 
sounds logical to me, and we will await that. And I deeply 
appreciate it. Dr. Casscells--and I will be yielding back here 
because we do have other members--I took to heart your comments 
about recruitment. And the Army has been in the news lately. 
They failed to meet their last two months' recruiting goals. 
And the environment has been tough across the board for a 
number of reasons. And clearly it is compounded when you get 
into the question of mental health care professionals.
    I mentioned a hearing we had on this two years ago, but we 
have also had budget hearings. And in one of Dr. Winkenwerder's 
last appearances, he and I had a discussion about some of the 
military to civilian conversions that have been occurring 
across the services. Since 2005, about 5,500, a few more, 
conversions, and about 406 of those were military mental health 
care professionals. I was concerned about that just from the 
numerical perspective. Dr. Winkenwerder, I think, said the 
right thing. He goes, well, ``they,'' meaning the Department, 
were fully willing to reconsider that. We have put language in 
the 2008 Authorization Bill in the House version that would 
freeze those civilian conversions, to civilian conversions for 
a variety of reasons, not the least of which is the concerns 
that we have about the erosive effect in the mental health care 
area.
    But in the meantime--and I am sure the Senate in its great 
wisdom will accept that version if we get a bill--but in the 
meantime, I am curious, has the Department reconsidered that 
military to civilian strategy.
    Dr. Casscells. Congressman McHugh, we have been talking 
about this with the personnel and readiness experts. And I have 
asked them this very same question, because it seems to me that 
there are some people who should--could certainly be civilian, 
say a radiation oncologist who will not deploy to Iraq. But 
when we are asking psychological health care providers to go to 
the sand and to take those risks and to be gone from their 
family and so forth, the civilians obviously cannot do that.
    So we have got to have a strong core of people who are 
willing to go and have dealt with these problems. The personnel 
and readiness experts who live at the DOD have numbers which 
suggest that they have not forced conversion of these 
deployable types of specialists. So I have asked that these 
numbers be reexamined, because the surgeons are uniform in 
feeling that we have gone far enough with military to civilian 
conversions. So this is the kind of honest disagreement which I 
think just needs data, because if we try to make the decisions 
by anecdotes, whether they are poignant or stirring or what 
have you, we are going to lead to a law or legislative redress 
that we might have to reverse.
    And so it would be premature to say whether we are--whether 
we have gone too far with military to civilian conversions or 
not far enough. I suspect as we get the data back we will find 
in lots of specialties we have done all the converting and 
efficiency wedging we can do. But there are others where there 
may be efficiencies to be had. And I think the principle that 
needs to be set out clearly is when the services, which are 
individual, independent engines of innovation, when they 
innovate and compete, quality improves, efficiency should 
improve, and they should retain those dollars for other uses 
that they identify. This message hasn't gotten out very 
clearly. And I want to say how important that is.
    So we will have more data on mil-civ conversions, but the 
principle of pay for performance, which is now permeating 
through the personnel system, is I think a good one and will 
put us in a good position for the future.
    Mr. McHugh. Well, we could have a spirited conversation 
about that particular factor, but for the moment my concern is 
not across--for the moment my concern is not across the board 
on military to civilian conversions initially, it is in the 
mental health care professions. What kind of radiation 
personnel did you say you don't want to deploy? I missed the 
second word.
    Dr. Casscells. A radiation oncologist.
    Mr. McHugh. I thought you said psychiatrist.
    Dr. Casscells. No, I don't think--we haven't gotten to 
radiation psychologists yet, although sunshine is a very 
important therapy.
    Mr. McHugh. Yes. Yes, it is. That is why I was confused. 
There are many reasons why, but that is one of them. But in the 
mental health care area, by all means, I would like to see the 
data behind that number. The number is troubling, because 
unlike the broader spectrum of civilian positions, and probably 
you could argue across most medical health care fields, in the 
mental health services you don't really have four-dozen 
categories of workers. I mean, they are rather specific in the 
task. And so when you get that I think that is important, and 
those data need to be looked at. And when it is appropriate, I 
would appreciate you sharing those with us as well. The other 
thing I would say, though, is deployability is more than a 
factor in just who is doing what.
    You have to hire an individual into a slot, regardless of 
what that slot is. The fact that that individual is civilian, 
and therefore cannot be deployed, is a determinant factor. 
Because that is somebody you aren't going to hire who can't be 
deployed. I know you understand. The services do. They have 
been extraordinarily creative with it over the last several 
years. So I just don't want that factor to be pushed aside. And 
I am sure you will give it your consideration. So thank you, 
Madam Chair.
    Dr. Casscells. Yes, sir. Thank you. I agree with what you 
said, sir.
    Mrs. Davis of California. Thank you for those questions, 
Mr. McHugh. And Mr. Snyder, again, I want to thank you for your 
leadership on this committee and for being such a good mentor 
and friend.
    Dr. Snyder. Thank you, Madam Chair, and I want to say even 
though I am on a five-minute clock, I think it is great for the 
country and great for men and women in uniform that you are 
going to be the chairperson of this subcommittee, and one of 
the great members of this Congress. Admiral Arthur, I want to 
pick up and continue on Mr. McHugh's line of questioning 
somewhat.
    On page 41 of the study, the top sentence says, ``The 
single finding that underpins all others in this report is that 
DOD currently lacks the resources--both funding and personnel--
to adequately support the psychological health of service 
members and their families in times of peace and conflict. 
Unless Congress provides sufficient new funds to allow adequate 
staffing to provide a full continuum of services, including 
enhancing the resilience of the force, prevention, assessment 
and treatment, few of the recommendations of this Task Force 
can be implemented.'' That is the end of the quote.
    My specific question for you is, when you were putting this 
report together did you consider saying that what is really 
needed is a really strong efficiency wedge?
    Admiral Arthur. I wouldn't use strong and efficiency wedge 
in the same sentence.
    Dr. Snyder. Did you consider saying what is really needed 
is no more funds, but a really strict group or innovative new 
group and setting in providing the care? Isn't it clear what is 
going on is we haven't had adequate funding in this area for 
years? And on top of that, we have had these mandates come down 
from on high in the Pentagon saying you had to find cuts in 
services? Isn't that the reality of what has gone on in the 
last several years?
    Admiral Arthur. I find myself in an awkward position being 
the co-chair of a task force and also the Surgeon General.
    Dr. MacDermid. Would you like me to answer the question?
    Dr. Snyder. As Surgeon General, Admiral Arthur, you have 
been pretty candid about what you thought about the efficiency 
wedges. The point is made. You all very clearly say that unless 
more funding comes, few of the recommendations of this task 
force can be discussed.
    The second point I want to pick on--
    Admiral Arthur. May I make one comment, Dr. Snyder?
    My comment before about the 30-year interim between real 
sustained deployed combat operations has really honed our 
psychological and some of our other services to be what they 
are today. We are not capable today of meeting all of the needs 
we should because we have honed them to where we thought they 
should be during a long, extended period of peacetime.
    So while the assets, the required personnel and other 
services are not adequate today, it is not because we have not 
been providing the services that we should have over that 30 
years. It is because this is a combat operation that is 
creating workload for us and a psychological debt of the 
servicemen and women who are in extraordinary circumstances.
    Dr. Snyder. I think the evidence is pretty clear, the 
President's budget has been inadequate for more than just the 
recent year.
    Which brings us to the second point. You all say here right 
after that recommendation, 5.3.1.1 on page 41, ``Congress 
should provide and the military services should allocate 
sufficient and continuing funding to fully implement and 
properly staff an effective system supporting the psychological 
health of service members and their families.''
    Dr. Casscells, if I was writing that, I would have said, 
``the President must request and the Congress should fully 
fund.'' I hope that you will take back from this report that 
this committee and the full committee and the Congress is not 
going to be at all receptive to another President's budget that 
comes down and says, Oh, by the way, you are $2.1 billion 
behind from the get-go.
    This report clearly says, you all have got to budget better 
for mental health services. Is that not the take-home of this 
language on page 41?
    Dr. Casscells. Yes, sir, Dr. Snyder, I read it the way you 
do.
    Dr. Snyder. That is a good answer. Let's stop there.
    I yield back. Thank you.
    Dr. Casscells. I would just like to say that we appreciate 
the Congress filling that hole this year with generous support 
for PTSD and traumatic brain injury (TBI). The President's 
budget, as you know, must balance lots of important issues. And 
as someone for whom mental health is a high priority, I have to 
recognize I probably won't get all the funds all of our 
providers could want. We will be in a position of being as 
innovative as we can and deputizing as many people as possible 
to make mental health a priority; and to recognize that it is 
not all a matter of psychotropic drugs, and it is not all a 
matter of psychiatrists, but it is regular doctors like 
yourself and me and the nurses and everybody who has got to 
make this part of their business. We need all hands on deck 
here for this.
    Pardon me. I am an Army guy, I shouldn't use those kinds of 
terms. But--we won't have every nickel that everybody has 
requested in the military health system I inspect, but we are 
certainly going to do everything we can to do it.
    Let me mention, though, that if you step back a little bit 
and look at our rates of PTSD, compared to Operation Desert 
Storm or Vietnam, we are actually doing better. If you look at 
our suicide rates compared to then and to the civilian world we 
are doing better. In Vietnam, as you recall, the military 
suicide rates were almost double civilian. We are below 
civilian and we have stayed below. The rates of soldiers 
getting involved in doing dumb things when they come home or 
malicious things are gratifyingly low.
    Divorce, despite the enormous stress of this conflict and 
the protracted nature of it and the anguish about the whole 
mission, particularly among the American population stateside, 
the divorce rate has maintained flat. I think it is a tribute 
to what the Army, Navy, Air Force and Marines have done in 
psychological resilience and in a community of caring that they 
are beginning to establish. We are developing service members 
who live a rubber-band defense; they stretch but they don't 
snap. We are developing soldiers who, by and large, are 
stronger, but not brittle; who are tougher, but not hardened.
    I think there really is--when you step back and look at 
previous conflicts about the civilian world, there is a lot to 
be proud of. Having said that, we have got to improve, and with 
your help we can.
    Dr. Snyder. I hope this page 41 is something Secretary 
Gates and Dr. Chu and the people of Office of Management and 
Budget (OMB) have already read, because Congress just can't 
tolerate the kind of budgeting that has gone on with the 
military health care budget the last two or three years. Thank 
you.
    Mrs. Davis of California. Thank you, Mr. Snyder.
    Mrs. Drake.
    Mrs. Drake. Thank you, Madam Chairwoman. First of all, 
congratulations on your chairmanship, and I look forward to 
your leadership.
    Thank you all for being here, and I think you have all said 
it, that you know this subcommittee and this committee and this 
Congress agree with you that mental health issues are extremely 
important, and we want to do the best job we can do. And we 
want to find the money to do what needs to be done.
    My first question is, in the New England Journal of 
Medicine they make the statement that 16 percent of our 
returning soldiers and Marines returning from Iraq have 
experienced mental health issues.
    Do you agree with that number? And how do you think that 
compares with other conflicts? Or have you seen that number and 
given it any thought?
    Admiral Arthur. I haven't seen that article, ma'am, but I 
can tell you that, as we expressed before you came in, no one, 
in my opinion, goes into combat and comes out without being 
significantly affected by the experience. And it runs the 
gamut, the spectrum, from post-traumatic stress disorder to 
just post-traumatic stress effects.
    The entire spectrum is treatable. Just because you are 
labeled once as having a disorder doesn't mean that is a 
forever diagnosis. There are many people who come into the 
services already experiencing post-traumatic stress disorder. 
In the civilian sector, the rate is not in double digits, it is 
in single digits; but certainly people going into combat are 
significantly stressed by the experience.
    Mrs. Drake. Have we ever looked at what is the comparison 
with our, I would call it active duty, regular duty, as 
compared to Special Operations Forces, when they return? Is 
there a greater percentage in either of those two groups?
    Admiral Arthur. The correlation is really in the proximity 
to fearful events, proximity to combat. If you are in Kuwait in 
a relatively protected area, you have fewer post-traumatic 
stress issues than if you are in Fallujah or in Baghdad and 
going on the streets every day carrying a rifle; you are on the 
convoys wondering if you are going to be blown up by an 
improvised explosive device (IED), or if you have seen somebody 
who has been killed or wounded, you have been affected by an 
IED blast. It is your proximity to the threat.
    There is also a correlation with the resilience and the 
leadership qualities of the commanders, both the officers and 
enlisted members of the battalions, and the folks who are out 
there. Those who have leaders who are very resilient, very 
charismatic and very caring about their service members will 
see less post-traumatic stress disorder in their subordinate 
troops than those who are themselves significantly affected.
    And that goes back to our concept of resilience and how we 
can perhaps shape the military training efforts to increase the 
resilience of all of our service members. But especially to 
focus our leaders on the importance of maintaining and 
improving psychological health as well as physical type of 
fitness.
    Mrs. Drake. But my question on that was--in my own mind 
was, and you mentioned it in the beginning--was about training. 
You said it again.
    Also, what is the mission and what is the expectation of 
that service member as they go into that battle? This is a big 
issue at home. I have talked to a lot of people about how we 
are going to deal with this. And one of the young men that has 
come back, he is guard, said that they were offered their exam 
where they could go home with their unit. So that seemed odd to 
me because, of course, you are going to say, Why would I wait 
two or three days here; I am going to go home with my unit. And 
it seems to me that we should rethink how we do that.
    And maybe, just tying this to what another mental health 
professional in our city told me--she said, ``Some come back by 
ship, Marines will come back with a Navy ship, and they have 
got that time between the battlefield and returning to their 
regular lifestyle to deal with some of the issues to recover.''
    You have talked about it--you did, Secretary Casscells--
about getting some sleep, getting some food, being warm or 
cooling off if you are real hot. So I wondered if we have 
looked at that too. What is the difference if maybe people, 
rather than being given the choice, Are you going home today, 
or are you going to stay two or three days for this exam, if we 
don't give them a choice and we keep them or the longer trip of 
a marine to come home on a ship?
    Admiral Arthur. Many units now are starting the 
decompression cycle in theater, and they are taking some time--
days, a few days or many days, to decompress, have people come 
in and talk to them and try to go through that process.
    One of the things we did mention in the report is, the 
immediate survey of people just coming out of theater about 
their stress reactions may not be very productive. Because we 
have heard many, many times, very consistently, that, Gosh, I 
am afraid if I check ``yes'' on anything, I won't get to see my 
family today, and I want to see my family today.
    So one of our recommendations--and the services are already 
doing this--is to rethink the timing of that and to, especially 
for Guard and Reserve, rethink the reunification of the 
families and getting back together as a group, not taking six 
months off, but come back together in a month or three months, 
not to drill necessarily, but just to get back together and 
form that unit integrity and go through the decompression 
process.
    So there are a lot of things that we have thought about 
along those same lines.
    Mrs. Drake. Thank you very much.
    Thank you, Madam Chairwoman.
    Mrs. Davis of California. Thank you.
    Ms. Sanchez.
    Ms. Sanchez. Thank you, Madam Chair. It is great to see you 
in that seat.
    And thank you to our Task Force here. We really appreciate 
the work that you have done. We have been battling this whole 
issue of mental health, not just in the military, but as you 
know, also in just the general civilian population. We continue 
to have a bill in the House on mental parity and just can't 
seem to understand how important this whole issue of mental 
health can be to the future of our country.
    And, of course, we have been working on this committee. I 
am glad that you acknowledge that this committee in particular 
has worked on this issue since before the war began. But, of 
course, we are very worried about this.
    And I know that we have been pushing for more funds and 
programs, and I want to associate my words with both Mr. McHugh 
and Chairman Snyder with respect to how important it is to get 
the President to put funds and to acknowledge that this is a 
need, this is a real need, for our country.
    But I want to go back to something that is important, which 
is the whole issue of stigma, which of course, you bring up in 
the report--mental stigma, health stigma. It is difficult in a 
civilian situation, and I figure it is even more difficult 
within the military.
    I happen to have two friends, two family friends who are in 
the military. And one got--well, one particular soldier got out 
because she went to seek mental health services and had to go 
once a week and finally had to tell her superior why she was 
missing three hours in the morning on a Tuesday or what have 
you. And the next thing she knows, where she has had perfect 
promotions each and every time, the next time she gets passed 
over. And really when you look at the record it is due to the 
fact that in the writings of her superior, he commented that 
maybe she wasn't ready to keep going up the ranks.
    And then I have a personal friend who is enlisted and has 
seen a dramatic change in the way the perception is toward him 
in the units he has been with because of having gone to seek 
mental health. What do we do to change that? I mean, I am 
reading here where you say structurally it is not really in the 
structure. I mean, under your combating structural stigma. But 
the reality is, it is in the military. This is.
    Once you turn yourself over and say, I need to get some 
help for this, whether it is something from your previous life 
or whether it is something because you came back from the war. 
And you are seeing this when people find out it affects your 
career.
    What do we do about that? This is not just about money. 
People don't want to go and seek help if it is going to affect 
their career.
    Admiral Arthur. Yes, ma'am. Much of this is a leadership 
issue. I expressed earlier that if you get cancer, even if you 
get lung cancer and you smoke for 40 years, we don't blame you. 
We feel compassion for you and your family. Smoking is a habit, 
it causes lung cancer, but we don't blame. Yet we will blame 
people for having a natural reaction to incredible 
psychological stress.
    Some are more capable than others. If you look at the 
military culture, all our advertisements, all our training 
point to people who are hardened. And I would ask, who else 
would go and walk down the streets of Fallujah carrying a 
rifle, or aim his or her F-18 at an adversary and know that she 
would be victorious, even though the odds are 50-50.
    Ms. Sanchez. How do we change it? How do we decide to 
change it? How do we measure that change going on within our 
ranks?
    Admiral Arthur. We change it by focusing our leadership on 
psychological health, and that the psychological health of our 
service members is as important as physical fitness, the 
psychological fitness. And we need to have some leaders stand 
up and say, ``Boy, that was a frightening evolution that we 
just went on, you know, I am still shaking; I think I need to 
decompress, how do you feel about that?''
    If a colonel or a first sergeant, sergeant major gets up 
and says, ``Boy, I was scared, I have been so scared, and 
others are going to say, no problem, I can handle it, when they 
really can't.''
    As Dr. Casscells was saying, ``We are all frightened, we 
are all changed by the experience.'' And my wife told me when I 
came back from combat in Desert Storm it took me six months to 
get back to baseline. She didn't say normal, but she said to 
get back to yourself, to get back to stop being inward, to stop 
being a bit sullen, to stop looking over my shoulder at loud 
noises. These are things that affect normal people. But our 
military needs some extraordinary people who can walk down the 
streets of Fallujah and know they can be victorious. And how 
you balance those things is a matter of leadership and 
recognition that even if you have post-traumatic stress, it is 
not your fault.
    The other thing we can do that I mentioned before is to 
identify people who are most vulnerable, they are most 
vulnerable to post-traumatic stress, and not put them into 
those situations; give them military occupational specialties 
where they can contribute, but not be exposed to those 
extraordinary stresses.
    But we have to be open to the fact that normal people will 
get lung cancer, normal people will get post-traumatic stress 
disorder. Neither of those disorders is their fault.
    Putting on a uniform means you are a patriot, and you 
should be celebrated for your patriotism. And I think once you 
get to see psychological health as a component of each person's 
military specialty and something that can be trained, something 
that can be understood and rationalized, then we will 
destigmatize--but never entirely. Stigma has to do not only 
with other people's impressions of you, but your own self-
worth. And everybody is different, everybody has different 
self-worth, and it will be difficult to totally do away with 
stigma.
    But if you look at what the military has done with the 
integration and the racial equality, with the equality of 
women's rights within the services--we have women flying in 
combat air patrol now, women commanding ships, and we think 
nothing of it. It is just how we do business.
    I think to identify this as an issue that will be just how 
we do business in the future, we can do this. We are the 
military, and we have a society that we can better control than 
the general population. So we have handled very, very difficult 
social issues, and I think we can tackle this one too.
    Ms. Sanchez. Doctor, did you have a comment?
    Dr. MacDermid. I was going to add one thought which has to 
do with what you mentioned about parity, and the example that 
you gave is a very good one. We suggest in the report much more 
extensive training for military members and for military 
leaders. And Admiral Arthur correctly points out that we each 
have a responsibility.
    But all of us also are affected by stigma, and so we have 
to teach others, and we ourselves have to challenge ourselves. 
So when we write in fitness reports about someone's mental 
health, we have to challenge ourselves. Would we write the same 
thing if they had broken their leg and it was now repaired? Are 
we thinking about mental health in ways that acknowledge that 
illness can be treated, illness can be prevented, illness can 
be recovered from?
    And so the parity issue that you raise, I think, is very, 
very important. And as you go on to review future budgets and 
future programs, it might be a very good question that you can 
ask when mental health is being treated differently from 
physical health. Why is that? Every time we think it is 
important to educate someone about physical health, that is 
also a moment that we can train someone about mental health, 
and perhaps we should be doing it.
    Ms. Sanchez. Thank you.
    Mrs. Davis of California. Thank you.
    Mr. Jones.
    Mr. Jones. Madam Chair, thank you and congratulations to 
you as well.
    I wanted to be here for the full hearing. And I apologize. 
It is my fault. I didn't get here. I got here for the last ten 
minutes. But I look forward to carefully reading your 
recommendations and thank you for being here today.
    I want to very quickly piggyback on what Ms. Sanchez was 
talking about. I hope you can--Admiral Arthur, I hope you can 
change the mind-set; and to the doctors to your left and right, 
I will tell you a quick story that is just ironic.
    Three years ago I flew down with then-Secretary of the Navy 
Gordon England. And we were addressing, or he was addressing, I 
should say, a company of Marines that just got back from Iraq. 
And the company commander was standing at the podium with him, 
and I was on one side. And I will never forget, Gordon England 
said, If any of you Marines have any questions, I would hope 
you would step forward.
    And the second Marine that stepped forward said, I need 
some counseling; where do I go? You could have heard a pin 
drop. Secretary England didn't know how to respond. The company 
commander was fumbling, trying to get an answer out. And I felt 
so sorry for the Marine, for Secretary England, and really, the 
company commander. And I know that they do at the theater, at 
the war front, try to help them understand.
    But again, Ms. Sanchez is right; and I don't know if it 
will ever change or not, but I hope the Congress and people 
like yourselves, we can bring a different attitude. Because I 
am afraid--and your points have been well made, that we want to 
have men and women from Iraq and Afghanistan--especially Iraq, 
that they are going to need mental health counseling for 30 
years.
    It is not going to end. This is what I want to get to, and 
probably it is in your report, the families. I have told this 
story--my colleagues on the dais probably don't want to hear it 
again, but this has touched my heart so much that I will die 
and never forget this.
    A year ago I asked to be at Camp Lejeune at the grammar 
school to read Dr. Seuss to about ten kids whose parents are 
over in Iraq and Afghanistan, and at the end of it--I had 
trouble reading Dr. Seuss, by the way. I told the teacher, I 
apologize I couldn't pronounce some of those words. And she 
said, don't worry about it; I have trouble too.
    But anyway, I was letting the kids talk to me with 
questions or statements that they wanted to make. And it was 
pretty much, ``Have you been to the zoo? What do you all do in 
Washington? Have you seen the President?'' those kind of 
statements.
    ``I have been to Washington,'' a child said that.
    But this one kid, and I never will forget it, he was just 
wanting to make a statement, and the statement was, ``My daddy 
is not dead yet, my daddy is not dead yet.'' And I looked at 
the six-year-old child, and then I looked at the teacher. I 
don't know how I responded, but I responded, and it doesn't 
matter what I said.
    But my point is, we know we have mental health counselors 
in the military, on the bases. But I am really concerned that 
the children, I don't know what type of program and certainly 
it is up to the teacher to say, I think this child needs to 
talk to a counselor, but I think that it may not be that these 
children have any problems 10 or 15 years from now, but I am 
very concerned about the children who have their moms and dads 
deploying 3 and 4 and 5 times.
    You can't get away from the news. Whether you are for the 
war or against the war, you can't get away from the news.
    But this kid just really touched my heart; I will never 
forget it, ``My daddy is not dead yet.'' I mean, if you heard 
that child say that, would that bother you?
    Admiral Arthur. Congressman Jones, first, thanks for your 
support of the Marines. You supported me at Cherry Point when I 
was in command of the hospital there.
    Mr. Jones. Yes, sir. I enjoyed seeing you, sir.
    Admiral Arthur. I have repeated that story dozens of times 
already when I heard you say that in a full hearing in which I 
testified. It profoundly affected me. I get goose bumps now. I 
repeated it to the Task Force. And that story is the reason 
some of these recommendations are in there, that access 
anywhere, that the family members need them.
    Particularly, there are some recommendations and some prose 
in there about the teachers. And not just the teachers in the 
DOD schools at Camp Lejeune, but teachers around military bases 
that we can provide classes, educational material on what is a 
military family, what are the stressors that these young 
children are encountering with their military families; to 
train the school nurses, the guidance counselors and others, so 
that they get access to those mental health services--they 
don't have to go to a hospital; they get them--that teachers 
are more in tune to what these young, growing children are 
going to need.
    And that story is the reason that those are in this report.
    Mr. Jones. Thank you, sir. That is very encouraging. I look 
forward to reading the report. Thank you, sir.
    I yield.
    Mrs. Davis of California. Mrs. Boyda.
    Mrs. Boyda. Thank you, Chairwoman, I am so pleased to say. 
Thank you for your leadership.
    Chairman Snyder, I certainly have learned a great deal 
under you as a freshman, but I am of course thrilled to see a 
woman sitting in the chair. So, congratulations.
    I represent three districts or three military bases in the 
Second District of Kansas. And we are all telling our stories, 
so I will tell one of mine that touched my heart as well. And 
that was just speaking to a colonel who was stationed there. 
And this good, tough guy, you know, cares about the military 
and loves the military. And when we started talking about 
mental health services and things, and I was really questioning 
him about what we are doing, the man teared up and said, My son 
is serving over in Iraq right now, and I worry about his mental 
health.
    And his point to me was that everyone is very well aware of 
what is going on; that so many of our officers are needing the 
resources, that they are worried that we don't have the 
facilities to take care and the resources to take care, as they 
are active duty and certainly as they are in VA.
    So I had a couple of specific questions on Kansas. As I 
understand, and I apologize for having been late, but we don't 
have accredited health care, mental health care in Kansas. Can 
you speak to me specifically about what that means and how we 
are taking care of that?
    Dr. MacDermid. Sure. I am certainly not the most expert 
person on TRICARE in the world, but I will tell you what I do 
know.
    The specific type of treatment that I was referring to was 
residential and partial hospitalization treatment for substance 
abuse in particular. And even though that is not necessarily a 
large number of the patient population, it is obviously one 
that is a big concern if you have a teenage kid, during 
deployment, who needs treatment. It is going to be pretty hard 
for somebody to drive their kid every week to a neighboring 
state, which is what would be necessary in Kansas.
    Part of the issue is that TRICARE has very high standards, 
and for some services, TRICARE imposes an extra accreditation 
requirement. And providers testify to us that when that is 
combined with the low reimbursement rates for particular mental 
health diagnoses, it is a losing proposition and it is just not 
worth it.
    Mrs. Boyda. Are we working to untangle that web or what are 
we doing about that?
    Dr. MacDermid. That is a question I cannot answer. I shall 
look to my colleagues.
    Dr. Casscells. Congresswoman Boyda, on behalf of TRICARE, I 
would have to ask for your forbearance to get back to you about 
the specific services in your district. But please know that we 
have opportunities to make reasonable adjustments and 
reimbursement for services if we recognize an inadequacy.
    And General Granger who runs this program, runs TRICARE, he 
responds usually within 24 hours to a query, and not just from 
a Congresswoman. Patients send me e-mails, and he gets on them 
immediately and we look into it.
    And sometimes the anecdotes are out of date. It is from 
someone who tried to get a referral from a psychologist a year 
ago, when there was a temporary shortage, and they have now got 
enough people contracted with TRICARE. Or it is someone who 
didn't realize that they could go to a provider more than 30 
miles away.
    [The information referred to can be found in the Appendix 
beginning on page 162.]
    Mrs. Boyda. I hear about TRICARE reimbursements all over 
the place and how that really impacts access. In your opinion, 
or could I have some feedback at some time, is the 
accreditation on top of that? Is it a good balance? Are we 
pleased with that balance when we look at it today, or does 
that balance need to be looked at?
    And then as we--again, I apologize for not having been here 
at the outset, but where are we with working with the VA and 
not only making that transfer seamless, hopefully, but to 
utilize resources and co-utilize?
    Dr. Casscells. Thank you. I misunderstood your question. 
The accreditation is a tough issue since we responded to 
Congress's calls for quality by raising the bar. And this has 
had the effect of limiting people's access to less traditional 
providers.
    Mrs. Boyda. So when was the last time we actually looked at 
that balance?
    Dr. Casscells. Well, we have a big survey under way to look 
at this. And we had a number of complaints. For example, in the 
State of Washington, there has been an issue where some of the 
less traditional providers, maybe they are nutritionally 
oriented or oriented to Eastern approaches to therapy and have 
not been credited. So we are looking at ways we can utilize 
those providers.
    So we are reexamining this issue because standards evolve, 
and the needs of the service members evolve; their preferences 
evolve, and we increasingly are trying to recognize people have 
legitimate preferences.
    The traditional way in the military, of course, is a bunch 
of 18-year-old guys in their underwear, and they all get shots, 
and they don't get a chance to ask what shots they are getting. 
Well, this is really changing. People have rights. They have 
choices. They have preferences.
    We have much more diversity in the services than was true a 
couple of generations ago, and people are there by choice, so 
we have to honor choices. And that is the kind of thing that 
doesn't necessarily require legislation, it doesn't necessarily 
require that Congress throw money at it. It is a leadership and 
cultural issue. So we are struggling through that. Cultural 
change is slow.
    But if I could just point out a couple of things, because 
your committee has taken a broad view in the past under Dr. 
Snyder. I have looked back through the history of the 
committee, and I know that it has not just been medically 
focused, which I think is terrific, because so many things 
impact mental health.
    I am still kind of focused on theater, because I just got 
back from there a few months ago, but I am going again for a 
visit this coming month. But when General Casey abolished 
alcohol in theater, you know, that had a big impact, I think. 
But we can't say, because we don't really know how many of our 
problems were alcohol related in Desert Storm. We learned from 
Desert Storm that we needed more data, and even in this 
conflict we haven't gotten all the data we need.
    What about when guys and gals have cell phones in theater? 
They can be assured that their mom and dad are okay and their 
kids are okay. But then you get the phone call, like I did, 
that the kids' grades are going down. You are glad your kids 
are okay, but you are not happy about their grades going down 
while you are deployed.
    So, on balance, I think it is good not to have alcohol in 
theater. I think it is good to have cell phones.
    Cultural change is slow, but some things are happening. The 
Army yesterday announced that they are going to launch a big 
program, a required educational program about stigma and 
psychological care. This is going to be the biggest, most 
intense program since the sexual harassment program. Within 
five days they put together a program in All Army Activities 
(ALARACT) where everyone got training.
    Now, if this works in the Army, we obviously are going to 
ask the Navy and Marines and Air Force what they think of it, 
because this is unprecedented.
    Other little things, if I could address Ms. Sanchez's--I 
know she is gone--question of stigma. May I just say a couple 
things about that, Madam Chair?
    As you leave theater, you fill out the post-deployment 
health assessment on a Personal Digital Assistant (PDA), you 
know, a BlackBerry in theater. And we are changing that now so 
that it says at the top, if you give an answer suggesting you 
are highly stressed, it is okay, you will still get on the 
plane; we are not going to keep you in the sand, it is okay to 
fill it out honestly.
    Second, at six months not everyone has gotten back to us on 
the post-deployment health reassessment. So we are trying to 
build a network of people who would contact those people; maybe 
it is retired personnel, maybe it is chaplains, volunteers. We 
will be talking to the military families' organization about 
that, because it is not enough that half the people fill out 
the six-month post-deployment health reassessment. We need 
everybody filling that out.
    Another issue I have asked the line commanders to look at 
is, when your battle buddy dies in theater--and this is what I 
learned at Fort Bragg recently--the spouse really would love to 
have someone come home with the deceased and say how he or she 
died. And they want to know, of course, that the person died 
quickly, painlessly, that they were doing their duty. They 
would like to know the circumstances, they would like to 
visualize it.
    And it is very helpful, of course, if the battle buddy 
happens to have something to say about how they were doing and 
felt good about things and talking about their family. That 
helps enormously. It helps the family put things to rest; and 
it also helps the battle buddy, who otherwise feels that they 
have not done everything they could.
    So the line commanders are rethinking this, I am proud to 
say, and I have asked them, ``Please let the battle buddy go 
home with the deceased and attend the funeral and speak,'' and 
so forth.
    Last, whatever the committee can do to nudge the military 
health system in the direction of patient privacy and patient 
choice, these are important. And I am not sure they are 
financial, but they are cultural. In the military, the 
confidentiality of talking to your chaplain is absolute. The 
confidentiality of talking to your doctor is not; the line 
commander is entitled to get those records. I think it is worth 
reexamining.
    Thank you.
    Mrs. Davis of California. Thank you very much. As you can 
see, we are going to have some votes. But I want to take a few 
minutes to wrap up for everyone's benefit. I believe it is one 
15-minute vote and two 5-minute votes.
    You have all been terrific. I have really appreciated 
listening. We obviously haven't gone by the clock today so 
much, because it has been important to have the breadth of your 
comments.
    I had the opportunity to just come back from Iraq. A 
snapshot always; it is not something that you can do any major 
survey by. One thing that I did pick up in numerous 
conversations with troops and walking around was basically that 
people were more open to the issue.
    I can remember, and even when I have traveled in my own 
community of San Diego and gone to Balboa Hospital and asked to 
speak to a number of troops that were there--I have gone to the 
mental health wards both there and at Walter Reed--and it was 
kind of like nervousness around even having a member want to 
speak to the troops in that regard.
    And I certainly have a better sense of openness now. If you 
asked a question, people talked about it, and commanders said 
how important it was for them to sensitive. They didn't want to 
have full responsibility; they wanted to have somebody nearby. 
They wanted to be sure that if somebody brought up an issue and 
they needed help, that they were seen, that there was somebody 
there. They wanted to have information, but they didn't want to 
be the one who had to deliver any kind of therapy, if you will, 
in quotes.
    I had a different sense this time, and maybe because I was 
a little bit more focused on it, as well, but a real openness. 
And maybe that is a good thing; maybe we are moving in that 
culture.
    One of the things I wanted to just come back to very 
quickly, because we are going to want to look at the priorities 
in terms of legislation and what we can do. One of the issues 
that I believe Dr. MacDermid brought up was the derating and 
how that is done, how we are able to capture, I guess, value-
added even, if you will, on forms for the DOD and for TRICARE.
    We know that when we begin to assess the relative value of 
a unit-based system, how much money needs to be there for the 
number of individuals that are being served. Do we take into 
account the fact that people have had multiple deployments? Are 
we really understanding what that means not just in terms of 
the quality of care, but the number of visits, in fact, that 
might be required? Is that part of the system today? How do we 
readjust that? Is that something that you think we should be 
looking at? Would that be one of the priorities that you would 
suggest?
    Admiral Arthur. Yes, I think it should be prospectively. It 
is not only the number of deployments. But as I said before, 
the amount of combat stress, the time between deployments that 
they have. And there are many, many factors that are involved. 
How close are you to the actual fearful events that cause post-
traumatic stress? Yes, all those factors are considered.
    Dr. MacDermid. I would like to add that one concern I have 
is that I am not sure that we are gathering enough data to know 
the answers to your questions with regard to families. Our 
report contains a number of recommendations about research 
related to families. Their needs have not figured prominently 
in the lists of funded projects in recent years, at least on 
the medical side; and it is self-serving of me to point it out 
perhaps, but I think it is relevant to your question.
    Mrs. Davis of California. Thank you.
    Mr. McHugh, did you have a wrap-up question?
    Mr. McHugh. A wrap-up comment, Madam Chair. Thank you. And 
I share your appreciation for the panelists.
    And we look forward to a very grand body of work, because 
this is a grand challenge. And the Task Force report, I think, 
in the seven pages it lists very, very adequately all of the 
important points we need to cover.
    The only other thing I would say is, I was heartened, Dr. 
Casscells, that you are looking at the issue of accreditation, 
TRICARE accreditation, on mental health beds. The fact that the 
State of New York--and I imagine Kansas is in a similar 
situation--but the fact that the State of New York does not 
have any of these facilities that could be possibly accredited 
suggests that accreditation needs to be reexamined. Jayco is 
the widely accepted process for that; and TRICARE goes beyond, 
and I understand the need and the interest of TRICARE 
maintaining the highest possible quality. But I think we are in 
a real bind here that can be worked through. So I commend you 
for that.
    The other thing I would say is, part of the problem we have 
now is that military treatment facilities don't have these beds 
any longer, because at that time the judgment was made the 
civilian community can do it. Well, the civilian community 
isn't doing it. It goes back to TRICARE. But it is a cautionary 
tale about military and civilian conversions and writ large, if 
you will.
    So with that editorialization, again my deepest thanks.
    And again, Madam Chair, congratulations, and a pretty good 
job on your first voyage.
    Mrs. Davis of California. Thank you very much.
    You all made this morning very beneficial to all of us, I 
think; and your insights are greatly appreciated. But we look 
forward to the next steps. And I think part of the question is, 
at what point are we able to come back and really put the 
numbers in place to understand better really the dynamic from 
leadership's perspective, from filling in those positions, in 
fact, if that is what is needed, having people who actually are 
accountable for what is happening in this particular arena that 
we can look to. And that would be very important for us.
    And I wanted to ask you, do you have a time frame, 
Secretary Casscells, in terms of when we will begin to better 
understand the numbers and how we can work with those?
    Dr. Casscells. Madam Chair, we will have a set of numbers 
for the Secretary of Defense; September 12 is my deadline. I 
suppose he will study that, and he has a six-month period to 
get back to Congress.
    He has stated very clearly, he intends to do it in half 
that or so, so I think he will have had a chance to look these 
numbers over by the end of September and have some thoughts 
about it.
    Mrs. Davis of California. Thank you. We look forward to 
bringing together a piece of legislation that addresses all the 
good work that you did. Thank you very much for being here.
    [Whereupon, at 11:48 a.m., the subcommittee was adjourned.]


      
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                            A P P E N D I X

                             July 12, 2007

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              PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                             July 12, 2007

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                   DOCUMENTS SUBMITTED FOR THE RECORD

                             July 12, 2007

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             QUESTIONS AND ANSWERS SUBMITTED FOR THE RECORD

                             July 12, 2007

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            QUESTIONS SUBMITTED BY MRS. DAVIS OF CALIFORNIA

    Mrs. Davis. Please provide the subcommittee with a copy of the 
``Risk-Adjusted Population-Based Model'' used to determine staffing and 
resource allocation levels.
    Admiral Arthur. A Risk-Adjusted Population-Based model for 
determining Mental Health staffing within DOD does not yet exist. 
Elements within Health Affairs have been tasked with the development of 
such a model. This is an extraordinarily complex undertaking that 
involves an assessment of individual and group risk factors (such as 
deployment, the area to which one is being deployed, the frequency and 
length of deployment, and the intensity of combat in a particular 
deployment issue). We know that individuals exposed to more intense 
combat experiences are at higher risk for the development of combat 
stress related disorders. We also know that the incidence of such 
disorders increases with the number of deployments any particular 
service member has experienced. We do not know the effects of these 
factors on family members, nor do we know how such risks affect overall 
utilization of mental health services.
    We have solicited proposals for assistance in the development of a 
definitive model. We are in the process of currently reviewing some of 
those proposals. Our timeline is to have a model constructed in the 
next 7 to 12 months.
    Mrs. Davis. Please provide the subcommittee with a discussion (with 
specific examples) on how it would improve access to care by making 
certain mental health-related ICD-9 diagnosis codes (specifically ``V'' 
codes) reimbursable by TRICARE, which currently are not reimbursable.
    Admiral Arthur. V codes refer to problems in living or adjustment 
that are not attributable to a specific mental health disorder. In 
other words, they may be construed as life problems for which 
counseling may be of assistance but which do not connote the presence 
of mental illness. Mental Health V codes are not reimbursable under 
current TRICARE policy, as their treatment is not deemed medically 
necessary. Some examples of V codes for which clinical attention may be 
sought in a deployment related situation are (using DSM-IV 
categorizations):

V61.20--Parent-Child Relational Problem
V61.10--Partner Relational Problem
V61.8--Sibling Relational Problem
V62.81--Relational Problem Not Otherwise Specified, Problems Related to 
Abuse or Neglect
V71.02--Child or Adolescent Antisocial Behavior
V62.82--Bereavement
V62.2--Occupational Problem
V62.89--Phase of Life Problem

    Available evidence informs us that readjustment problems, 
particularly with family members, and occupational problems are 
significant for returning combatants. Family members may also 
experience similar adjustment difficulties. While service members and 
their families may seek care for such difficulties in military 
treatment facilities, or via Fleet and Family Support Centers or 
Military One-Source, these resources may be unavailable or of limited 
availability. The ability of service members or their families to seek 
counseling for such difficulties in non-DOD facilities will be enhanced 
if reimbursement were permissible for these problems.
                                 ______
                                 
                   QUESTIONS SUBMITTED BY MR. MCHUGH
    Mr. McHugh. You have got a seven-page list of recommendations here, 
and they are broken out into three different categories. Some do 
require legislation, others are policy and action. I think they all 
require money, or certainly most of them require money. So let me ask 
you, and you did define, and Dr. MacDermid defined what she felt were 
some of the most important things that the Congress do.
    Let me ask you to tick off, if you can, if you agree, three or four 
of the more important off of this list, because my understanding is 
this is not really prioritized in any particular way, so that we can 
get a focus in an area and think about translating policy into dollars, 
which is the ultimate challenge for us, frankly. Would that be possible 
today?
    Admiral Arthur. The accompanying Excel spreadsheet lists VADM 
Arthur's and Dr. MacDermid's recommendations for top/priority issues to 
be considered by the House Armed Services Committee when drafting 
legislation to enact the Mental Health Task Force's recommendations.
    The list is a combination of items that may require legislation, 
policy, and/or other action. The reason for this was to identify issues 
that are a priority, but that may not be fully accomplished without 
legislation.
                                 ______
                                 
                   QUESTIONS SUBMITTED BY MRS. BOYDA
    Mrs. Boyda. We don't have accredited health care, mental health 
care in Kansas. Can you speak to me specifically about what that means 
and how we are taking care of that?
    Dr. Casscells. There are currently no TRICARE certified residential 
treatment centers (RTCs) or partial hospitalization programs (PHPs) in 
the State of Kansas.
    The TRICARE Management Activity (TMA) is aggressively pursuing 
initiatives to improve beneficiaries' access to these facilities.
    (1) Access--TMA is comparing the physical location of TRICARE 
authorized behavioral health providers (both in network and outside 
network) to the physical location of TRICARE beneficiaries. Where 
deficiencies are identified, TMA will develop and implement process 
improvements to close gaps.
    (2) PHP Certification--TMA is revising the Code of Federal 
Regulations, TRICARE Reimbursement Manual, managed care support 
contracts, and the National Quality Monitoring Contract so that Joint 
Commission accreditation of a hospital will be sufficient for it to be 
a TRICARE authorized provider of psychiatric PHP services. This 
initiative is expected to be completed late 2008/early 2009. Upon 
completion, TRICARE certification of hospital-based psychiatric PHPs 
would no longer be required.
    (3) RTC Certification--TMA is reviewing TRICARE certification 
standards for RTCs to determine the advisability of modifying or 
eliminating some or all of them. The timeline for completion is March 
2008.
    The number of network outpatient mental health providers for the 
State of Kansas is 915, broken out as follows:

        Psychiatrists: 116
        Psychologists: 140
        Masters' Level Behavioral Health Professionals: 659

    Mrs. Boyda. Why is there a need for TRICARE to require higher 
provider standards for mental health services than is required by the 
state of Kansas?
    Dr. Casscells. Title 32 of the Code of Federal Regulations, Part 
199.6 implements the statutory authority under title 10, United States 
Code, section 1079(j) for institutional providers, and states that 
providers of health services are required to meet all licensing, 
certification and participation requirements to be an authorized 
provider eligible to receive payment for services provided to TRICARE 
beneficiaries.
    The strict certification standards adopted by TRICARE were the 
result of a review of the mental health care system in response to 
allegations of abuse and fraud in mental health facilities during the 
late 1980's and early 1990's. TRICARE recognizes that the certification 
standards may impose a burden on potential providers. However, 
standards for these facilities were developed in consultation with 
national mental health professional organizations including the 
American Psychological Association, the American Psychiatric 
Association, and the National Academy of Child and Adolescent 
Psychiatry. When these standards were developed, they were referred to 
as the ``gold standard in the industry.''
    Substance abuse disorder rehabilitation facilities that are part of 
TRICARE authorized hospitals only need behavioral health accreditation 
certification from the Joint Commission on Accreditation of Healthcare 
Organizations to participate in TRICARE; they do not require the 
additional TRICARE certification performed by the National Quality 
Management Contract. Currently, there are 196 TRICARE authorized 
hospital-based rehabilitation facilities in the TRICARE West region.
    An internal review by the TRICARE Management Activity (TMA) and 
recommendations of the Department of Defense Task Force on Mental 
Health cited issues related to beneficiary access to residential 
treatment centers, partial hospital programs, and substance abuse 
disorder rehabilitation facilities. Actions are under way to improve 
access to partial hospitalization programs and treatment for substance 
abuse disorders. Finally, TMA requested that the Joint Commission 
prepare a side-by-side comparison of their standards and TRICARE 
standards for residential treatment center. The comparison will provide 
a foundation for a detailed examination of TRICARE certification 
standards for these facilities from clinical, administrative, and 
patient safety perspectives. Moreover, the comparison will provide a 
basis for recommendations on the future of those standards.

                                  
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