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


                                     

                         [H.A.S.C. No. 110-116]
 
THE STATUS OF THE IMPLEMENTATION OF THE ARMY'S MEDICAL ACTION PLAN AND 
          OTHER SERVICES' SUPPORT FOR WOUNDED SERVICE MEMBERS

                               __________

                                HEARING

                               BEFORE THE

                    MILITARY PERSONNEL SUBCOMMITTEE

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                              HEARING HELD

                           FEBRUARY 15, 2008

                                     
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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
NIKI TSONGAS, Massachusetts
               Dave E. Kildee, Professional Staff Member
              Jeanette S. James, Professional Staff Member
                     Rosellen Kim, Staff Assistant


                            C O N T E N T S

                              ----------                              

                     CHRONOLOGICAL LIST OF HEARINGS
                                  2008

                                                                   Page

Hearing:

Friday, February 15, 2008, The Status of the Implementation of 
  the Army's Medical Action Plan and Other Services' Support for 
  Wounded Service Members........................................     1

Appendix:

Friday, February 15, 2008........................................    41
                              ----------                              

                       FRIDAY, FEBRUARY 15, 2008
THE STATUS OF THE IMPLEMENTATION OF THE ARMY'S MEDICAL ACTION PLAN AND 
          OTHER SERVICES' SUPPORT FOR WOUNDED SERVICE MEMBERS
              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

Schoomaker, Lt. Gen. Eric B., the Surgeon General of the United 
  States Army, and Commander, U.S. Army Medical Command, U.S. 
  Army; Brig. Gen. Michael Tucker, Assistant Surgeon General for 
  Warrior Care and Transition, U.S. Army; Vice Adm. Adam M. 
  Robinson, Surgeon General, U.S. Navy; Lt. Gen. (Dr.) James G. 
  Roudebush, Surgeon General, U.S. Air Force beginning on........     3

                                APPENDIX

Prepared Statements:

    Davis, Hon. Susan A..........................................    45
    McHugh, Hon. John M..........................................    48
    Robinson, Vice Adm. Adam M...................................    57
    Roudebush, Lt. Gen. (Dr.) James G............................    65
    Schoomaker, Lt. Gen. Eric B. joint with Brig. Gen. Mike 
      Tucker.....................................................    50

Documents Submitted for the Record:

    Army Medical Action Plan Update..............................    84
    Statement of Mutual Support submitted by James B. Peake, 
      Secretary of Veterans Affairs and Pete Geren, Secretary of 
      the Army...................................................    83

Questions and Answers Submitted for the Record:
    [There were no Questions submitted.]
THE STATUS OF THE IMPLEMENTATION OF THE ARMY'S MEDICAL ACTION PLAN AND 
          OTHER SERVICES' SUPPORT FOR WOUNDED SERVICE MEMBERS

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
                           Military Personnel Subcommittee,
                         Washington, DC, Friday, February 15, 2008.
    The subcommittee met, pursuant to call, at 10 a.m., in room 
2212, Rayburn House Office Building, Hon. Susan Davis 
(chairwoman of the subcommittee) presiding.

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

    Mrs. Davis. Good morning everyone. Thank you for being here 
with us today. The purpose of the hearing today is for members 
to get an update on the implementation of the Army Medical 
Action Plan (AMAP) for--are we calling that AMAP?--and hear how 
the Navy, Marine Corps, and Air Force are caring for their 
wounded warriors.
    At our last hearing on this subject, back in June of last 
year, the Army's Vice Chief of Staff, General Cody, suggested 
that we have him back in October and January to testify on the 
progress of AMAP toward full operational capability. 
Unfortunately, he is not able to join us this morning. I 
believe he is just on his way back from Iraq. But we are going 
to push forward and learn how far the AMAP has come and how far 
it still has to go.
    I want to also be clear that while we have spent a great 
deal of time focusing on the Army, we also are concerned about 
the Navy, the Marine Corps and the Air Force and how they are 
insuring that their wounded warriors and their families receive 
the appropriate care and the support needed.
    The subcommittee started to raise concerns about the 
quality and completeness of care provided to wounded warriors 
back in 2005 and we will certainly continue to focus on this 
issue.
    This hearing marks the first time that Vice Admiral Adam 
Robinson, Surgeon General of the Navy, has come before our 
panel. Welcome, sir. I am very happy to have you here.
    I also wanted to mention that while we have had these Army 
leaders testify about Walter Reed Army Medical Center before 
this subcommittee previously, today they are here in new roles.
    Lieutenant General Eric Schoomaker, formerly the Commander 
of the North Atlantic Regional Medical Command in Walter Reed 
Army Medical Center, became the Army's new Surgeon General in 
December.
    And Brigadier General Michael Tucker, formerly the Deputy 
Commander of the North Atlantic Regional Medical Command in 
Walter Reed Army Medical Center, is now the Army's Assistant 
Surgeon General for Warrior Care and Transition.
    In his opening statement last year, at the last hearing on 
this subject, Dr. Snyder remarked on the power of focus and 
about how true the revelations at Walter Reed and its aftermath 
almost all involved parties, including our wounded soldiers, 
family members, commissioners and advocates, and nothing but 
good things to say about the quality of inpatient care wounded 
soldiers have received at military hospitals.
    The Army Medical Action Plan has strived to set up new 
focus, a new structure to focus on the unmet needs of wounded 
warriors so that hospitals could continue their focus on 
patient care.
    Our challenge and our responsibility is to make certain 
that the military as a whole, and not just the military health 
care system, remains focused on the recovery and the 
rehabilitation of our wounded soldiers and their families, and 
that is what we are really here to do today and to see how that 
progress has occurred.
    I want to turn the meeting over to Mr. McHugh, also, for an 
opening statement.
    [The prepared statement of Mrs. Davis can be found in the 
Appendix on page 45.]

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

    Mr. McHugh. Thank you very much, Madam Chairman.
    I would ask that my prepared statement be entered in its 
entirety in the record and in the interest of time, let me just 
make a couple of comments.
    First of all, I want to add my words of welcome to our 
distinguished panelists this morning. As you noted, Madam 
Chair, we both appreciate and look forward to their 
participation here today, but more importantly, for the 
leadership and the concern they bring on behalf of all of us 
toward those who have worn the uniform and who have given so 
much in service to their country.
    I think we have come a long way. I think, as the chair 
noted, with respect to the Army, the AMAP plan has begun to 
address, with some good efficacy, the challenges and problems 
we saw arising out of Walter Reed.
    I think as you look at the other services, as well, notably 
the Air Force and the Navy, their programs are striving in 
directions that portend a lot of progress and a lot of help for 
those who need it.
    I do think there are challenges that remain, some 
disturbing developments through the warrior transition units, 
that we look forward to General Schoomaker's comments upon, 
from a parochial perspective, some recent press reports with 
respect to the transitioning and the working of the veterans' 
benefits administrators and assistance providers and the Army 
at Fort Drum.
    So we have tried to address those, but I am looking forward 
to General Schoomaker talking on a bit broader basis about 
those, as well.
    So our interest, our concerns are all similar here and that 
is to do everything that is necessary, everything that 
certainly is appropriate and more to pay back in some small way 
those who find themselves in medical need after serving so 
proudly in the uniform of this Nation.
    So thank you again, gentlemen, not just for being here, but 
for what you do, and we look forward to your testimony.
    With that, Madam Chair, I would yield back.
    [The prepared statement of Mr. McHugh can be found in the 
Appendix on page 48.]
    Mrs. Davis. Thank you, Mr. McHugh.
    General Schoomaker, if you want to begin and we will go 
down the line, and then we will have plenty of time for 
questions.
    Thank you, gentlemen, once again for being here.

 STATEMENT OF LT. GEN. ERIC B. SCHOOMAKER, THE SURGEON GENERAL 
  OF THE UNITED STATES ARMY, AND COMMANDER, U.S. ARMY MEDICAL 
   COMMAND, U.S. ARMY; BRIG. GEN. MICHAEL TUCKER, ASSISTANT 
  SURGEON GENERAL FOR WARRIOR CARE AND TRANSITION, U.S. ARMY; 
  VICE ADM. ADAM M. ROBINSON, SURGEON GENERAL, U.S. NAVY; LT. 
 GEN. (DR.) JAMES G. ROUDEBUSH, SURGEON GENERAL, U.S. AIR FORCE

            STATEMENT OF LT. GEN. ERIC B. SCHOOMAKER

    General Schoomaker. General Tucker and I have a single 
statement for the Army.
    Chairwoman Davis, Congressman McHugh and distinguished 
members of the subcommittee, thank you for providing the joint 
medical service Surgeon General and my Assistant Surgeon 
General and colleague, Brigadier General Mike Tucker, and me 
the opportunity to discuss warrior care and for us to discuss 
the total transformation that the Army is undergoing in the way 
we care for soldiers and families.
    And, ma'am, I noted in your introductory comments that your 
focus is on our services and how we as an entire service are 
focused on that, and I would like to talk about that here 
today.
    We as an Army are committed to getting this right and to 
providing a level of care and support to our warriors and 
families that is equal to the quality of their service.
    February 18, 2007, almost a year ago to the day, is the day 
that a series of ``Washington Post'' stories began about 
problems in the care that were provided soldiers and their 
families at one of our premier medical centers.
    It was a day that the Army will not soon forget. It was a 
painful day for us, as a proud institution, Army medicine, 
which truly prides itself in looking out for each other and for 
our brothers and sisters in arms.
    But because of those revelations and the strong response of 
Army leaders by our Secretary of the Army, Pete Geren, our 
Chief of Staff, General George Casey, and our Vice Chief of 
Staff, General Cody, we truly are a better Army today with 
respect to how we care for our soldiers.
    The Army remains committed to continuing to improve our 
care and support for those who have borne the battle and for 
their loved ones. We have instituted a comprehensive Army 
Medical Action Plan that you alluded to earlier, with which I 
believe all of you are familiar.
    While we are continuing to move forward, I would like to 
highlight a few of our accomplishments as part of this truly 
unprecedented effort.
    We now have more than 2,400 soldier leaders, 2,400 soldier 
leaders assigned as cadre to 35 warrior----
    Mrs. Davis. Excuse me, General, if you could just bring the 
mike a little bit further. I think they were having a little 
trouble hearing you.
    General Schoomaker. Yes, ma'am. Is that better?
    Mrs. Davis. Thank you.
    General Schoomaker. That is about as close as I can get it.
    Mrs. Davis. We can hear you just fine here, but I think 
they were having trouble in the back.
    General Schoomaker. We now have more than 2,400 soldier 
leaders assigned as cadre to 35 warrior transition units, small 
units that exist throughout the Army today, collocated with our 
medical treatment facilities, that did not exist last February.
    This is 2,400 small unit leaders in jobs where last year at 
this time we had fewer than 400 cadre for about the same number 
of patients, many with very complex injuries and illnesses.
    The most significant feature of these warrior transition 
units is a triad, which consists of a primary care physician, a 
nurse case manager and the squad leader, where they work 
together to attend to the needs of each individual and the 
family.
    The regular meetings and coordination between every leg of 
this triad really creates a web of overlapping responsibility 
and accountability that embraces every warrior for the duration 
of their treatment, their recovery and their rehabilitation, 
and then transition back into uniform and service or fully 
recover back into a productive civilian life or into continued 
care and rehabilitation in the Veterans Administration (VA) or 
into our network of private health care.
    Our squad leaders, many of them are combat arms soldiers 
and former patients themselves, are trained and responsible for 
the well being of a small group of warriors in transition in 
their squad, just like any other Army unit.
    In the room today, if I might, ma'am, I would like to 
introduce four of the warrior transition brigade small unit 
leaders at Walter Reed today. Colonel Terran McKendrick is a 
career infantryman who has the distinction of having stood up 
the first warrior transition unit in the Army. He and his 
Command Sergeant Major, Jeff Hartless, who is with him here 
today; Major Steve Gventer, one of our company commanders and 
First Company Commander in the Walter Reed warrior transition 
brigade; and, his First Sergeant, Matthew Dewsberry, are here 
with us today and I would just like to acknowledge them and the 
terrific work that all of them have demonstrated here.
    These are the soldiers who really wrote the doctrine, wrote 
the training courses and taught us how to do this right, and I 
would like to thank them for being here today.
    Thank you, gentlemen.
    Mrs. Davis. Thank you.
    General Schoomaker. All four are combat tested leaders. 
They spend their busy day looking out for the best interests of 
their wounded, ill and injured soldiers. Two, in fact, have 
been wounded themselves in combat and were patients at Walter 
Reed. So they have tremendous insight into what could make that 
place work better and what they felt worked well for them and 
their families.
    In less than one year, and this is noteworthy, in less than 
one year, the Army has funded, staffed and written the doctrine 
to establish these new organizations.
    It is a significant change and it is the backbone of our 
Army Medical Action Plan.
    Another improvement in the care of the soldiers is that a 
year ago, our wounded, ill and injured believed that their 
complaints were falling on deaf ears within the Army. Now, we 
have established a medical command-wide ombudsman program, with 
ombudsmen at 26 of our installations across the Army and we are 
hiring more every day.
    Everyone at our treatment facilities knows who the 
ombudsmen are, they know how to find him or her. Many are 
retired NCOs, non-commissioned officers, or officers themselves 
with medical experience. They work outside of our chain of 
command, but they have direct access to the hospital commander, 
to the garrison commander, to the installation senior mission 
commander, to get problems fixed.
    We have also established a 1-800 wounded soldier and family 
hotline, and I would draw your attention to a card that you 
have here. I encourage you to take it back with you.
    In fact, we hand them out as often as we can to people who 
are interested in this, and Congressman McHugh may be 
interested, but when we worked with the VA recently in putting 
together our memorandum of understanding, we actually gave them 
these and they are setting up a similar hotline for the VA to 
solve problems for soldiers and families on the fly.
    They can share concerns through this 1-800 line 24 hours a 
day about any aspect of their care or administrative concerns. 
We have fielded in excess of 7,000 calls to date and we answer 
that call and find a solution for them and get the process 
going to get it ultimately fixed within 24 hours.
    Over the last year, we have developed multiple feedback 
mechanisms so that we can see ourselves from a variety of 
perspectives. This is one of the things that the ``Washington 
Post'' stories taught us, that we weren't seeing the full 
picture.
    To accomplish this, we monitor and evaluate our performance 
through 18 internal and external means, including the ombudsmen 
and the hotline that I mentioned earlier.
    We also use a contracted industry leader in patient surveys 
to provide us a very granular view of how our patients and 
families feel we are doing for them.
    We host numerous visits from Members of Congress and your 
staff. In January alone, we opened our warrior transition unit 
doors to more than a dozen congressional visits.
    These visits give us a valued external perspective and 
allow us the opportunity to be as open and as transparent in 
our operations as possible, and, quite frankly, your feedback 
on these visits and your staff's feedback has been instrumental 
in our success, and we extend our appreciation for that.
    As you well know, despite these successes there is much 
progress still to be made. We still need more research into 
psychological health and traumatic brain injury.
    Congress jumpstarted us last year with supplemental funding 
for both research and care, for which we are truly grateful, 
but research needs to be our continuing priority effort.
    We must continue to look into the physical disability 
evaluation system and the ways to make it less antagonistic, 
more understandable and more equitable for soldiers and their 
families, and more user-friendly.
    I can tell you that one of the most difficult aspects of 
being the commander at Walter Reed and going through this 
troubled period was as a physician who spent his career trying 
to help patients, standing in front of town hall meetings with 
patients and families and feeling that I was the enemy, that I 
wasn't there to help them, that I was hurting them in some 
aspect, and I would submit that that is a direct outgrowth of 
our divisive and antagonistic physical disability evaluation 
system between the Department of Defense (DOD) and the VA.
    I believe that the pilot program that we have started in 
the National Capitol region is a good start, but I want to 
continue to pursue changes in the disability evaluation system 
as aggressively as possible and to get legislative relief for a 
single disability adjudication.
    We need your continued support so that we can move forward 
together in 2008 as we have in 2007. This year's National 
Defense Authorization Act was very consistent with how the Army 
is approaching wounded warrior matters.
    I truly appreciate the flexibility you provided us to 
develop policies and to achieve solutions and not to 
micromanage details of how we do that and how we develop and 
grow our warrior transition units.
    Your bill not only helps our warriors, it helps our 
families, it helps health care providers in caring for them, 
and we truly thank you for the time you took to listen to us 
and to work with us.
    The Army's unwavering commitment and a key element of our 
warrior ethos is that we never leave a soldier behind on the 
battlefield or lost in a bureaucracy. We are doing a better job 
of honoring that commitment today than we were at this date 
last year.
    In February of 2009, I want to come back to you and report 
that we have achieved a similar level of progress as we have 
over this last year. I am proud of Army medicine's efforts over 
the last 232 years and especially over the last 12 months to 
help our warriors and their families.
    I am convinced that, in coordination with the Department of 
Defense, my colleagues here at the panel today, the Department 
of Veterans Affairs, and the Congress, we have turned the 
corner.
    Thank you for holding this hearing. Thank you for your 
continued support of our warriors and their families. We are 
truly honored to serve them.
    I look forward to your questions.
    [The joint prepared statement of General Schoomaker and 
General Tucker can be found in the Appendix on page 50.]
    Mrs. Davis. Thank you.
    Admiral Robinson.

            STATEMENT OF VICE ADM. ADAM M. ROBINSON

    Admiral Robinson. Good morning. Thank you, Chairwoman 
Davis, Ranking Member McHugh, and distinguished members of the 
committee.
    Your unwavering support of our service members, especially 
those who have been wounded during Operations Enduring Freedom 
(OEF) and Operation Iraqi Freedom (OIF), is deeply appreciated.
    In the last year or so, the interest and concern about the 
care and support being provided to our service members when 
they return from combat has increased dramatically.
    From those with severe injuries to those whose significant 
injuries may not be visible to the naked eye, our Nation is 
providing care to a generation of veterans unlike those from 
previous conflicts.
    For Navy medicine, the progress a patient makes from 
definitive care to rehabilitation and in the support of 
lifelong medical requirement is the driver of where a patient 
is clinically located in the continuum of care.
    Medical and administrative processes are tailored to meet 
the needs of the individual patient and their family, whatever 
that may be. For the overwhelming majority of our patients, 
their priority is to locate their care as close to home as 
possible.
    We learned early on that families displaced from their 
normal environment in dealing with a multitude of stressors are 
not as effective in supporting the patient in his or her 
recovery.
    Our focus is to get the family back to normal or as close 
as we can possibly get it as soon as possible, which means 
returning the patient and their family home to continue the 
healing process.
    Navy medicine takes into consideration family dynamics from 
the beginning and they are looked on as part of the care team. 
Their needs are also integrated into the care plan. They are 
provided with emotional support by encouraging the sharing of 
experiences among other families, that is, family-to-family 
support, and access to mental health services.
    Also, families receive assistance dealing with 
administrative issues when necessary through the Marine 
Casualty Services Branch. I may say that we also have Army and 
Air Force liaisons that do the same thing.
    One of the cornerstones of Navy medicine's concept of care 
is to capitalize on our longstanding and effective partnership 
with the Marine Corps in caring for injured and ill Marines. 
The Marine Corps has always maintained a presence in our 
medical treatment facilities in the form of a Marine Corps 
liaison office staffed with Marine Corps personnel and 
Administration experts.
    At the outset of OEF/OIF, the Marine Corps quadrupled the 
size of their liaison offices at key casualty receipt 
locations, anticipating the increased volume and the unique 
needs of this patient population and their families.
    Working side by side with Navy medicine providers, the 
recently established wounded warrior regiment, in April of 
2007, made Marine liaisons available immediately to the 
patient, their family and the clinical care team.
    Navy medicine takes care of the patient's clinical needs 
and the wounded warrior regiment becomes an optimizing adjunct 
to the patient care plan.
    Based on a concept of care of Marines taking care of 
Marines, the Wounded Warrior Regiment has ensured that the care 
provided to our wounded, ill and injured is not just a process, 
but a relationship with lifelong care.
    Like the Wounded Warrior Regiment, Navy established a safe 
harbor program in 2005 to meet the needs of severely injured 
sailors from OEF/OIF. It is expected that approximately 250 
sailors each year will need the services provided by this 
program, which will include non-clinical case management for 
the sailors and their families.
    Safe harbor case managers are actively collecting feedback 
from program participants to closely monitor the program's 
successes and to make improvements where needed.
    In Navy medicine, we have established a dedicated trauma 
team, as well as a comprehensive multidisciplinary care team, 
which works to maximize the interface with all of the partners 
involved in the continuum of care.
    To move patients closer to home requires a great deal of 
planning, interaction and coordination with providers, case 
workers, and other health care professionals to ensure smooth 
movement across the continuum of care.
    Our single trauma service admits all OEF/OIF patients with 
one physician serving as the point of contact for the patient 
and for their family.
    Other providers serve as consultants, all of whom work on a 
single communication plan. In addition to providers, other key 
members of the multidisciplinary team include the service 
liaisons at the MTFs, the medical treatment facilities, the VA 
health care advisors, and the military service coordinators.
    We also expanded our nurse case management capabilities, 
increasing the number of case managers from 85 in 2006 to 148 
funded positions today. In addition, VA has established liaison 
offices at Navy hospitals and at Navy clinics for the purposes 
of coordinating follow-on care requirements and providing 
education on VA benefits.
    Also, the newly created Federal recovery coordinators are 
located at National Naval Medical Center (NNMC) and Naval 
Medical Center San Diego.
    The lessons learned at Bethesda, NNMC, the Navy facility 
that has treated most returning casualties, have been exported 
to other facilities, both in and out of the Navy, involved in 
casualty care.
    The development of these lessons was a collaborative effort 
to improve processes and outcomes. Currently, weekly 
teleconferences between our hospitals, between NNMC and Balboa 
and others and the VA polytrauma rehabilitation centers is 
ongoing to ensure continuity of care.
    One key issue for patients requiring care at another 
facility is the physical transition of leaving the protective 
environment of an acute care facility and moving to a 
rehabilitative environment.
    When a patient is headed to a VA facility, there is 
significant coordination between the military, the VA liaison 
and the transferring Navy medicine MTF, medical treatment 
facility, and the electronic copies of medical records are 
transferred to the receiving facility.
    We continue to make significant strides toward meeting the 
needs of military personnel with psychological health needs and 
traumatic brain injury related diagnoses, their families and 
their caregivers.
    Service members who return from deployment and have 
suffered such injuries may later manifest symptoms that do not 
have a readily identifiable cause, with potential negative 
effects on their military careers and, of course, on their 
quality of life and most directly on their families.
    Our goal is to establish comprehensive and effective 
psychological health and traumatic brain injury services 
throughout Navy and Marine Corps. This effort requires seamless 
programmatic coordination across the existing line functions, 
while working numerous fiscal, contracting and hiring issues.
    Your patience and your persistence are deeply appreciated 
as we work to achieve long-term solutions to provide the 
necessary care.
    Chairwoman Davis, Ranking Member McHugh, distinguished 
members of the committee, I again want to thank you for holding 
this hearing and continuing to shed light on these important 
issues.
    Also, it is my pleasure to testify before you today and I 
look forward to answering any of your questions.
    Thank you very much.
    [The prepared statement of Admiral Robinson can be found in 
the Appendix on page 57.]
    Mrs. Davis. Thank you.

         STATEMENT OF LT. GEN. (DR.) JAMES G. ROUDEBUSH

    General Roudebush. Good morning. Madam Chairwoman, Ranking 
Member McHugh, distinguished members, it certainly is an honor 
and privilege for me to be here with this distinguished panel, 
my partners in providing individual and collective joint 
capabilities to our wounded warriors.
    This is indeed important business and it is a pleasure to 
be here before you today to be able to discuss that with you.
    Your Air Force is America's force of first and last resort 
to guard and protect our Nation. To that end, we Air Force 
medics--and when I use medics, I use that term broadly--our 
officers, enlisted, all professionals within the Air Force 
Medical Service, we Air Force medics work directly for our line 
leadership in addressing our Air Force's top priorities--
winning our Nation's fight today, taking care of our people and 
preparing for tomorrow's challenges.
    No modern war has been won without air superiority and no 
future war will be won without airspace and cyberspace 
superiority. The future strategic environment is complex and 
uncertain. Be assured that your Air Force and Air Force Medical 
Service are ready for today's challenges and are preparing for 
tomorrow's.
    It is important to understand that every Air Force base, at 
home station and deployed, is an operational platform and Air 
Force medicine supports war fighting capabilities at each of 
our bases.
    Our home station military treatment facilities are the 
foundation from which the Air Force provides combatant 
commanders a fit and healthy force capable of withstanding the 
rigors and physical challenges associated with combat and other 
military missions today.
    Our emphasis on fitness and prevention has led to the 
lowest disease and non-battle injury rate in history. Deployed 
forward, the Air Force Medical Service is central to the most 
effective joint casualty care system in military history.
    Forward stabilization followed by rapid air evacuation has 
been repeatedly proven to be the gold standard in saving lives.
    We have safely and rapidly moved more than 48,000 patients 
from overseas theaters to stateside care during Operation 
Enduring Freedom and Operation Iraqi Freedom. Today, the 
average patient arrives from the battlefield to stateside care 
within three days and, if required, within 18 to 20 hours.
    This is remarkable given the severity and complexity of the 
wounds that our forces are sustaining and has directly 
contributed to the lowest died-of-wounds rate in history.
    The daily delivery of health care at our medical treatment 
facilities is also critical to maintaining those critical 
skills that guarantee our readiness capability and success.
    We care for our families at home. We respond to our 
Nation's call supporting our warriors and we also provide 
humanitarian assistance to countries around the world.
    To execute these broad missions, all of our services, Air 
Force, Navy and Army, must work interoperatively and 
interdependently. Every day, together, those that you see 
before you here today, every day, together, we earn the trust 
of America's all volunteer force, airmen, soldiers, sailors and 
Marines and their families, and we hold that trust very dear.
    Today we are here to address the health needs of our 
returning warriors. The Air Force is in lockstep with our 
sister services and Federal agencies to implement the 
recommendations from the President's commission on the care for 
America's returning wounded warriors. We will deliver on all 
those provisions, as well as those set forth in the 2008 
National Defense Authorization Act (NDAA) and provide our war 
fighters and their families the help they need and deserve.
    The Air Force Medical Service is focused on the 
psychological needs of our airmen and reducing the effects of 
operational stress. The incidence of post-traumatic stress 
disorder (PTSD) is low in the Air Force, diagnosed at less than 
one percent of our deployers.
    For every airman affected, we provide the most current 
effective and empirically validated treatment for post-
traumatic stress disorder. We have trained more than 200 
psychiatrists, psychologists and social workers to recognize 
and treat PTSD in accordance with the VA/DOD PTSD clinical 
practice guidelines.
    We hired an additional 32 mental health professionals for 
those locations with the highest operational tempo to enhance 
the care for our airmen and their families.
    The Air Force is also an active partner with the Defense 
Center of Excellence for Psychological Health and Traumatic 
Brain Injury, the VA, the Centers for Disease Control (CDC), 
industry and academia in collaborating on research in traumatic 
brain injury prevention, assessment and treatment.
    We thank Congress for fiscal year 2007 supplemental 
funding, which strengthened our psychological health and 
traumatic brain injury program research, surveillance and 
treatment. It has improved access, coordination of care and the 
transition of our patients.
    The Air Force wounded warrior program, formerly known as 
Palace Heart, continues to maintain contact and provide 
assistance to wounded airmen both on active duty and following 
separation from the Air Force for a minimum of five years.
    We are committed to meeting the health needs for our airmen 
and their families and will continue to execute and refine 
those programs.
    In closing, Madam Chairwoman, I am humbled by and intensely 
proud of the daily accomplishments of the men and women of the 
United States Air Force Medical Service. The superior care 
routinely delivered by Air Force medics is a product of 
preeminent medical training programs, groundbreaking research, 
and a culture of personal and professional accountability 
fostered by the Air Force's core values.
    With your help and the help of this committee, the Air 
Force and partnering with our Navy and Army counterparts and 
comrades in arms will continue our focus on the health of our 
war fighters and their families.
    Thank you for your enduring support and I look forward to 
your questions.
    [The prepared statement of General Roudebush can be found 
in the Appendix on page 65.]
    Mrs. Davis. Thank you very much. Thank you for all of your 
presentations. And you certainly stayed within a good time 
frame, as well.
    What we are going to do, I am going to keep to my five 
minutes, and I think we can have at least two rounds and all 
questions from members that are here.
    Let me start, General Schoomaker, with you, if I may. And I 
think that we are impressed by the changes, the response that 
you all have made and we would hope, certainly, that our men 
and women who are serving us today are feeling the impacts of 
the changes that have been made and in a very positive way.
    Could you then speak to the sustainability of this effort, 
both as it relates to our budget and personnel, as well, 
because we seem to have very high caliber of those who are 
serving in the capacities that you have outlined today, and, 
yet, how can we sustain that effort, as well?
    But, first, on budget. Where is this in the budget, in the 
2009 budget, and is that, do you think, where it should be?
    General Schoomaker. Yes, ma'am, and thank you for that 
question. I think that is one of the issues that the Army and 
the Department as a whole is very focused on right now, the 
sustainability, and many ask what evidence we can present that 
shows that this is going to be a long-term, sustainable 
process.
    I would answer that in three forms. First of all, we 
respond in three ways to sustainability. First, through our 
organizations, do we have tangible evidence in our 
organizations that we have changed the way we do business.
    And I would point to the assistant surgeon general for 
warrior care and transition who oversees a cell now that is 
codified in our organization, in the medical command, in the 
Office of the Surgeon General, as well as the warrior 
transition units that are embedded within each one of my 
regional medical commands and medical treatment facilities.
    This is----
    Mrs. Davis. I think, General, does that lie in the base or 
in the supplemental?
    General Schoomaker. Currently, most of the funding to 
support administratively and the barracks that would be built 
to support those warrior transition units are in supplemental.
    They have been programmed--they have been placed in the 
Program Objective Memorandums (POMS) of our submissions and 
proposed supplemental adjuncts for both fiscal year--they went 
into the fiscal year 2008 budget and I am told they are in 
fiscal year 2009.
    And we have some substantial requests for funding for 
barracks and the like. That is the second way that we are 
showing sustainability. And, third, of course, our policies, we 
are writing formal Army policy and doctrine that will be out 
there and will drive the way that these organizations and these 
soldiers are cared for.
    Mrs. Davis. I think, though, in many ways, if we are 
thinking of this in an institutional way, we are looking to ask 
whether or not it should be in the base budget as opposed to 
the supplemental budget.
    General Schoomaker. And, ma'am, I think----
    Mrs. Davis. Why does that work for you?
    General Schoomaker. I think you are echoing the Chief of 
Staff of the Army, whose challenge it is to migrate more of our 
funding in the supplemental into the base.
    Mrs. Davis. More of the supplemental?
    General Schoomaker. Into the base.
    Mrs. Davis. Into the base.
    General Schoomaker. Into the Army's base.
    Mrs. Davis. And the Army has forecasted that it would need 
about $1.4 billion in fiscal years 2008, 2009 and 2010 to build 
the warrior transition complexes.
    Is this the funding coming, again, out of other medical 
projects or is it new funding? You mention in the supplemental, 
but----
    General Schoomaker. It is new funding.
    Mrs. Davis. It is all new funding.
    General Schoomaker. It is all new funding, and it is 
largely being carried not by the medical command, it is carried 
by the installation management command as a part of the 
building of our installations.
    It provides barrack space, administrative space and all of 
those areas necessary to house the soldiers and the cadre that 
are going to be caring for them.
    Mrs. Davis. Thank you. And if I could quickly just move to 
personnel and how we can expect the Army to fill the warrior 
transition unit positions, given the challenges that you face 
in Iraq and Afghanistan, and grow the Army.
    How do we do that?
    General Schoomaker. The Army has been very forthcoming. We 
stood up the warrior transition units in June, and we had full 
operational capability in early January. We currently stand at 
in excess of 90 percent of the cadre necessary to run all of 
our warrior transition units on the documents that were 
provided, and we are at the projected ratios that we require 
for squad leaders, for nurse case managers and primary care 
managers for each one of those warrior transition units right 
now.
    Mrs. Davis. In visualizing this and the large number of men 
and women that are required to fill these positions, I 
understand it is more than in a brigade combat team. Is that 
correct? As you look at the E-5s and E-6s or, I guess, the bulk 
of the 2,500 Warrior Transition Unit (WTU) cadre that are mid-
grade and non-commissioned officers.
    General Schoomaker. Can you speak to that?
    General Tucker. No, ma'am. Although these are units that 
are representative of companies, battalions and brigades that 
we have in the Army, the amount of leadership, comparatively 
speaking, leader for leader, there are not as many leaders.
    I will give you an example. At the lowest level, the squad, 
the squad leader is a staff sergeant. The 1-to-12 ratio on 
which we based it was based on FM-7-8, the infantry platoon, a 
longstanding document in our Army to which we have always based 
command and control.
    In an infantry platoon, however--an infantry squad--excuse 
me--you have a staff sergeant commanding the squad, as we have 
in a WTU, but that squad leader also has two team leaders who 
are sergeant E-5s, and we don't have those sergeant E-5s, 
because you don't need those sergeant E-5s because it is not a 
tactically deployed unit.
    They break off into rifle teams and deploy, so to speak, 
tactically. But we have the staff sergeant there where we 
didn't have the staff sergeant before. Before, we had a platoon 
sergeant, who, in most cases, was a staff sergeant, but it was 
1-to-50. Now we have a staff sergeant 1-to-12.
    And so the number of leaders, per se, to soldier in a WTU 
is not exactly the same numbers you would see in a brigade 
combat team, ma'am.
    Mrs. Davis. Will we be able to look at those numbers soon 
as we would other readiness units, so we can determine the 
extent to which we have the people that are necessary to fill 
these positions?
    General Tucker. Yes, ma'am. And just to back up, if I could 
expound a little bit on it, the squad leader in this case is 
not standing alone. He has got a nurse case manager, a primary 
care manager alongside of him, a platoon sergeant to help, as 
well, and an entire arsenal of other medical care providers 
that work with the squad leader every day to take care of the 
social workers, occupational therapists, vocational education 
specialists, just to add a few that are part of the whole team.
    General Schoomaker. But to answer directly, we are 
currently doing exactly what you say, ma'am, and we will be 
holding quarterly training reviews of exactly these questions 
to make sure that we are sufficient for staffing.
    The Vice Chief of Staff of the Army has, throughout the 
standup of these units, done that personally with all of the 
warrior transition teams.
    Mrs. Davis. Thank you.
    General Tucker. And every 90 days, we review the table of 
distribution allowances (TDA), that has authorized our numbers 
per unit. We review that every 90 days and determine whether or 
not it is the right mix, at the right pay grade, at the right 
numbers for our population, to keep ourselves abreast of what 
is changing as we continue to progress.
    Mrs. Davis. Thank you.
    Mr. McHugh, beg my indulgence, I went over.
    Mr. McHugh. Thank you, Madam Chairman.
    Just another question on that point. General Schoomaker, 
you mentioned the vice chief. The vice chief had a directive 
that these units be fully manned up by January 2.
    Your testimony and your comments, you are a little over 90 
percent. When are we going to hit 100?
    General Schoomaker. In some cases, for particular roles 
within the cadre, we are over 100 percent. Across the board, I 
gave you the rollup. And by the way, when we gave the fully 
operational and capable briefing to the vice chief on or about 
that date, we were agreeing, that is, that we had achieved a 90 
percent or above goal by that date.
    And I say that is a grand rollup of all of those roles, 
squad leaders, company commanders, nurse case managers, 
physicians.
    Mr. McHugh. So you are full up now.
    General Schoomaker. Yes, sir. For all intents and purposes, 
we are entirely staffed at the point we need to be staffed.
    Mr. McHugh. Okay, because I know the directive said 100 
percent. It didn't distinguish. But if you are full up, that 
was the question.
    I thank you for bringing those soldiers that are heading up 
these transition units. They are the face of this program and 
its success is going to rise, as you know, General, from their 
dedication and I have every confidence they are going to do a 
great job.
    But there have been some challenges lately, three deaths in 
warrior transition units just in the last three weeks, another 
apparent unintentional suicide from an overdose in Kentucky.
    Can you give us any insight as to what you have done to 
look at the deaths and what, if anything, you have or hope to 
be able to do to respond to those?
    General Schoomaker. Yes, sir. Thank you for that question.
    You are right, now that we are concentrating all of our 
wounded, ill and injured soldiers in our warrior transition 
units, we are beginning to have the visibility that we didn't 
have heretofore. All of us have experiences of soldiers within 
units, patients or non-patients, formerly within our hospitals, 
who may have inadvertently overdosed with either near lethal or 
lethal consequences.
    But now what we are seeing is, having concentrated all of 
our soldiers within the units, we are seeing a pattern 
emerging, a trend. We have now had 11 deaths since June in our 
warrior transition units, three from accidental death from 
overdoses, four suicides, frank suicide, and I contrast the 
accidental overdoses with suicide.
    I truly think these are unintentional. These are 
accidental, not unlike what the CDC, the Centers for Disease 
Control and Preventive Medicine has reported recently has 
become an almost epidemic problem in the United States with 
prescription drugs.
    And we have had deaths from motor vehicle accidents and we 
still have several under investigation.
    We have recently brought together a team of experts, 
epidemiologists, pharmacy specialists, some of our warrior 
transition unit leaders, physicians, nurse case managers, 
specialists from the Army's Combat Readiness Center or formerly 
our safety center to look at how--what are the root causes of 
these and near misses that we have had, because we have been 
able to find, again, through a better tabulation of clinical 
events in our electronic health record, that there are other 
near events that could have very easily resulted in death, as 
well.
    The combination of multiple prescription drugs in patients 
who have chronic pain, and not always chronic pain from severe 
battle injuries, most of these, in fact, were training 
accidents or degenerative problems of a kind.
    Compound that with behavior health or mental health 
challenges and then you add alcohol to that combination, 
especially on a weekend, if it is unsupervised, and you get a 
toxic combination that can result in death, and that is exactly 
what has happened in several of those accidental deaths.
    We are now instituting some policies that are going to 
mitigate those risks from sole provider programs. So that as 
you begin to amass greater needs for prescription drugs that 
may obscure the sensorium or may be potentially lethal, that we 
have a single provider, a single physician or nurse 
practitioner prescribing those drugs so that they can monitor 
them effectively.
    We have better accountability through our triad in the 
warrior transition units and that we create alcohol-free zones 
around the barracks and around the treatment areas that our 
patients are in.
    Understand, sir, that these are not inpatient. These are 
outpatients. They are living, some of them, with families in 
guest homes and the like, and we have recognized that that is a 
problem.
    Does that answer your question, sir?
    Mr. McHugh. Yes, for the most part. Obviously, tighter 
control on the allocation of prescriptions and where you might 
have counter indications there, it would be important.
    But it is something we want to follow and I just want to, I 
guess, add, for the record, that we are, as a committee as a 
whole, and I know you are, as well, I didn't mean to suggest 
you are not, are deeply concerned about this. So we will be 
watching you progress.
    Thank you. Thank you, Madam Chair.
    Mrs. Davis. Thank you, Mr. McHugh.
    Mrs. Boyda.
    Mrs. Boyda. Thank you.
    Thank you all for coming and for the soldiers that have 
come and joined us today.
    I was out at Walter Reed a little while ago and what a 
difference a year makes. So thank you very much for how the 
Army has addressed this issue and moved forward.
    I am going to have a couple rounds of questions, so I will 
just come back to what we were just talking about to get some 
additional information.
    When you have a prescription drug that has the potential 
for abuse, is the soldier given a 30-day supply of that or a 
15-day supply at a time or how is that actually administered?
    General Schoomaker. I think that is very dependent on the 
case, ma'am. Our soldiers are like any other patients that 
America has and they are treated by physicians, nurse 
practitioners and physician's assistants in accordance with 
clinical indication.
    I think you may know that there has been a great deal of 
attention over the last few years to ensure that our patients 
aren't in pain. There isn't a patient who goes into any clinic 
or emergency room in America today that isn't asked by the 
staff, ``Are you in pain? Is there anything we can do to 
mitigate pain?'' And I think that has contributed to probably 
our being very aggressive about prescribing drugs.
    That is not coordinated sufficiently, and especially if the 
patient isn't aware of the potential lethality of these 
combinations, you run into problems.
    And as I said before, if you also are suffering from an 
emotional or psychological problem, that further drives you to 
take more than you might have. If you add alcohol in 
combination, then we have a problem.
    Mrs. Boyda. With the 1-to-12 ratio in that unit, is it 
possible then to just not give overdose quantities at a time?
    General Schoomaker. That is going to be part--that is part 
of our policy case.
    The last thing I think that any of us wants to do is to 
take a patient who is on a stable course of medication for, 
say, pain relief and make them suffer because of draconian 
policies that we establish. But I think having the command and 
control that we now have, we can do a case by case assessment 
of what the risks are and do exactly what you are talking 
about.
    Mrs. Boyda. The 1-to-12, I mean, that is pretty close care.
    General Schoomaker. Yes, ma'am.
    Mrs. Boyda. And then the 1-to-18 on the nurse. The soldier 
that I had gone to visit at Walter Reed is doing well, saw him 
recently, and a good guy, a specialist, and I asked him how are 
things going and he couldn't say enough good about so many 
things.
    He was getting better. The doctors were good. He went on 
about how well things are going.
    There is a ``but'' coming.
    General Schoomaker. Yes, ma'am.
    Mrs. Boyda. And that ``but'' was he said, ``The only 
problem is it takes me forever to see the doctor.'' So I said, 
``Is it 1-to-200?'' He goes, ``Well, I don't know about that. I 
just know that it takes me about a month and a half to see a 
doctor.''
    Now, I would like to just--at some point, we will follow up 
on his case specifically, and that was just an off the--with a 
1-to-200 ratio of doctors, how often would you expect them to--
how many times a day or how many patients a day does a doctor 
see? How many patients a day and how often would you expect to 
see a doctor at 1-to-200?
    This is a man who is really so committed to his country, he 
is like so many of the other veterans, ready to get back just 
as soon as possible.
    General Schoomaker. Yes, ma'am.
    Mrs. Boyda. So he just said, ``I don't need''--it didn't 
seem to bother him too much. It is just that he wants to get 
back.
    General Schoomaker. Yes, ma'am. And I don't want you to 
walk away from this, the committee to walk away thinking that 
we have a structure now that allows us to have one physician 
for every 200 patients throughout Army medicine.
    We have----
    Mrs. Boyda. And he is part of the wounded transition. He is 
part of the wounded warrior transition.
    General Schoomaker. This program alone, we have set a very 
generous ratio of physicians and nurse case managers for our 
patients, 1-to-200. That is not typically the ratios that we 
have. They are more on the order of 1-to-1,000, 1-to-1,500 in 
most primary care models for, say, a family medicine doctor or 
general internist or pediatrician.
    But for this group, we have given them an additional 
population of physicians.
    We actually give patients within the warrior transition 
units accelerated access for care for routine, as well as 
specialty care. In fact, I am sure that the cadre who are in 
the room here today are cringing as you describe that patient 
and that he can't see his doctor very often.
    I suspect, ma'am, that what you are hearing is from those 
that are anxious to get back, anxious to get as much attention 
as possible to his or her wounds and then anxious not to have 
to sit there and heal during the time and probably resisting 
what they have told them, ``Listen, be patient, the time will 
come.''
    But if you will give us details after we----
    Mrs. Boyda. We will follow up, absolutely. I just feel it 
would be remiss to--again, this is a good guy that I have kind 
of been following and he can't say enough good about what is 
going on.
    So we will follow up with that and just see where--but I 
wanted to make sure the 1-to-200 ratio would mean that we are--
that there still is--you know, these are people who clearly 
need a fair amount of--they are wounded. So they are going to 
need care pretty often.
    General Schoomaker. And, ma'am, if I could add, just real 
quickly. It is a very important point.
    We are returning most of two-thirds or three-quarters of 
our soldiers back into uniform after injuries and illnesses, 
combat-related or not. That is a very important part of this.
    We are saving the equivalent of two combat brigades a year 
through our process of recovering and rehabilitating.
    Mrs. Boyda. We will go over the details and follow up again 
on it later.
    General Schoomaker. Yes, ma'am.
    Mrs. Davis. Thank you.
    Mr. Kline.
    Mr. Kline. Thank you, Madam Chair.
    Thank you, gentlemen, for being with us today.
    Admiral Robinson, could you tell us what your working 
relationship is, not your personal relationship, but your 
working relationship is with Colonel Boyle? How does that work?
    Admiral Robinson. With Colonel Boyle, who is the Marine 
Corps liaison at Bethesda?
    Mr. Kline. No, sir, I am sorry. He is the Chief Officer 
(CO) of the Wounded Warrior Regiment, and we have been talking 
about how the Army does that. I am just trying to see how the 
Navy and the Marine Corps does that.
    Admiral Robinson. Okay. The Wounded Warrior Regiment at 
Camp Lejeune or at Pendleton?
    Mr. Kline. Admiral, there is one wounded warrior regiment 
and it has battalions on each coast. I guess what I am hearing 
here is there is not--we are not very well plugged in there 
between the Navy Surgeon General and the Marines Wounded 
Warrior Regiment.
    The Army, you seem to be under one hat here. General 
Schoomaker talked about the installations providing the 
funding, it comes under installations command for the barracks 
and so forth, but it looks like your wounded warrior program in 
the Army falls under you.
    Is that right, General Schoomaker?
    General Schoomaker. Yes, sir.
    Mr. Kline. And with the Navy, you have a safe harbor 
program that treats 250 or so sailors a year. That falls under 
you, Admiral?
    Admiral Robinson. No. That falls under the Chief of Naval 
Personnel.
    Mr. Kline. So for neither the wounded sailors nor Marines, 
you don't have any direct connection with that follow-on 
program, that outpatient program, that mentoring and caring for 
program that we are hearing about in the Army.
    Is that what I am hearing from you?
    Admiral Robinson. Well, other than doing the initial health 
care in the institution, then doing the medical case management 
and the non-medical case management, going through the 
continuum of care and transitioning them to the appropriate 
facility, such as the polytrauma or wherever they need to be, 
and then, when ready, getting them back as close as they can to 
their home unit, Lejeune or Pendleton, or wherever that may be, 
and we do that through the wounded warrior program.
    I think that we have a very good hookup. The fact that 
Colonel Boyle, who I do know, and who does have the regiment 
and the fact that we have one at Lejeune and at Pendleton that 
I don't have daily cognizance over, doesn't mean that Chris 
Hunter at Balboa, who is the Commander at medical center at 
Balboa, and that Marl Olsen, who is the Commander, my Commander 
of the naval hospital at Camp Lejeune, aren't talking with 
them.
    And for my three years at Bethesda as the Commander, the 
Assistant Commandant of the Marine Corps (ACMC) and the 
Commandant of the Marine Corps (CMC) and the Sergeant Major of 
the Marine Corps and the wounded warrior Marine liaison that 
was there were a daily occurrence, are hooked into the 
multidisciplinary team that I spoke about.
    So those people are people that I have lived with on a day 
to day basis for the last few years.
    Mr. Kline. Thank you. I am a little bit concerned. Maybe it 
is time, and I would suggest, Madam Chair, that if we are going 
to look at this wounded warrior continuing care issue, that it 
would probably be helpful to have the Marines wounded warrior 
regiment, since that is an up and running organization that is 
connected.
    And the Admiral is explaining some of what is connected, 
but I would like to explore that a little deeper and I could do 
it on my own. Perhaps, as a subcommittee, we ought to do that. 
We ought to take a look at that.
    Admiral Robinson. Well, the deputy medical officer Marine 
Corps, Mike Anderson, who is sitting behind me, is here. The 
medical officer Marine Corps is Admiral Bill Roberts, who 
couldn't be here today, but that connection exists and it 
exists on a daily basis, and it has for a long time and it will 
in the future.
    Mr. Kline. It is not the same relationship, though, as what 
they have in the Army and I was just wondering----
    Admiral Robinson. No. It isn't the same relationship for a 
number of reasons, not the least of which is we don't have 
quite as many people involved in terms of wounded.
    But the relationship is a little different in terms of 
philosophy of how we manage the care.
    Mr. Kline. Exactly, and this is not meant as a criticism. I 
am trying to understand how it works. So I would like to 
explore that a little bit separately, because we have a 
different model here.
    There are a lot of similarities. The Marines are assigning 
officers and staff non-commissioned officers and barracks in a 
model very much like what the Army is doing, I think, and the 
cadre members are back here in the audience, but I am--in the 
Army's case, it falls under the Surgeon General of the Army, I 
understand, all one uniform, and in the Navy and Marine Corps 
case, it is a little bit different, and I would just like to 
understand how that works. That is all I am suggesting.
    I have got some other questions, Madam Chair, having to do 
with sort of an unrelated matter and I will wait for the second 
round.
    I yield back.
    Mrs. Davis. All right, thank you.
    Mr. Wilson.
    Mr. Wilson. Thank you, Madam Chairwoman.
    And, Generals, Admirals, thank you for being here today.
    I have a perspective that I am very grateful to share with 
Congressman Kline.
    He is a distinguished veteran. As you can tell by his label 
pin, he is still a Marine, and I am really grateful that he has 
had a son serve in the Middle East. I have had two of my sons 
serve in Iraq.
    I have had three sons in the Army National Guard. I am also 
very proud that one of my sons is a doctor in the Navy.
    So, Admiral, thank you for being here.
    I can also cover the Air Force. I have a nephew who is in 
the Air Force. My dad was in the Air Force.
    I visited my nephew in Baghdad while he was serving there, 
and they are all very proud and grateful for their service 
overseas.
    Additionally, I have had the extraordinary opportunity of 
visiting with the military medical personnel and patients in 
Baghdad, at Landstuhl, at Bethesda, at Walter Reed, at Fort 
Jackson, the naval hospital at Buford.
    Everywhere I go, I am impressed by the quality of 
personnel. There is no question that, to me, American military 
medicine is the best in the world and is the best it has ever 
been in the world.
    I also want to thank the persons here today with the 
warrior transition units, because we were all so disappointed 
in some of our troopers falling through the cracks, that we 
need one-on-one attention and persons who I see here today, I 
just have faith in their competence and ability to follow 
through.
    I have also had the opportunity to meet a person I consider 
an American hero, Major David Rosell, who has lost a leg. He 
was able to go back on duty. Then he has come back to encourage 
other persons to go back on duty, and it is so awesome to me.
    I have also seen the experience of Lieutenant Andrew 
Kinard, a Naval Academy graduate, who lost both legs, but, my 
goodness, when you are with him, his spirit is tremendous.
    And so I can see firsthand the success. With this, with the 
warrior transition units, some concern has been that some of 
the persons who are placed in these units are somewhat 
offloaded problem soldiers. But, again, by working one by one, 
General Schoomaker, General Tucker, how is it determined what 
care is given and what is needed for each person?
    General Schoomaker. A very good question, Congressman, and, 
by the way, we thank you for your contributions to our force.
    Mr. Wilson. I think all of us sitting up here are thankful. 
All the credit goes to my wife.
    General Schoomaker. Yes, sir. I think we can all relate to 
that, as well.
    You are exactly right. We now have approximately 9,500 
warriors in transition within warrior transition units. The 
directive of the Vice Chief of Staff and the Chief of Staff of 
the Army was go out into the Army at large, find those soldiers 
that are in long-term care or facing medical evaluation boards, 
and have the hospital commander, warrior transition unit 
commander, and line commander sit down and have a discussion.
    And based upon a risk matrix that we have developed for 
whether they are safer to stay within the unit, the line unit, 
and have a high probability of returning and being an active 
soldier with that unit or probability that they are going to 
have problems that they need to come into the unit, we do that.
    There has always been, sir, a prospect of a line unit 
turning to the medical community to solve the problems of a 
problem soldier. But the fact now that it is a negotiation, 
that we have some objective criteria that center around their 
health and behavioral health problems I think helps with that 
discussion.
    Mr. Wilson. Another interest I have, my National Guard 
unit, the 218th Brigade, 1,600 troops, are located in 
Afghanistan, training the Afghan police and army, they will be 
coming back this summer.
    I am delighted at the services provided on base. What will 
be provided for Guard and Reserve persons who maybe live in 
rural communities?
    General Schoomaker. Sir, I think that is a challenge to all 
the services and it is a major focus of Secretary Peake, the 
new Secretary of the Veterans Administration. He talks often 
about the fact that especially those that aren't recognized at 
reintegration and demobilization, but may later turn up with 
problems in remote areas, are soldiers that we are focused upon 
within the direct care system, through our TRICARE network, and 
through the VA, as well, and I think that is part of the 
importance of this coordination with the VA.
    Mr. Wilson. One thing that I saw, Madam Chairman, that was 
actually helpful, my sons, we still get their mail at home, and 
I was really impressed by the quarterly mailings that I just 
inadvertently see about--that service members receive who have 
been deployed overseas, with questions as to their care and 
suggestions.
    So thank you for what you do.
    General Schoomaker. Thank you, sir.
    Mrs. Davis. Thank you, Mr. Wilson.
    General Tucker, one of the things we know about you is you 
are a bureaucracy buster. Is that correct?
    General Tucker. Yes, ma'am.
    Mrs. Davis. Could you tell us, give us an example of some 
of those bureaucratic roadblocks that you overcame to make all 
these work?
    General Tucker. Ma'am, that is a great question.
    First of all, I would ask myself--we came to a lot of 
impasses as we worked our way through the problems as we saw 
them and began to conduct mission analysis.
    And when it came to a decision, we always basically erred 
on the side of healing. If this decision is going to result in 
allowing this soldier to heal, and his family, then unless it 
is illegal, immoral, unethical, we are going to take on the 
policy or regulation that is preventing that, and we have been 
able to create a book, it is about an inch thick, and I think 
that is testimony to how much bureaucracy was actually there 
that would prevent soldiers from--you know, these are--this is 
a population of people whose worlds have been taken off kilter 
by means out of their control.
    We should probably do everything we can to get it right 
side up and not continue to allow it to list. A couple 
examples.
    We authorize you a non-medical attendant if your activities 
of daily living are limited such to where you can't do some 
things on your own and you need an assistant.
    The policy said that the non-medical attendant had to be a 
family member. Well, what if your mom works and your sister is 
in college and your dad can't do this, and why can't your best 
friend do it, why can't your fiance do it, why can't a father-
like figure in your life do this for you?
    So we got policy changed to allow that.
    Some of the soldiers, in the initial stages of standing up 
the transition units, some soldiers were reluctant about coming 
to the warrior transition units because they were afraid they 
would never get to go back to their unit.
    So here is a soldier in an infantry platoon who doesn't 
want to leave his platoon or his company because if he goes to 
the warrior transition unit, thoughts are ``I will never come 
back.''
    And so we have published policy that says you will come 
back to the unit that you came from, regardless of even if it 
is an over-strength status, you are going to come back to the 
unit you came from.
    We established permanent change of station policies so that 
a family can leave their children at home, say, at Fort Bragg 
and come to Walter Reed and still draw per diem payments there, 
regardless of the status that the soldier is in at Walter Reed.
    We allow soldiers--soldiers do not want to wear this patch, 
the medical command (MEDCOM) patch in a warrior transition 
unit, even though they are assigned to the medical command 
under the Surgeon General, because their patch made them feel 
good. Feeling good is kind of what you could call healing, and 
so we authorize them to wear their patch, as well.
    And I could go on and on and on, but it is about an inch 
thick, ma'am, and if we continue to find--as we move in 
concentric circles out from ground zero, so to speak, we 
continue to find other bureaucracies out there that we haven't 
seen.
    I will give you another example. Our soldiers see drug 
counselors. The drug counselors and what they discover in 
counseling with soldiers, their information databases, so to 
speak, doesn't cross over to the physician that is also 
treating the soldier for their medical and their clinical 
condition.
    These two professionals should be able to talk about this 
soldier and their family and try to help them. So we tripped 
into that last week as we were doing a tiger team on some 
unexplained deaths in our WTUs.
    So we continue to protract this, ma'am.
    Mrs. Davis. Is there anything that Congress can do to be 
supportive of that? Is there anything legislatively that you 
discovered that needs to be changed?
    General Tucker. Well, we are going to go back to the 
physical disability evaluation system, obviously, and I think 
NDAA is moving in that direction, ma'am.
    The biggest challenge, ma'am, is culture. It is a cultural 
change. We have been having warrior transition units in the 
Army since 1778, when the first inspector general, von Steuben, 
said that we will stand up a regiment for the sick and the lame 
who cannot keep up in the regiment and they would be cared for 
by our non-commissioned officers.
    And so this is not new work. It is just work that we have 
got to get better at, and I think we are moving in the right 
direction.
    Mrs. Davis. Thank you.
    Admiral Robinson, perhaps along the lines of Mr. Kline's 
question earlier, has the Navy also had to break a few 
bureaucratic roadblocks in order to have their program work?
    I think part of our question really is whether the nature 
of Safe Harbor and I think multiple programs, in many ways, 
that you all have put together really are like what is 
happening over on the Army side.
    I mean, how will the comparisons work out and, in fact, if 
you had to create some of those opportunities, as well to 
change the way people look at this system?
    Admiral Robinson. Yes, ma'am, and I think I understand your 
question. The Navy medical department is different from the 
Army medical department in one fundamental way, and that is we 
are the medical department to both the blue Navy and, also, to 
the Marine Corps.
    So we have two services with distinctly different missions, 
but we provide care to both.
    So the safe harbor program, one of the things that we have 
done--and we need programs for both groups of people, because 
they are completely different in terms of who they are, where 
they are and the cultures, et cetera.
    One of the similarities, though, is to make sure that we 
take--I guess the phrase would be best of breed, because there 
are lots of parts of the wounded warrior program for the 
Marines that we have instituted in our safe harbor program to 
make sure that we are giving an equivalent level of care and 
concern for everyone.
    Again, the numbers are vastly different, because the 
numbers on the Navy side are much, much lower and the Marines 
have much higher and, of course, the Marines are still lower 
than the Army.
    In terms of rule sets, the Navy functions in a little 
different way. Our 232-year history is to get underway and to 
leave and for a long period of time, when communication was 
poor, we had to make decisions about how we were going to 
conduct affairs based upon the best circumstances that we found 
ourselves, very similar to what General Tucker was already 
talking about.
    So our history and our tradition has been to make sure that 
we get to the crux of what the problem is. In this instance, 
the concept of care for Navy medicine has long been patient and 
family centered, and I think that one of the things that Navy 
medicine does well, one of the things that MHS, military health 
service, has to do better is to help patients integrate their 
care.
    Integration of care is going to be a huge help in terms of 
people who are, in fact, injured, who are under tremendous 
stress, and I think we do that and we usually put patients and 
family concerns first when we have that.
    Mrs. Davis. Thank you, Admiral.
    Mr. McHugh.
    Mr. McHugh. Thank you, Madam Chair.
    General Schoomaker, you and I have had the opportunity to 
talk several times during the past few weeks regarding the 
circumstances current in the national media, where apparently 
there was--well, for the moment, we will call them a 
misunderstanding between the veterans administrative personnel 
at Fort Drum and the Army as to the propriety of the VA, and 
the Vietnam Veterans of America (VVA) in providing guidance and 
assistance in the preparation of soldiers' medical evaluations 
board papers.
    Since that time, you and Secretary Peake have--I guess it 
was Secretary Geren and Secretary Peake have executed an 
agreement that provides a way by which to approach that, those 
jurisdictional issues.
    There has been some confusion, based on calls I have 
gotten, as to what this agreement allows the veterans, VVAs to 
provide to the soldiers. If I read from the agreement itself, 
it says ``VA service representatives will assist and advise 
service members, but will not prepare documentation for other 
than VA benefit claims.''
    A lot of media representatives calling me were somehow 
interpreting that to mean that the VVAs were not allowed to 
provide any assistance.
    What my interpretation of this is, and I would like you to 
state for the record what your understanding is, is that the VA 
representatives could continue to advise, provide oral 
suggestions and guidance, but, just in the vernacular, couldn't 
sit down at the typewriter and actually fill out the paperwork.
    Can you help us understand exactly what your understanding 
is? Is VA assistance available now? And it is not just at Fort 
Drum, by the way. It will be anywhere where you have this nexus 
between the medical evaluation process and VA. True?
    General Schoomaker. Yes, sir. And my understanding is 
exactly yours, sir. Let me just go back real quickly and 
reconstruct what happened here.
    As we stood up the first warrior transition units and 
General Tucker began to bust bureaucracies and formulate the 
Army Medical Action Plan, a team was sent out from the Surgeon 
General's office, under the Acting Surgeon General, Gail 
Pollock, to rapidly get as much information as possible out in 
those camps, posts and stations where this was occurring every 
day.
    Where was it working well, where was it not? All facets of 
the care and transition into the VA system, to include the 
disability process. And Fort Drum happened to be the 11th place 
they visited and one of the last ones and they found really 
some of the best practices that they saw, very well embedded 
veterans benefits advisory group that there were giving good 
counsel to our families and soldiers.
    But I think that there was confusion across all of these 
sites as to exactly what the interface should be.
    When the stories surfaced about the exchange between the 
Army team and the VVA counselors at Fort Drum, Secretary Peake, 
with whom we were in pretty constant contact, said, ``You know, 
it is very clear here that we have got some heterogeneity of 
how the process operates and if we have got that kind of a 
patchwork going on, we need to establish from the top how this 
should happen so there is no question out there in the field 
that VVA counselors and the soldiers and their families should 
be working closely together,'' and that is exactly what that 
policy was intended to do.
    My understanding is it spoke to the strengths that the VVA 
counselors had, which was understanding of veterans' benefits. 
Yes, sir.
    Mr. McHugh. Absolutely. Thank you, General.
    Admiral, before your presence in the subcommittee, the 
subcommittee staff had visited your mobilization processing 
site in San Diego and Norfolk and, at that time, we heard some 
complaints from ill and injured sailors in the units regarding 
demobilization.
    And the complaints specifically were that they were being 
ordered to demobilize while still undergoing medical treatment 
and being told to go to VA or to TRICARE for transitional 
assistance management program for follow-on care.
    We brought those concerns to the attention of your 
predecessor. We were assured by the Navy leadership that that 
practice would end.
    Just this past week, the committee staff again has obtained 
information that suggests that soldiers, at least in some 
regard, are still being processed in that way and we have 
illustrations of sailors being demobilized a few days prior to 
scheduled surgery and told to obtain the surgery and recover 
while they are on training and leave and such.
    And I would like to get your comments on that for the 
record.
    Admiral Robinson. Sir, I have no information and no 
comments on any of the specific cases. I will tell you that 
from a physician and from a surgeon's perspective, and as the 
Surgeon General, I would like to make sure that all injured, 
ill personnel who are on active duty and who--and the folks 
that you are talking about are in the reserve capacity 
generally, but that they, in fact, have complete medical care 
before they leave the service or if the care isn't given to 
them before they leave the service, the condition that they 
have is something that can be cared for and that we know 
exactly how we are going to transition them to what provider 
for the proper treatment and for the proper care.
    From the surgeon in me, I am telling you that most of the 
time, I don't think that anyone should leave the service until 
their medical condition has been eliminated or treated, but the 
specifics here I don't know.
    Mr. McHugh. If I may, Madam Chair, I know the light is on, 
I will be very brief.
    But clearly I don't expect that you can possibly respond to 
the specific cases. I don't know if it is appropriate, we could 
probably get those to you for resolution, if nothing else.
    Admiral Robinson. I would like to have that, sir.
    Mr. McHugh. I appreciate that.
    But you have been clear, in general terms, it would not be 
the Navy policy to discharge a sailor who, a few days later, 
had surgery scheduled. Am I correct in that assumption?
    Admiral Robinson. That is correct. If a sailor had surgery 
that is needed and who has been on active duty, particularly if 
that injury or whatever has occurred because of the--it has 
occurred during the period of duty, then I would expect that we 
would care for them and, again, pending the particulars, I 
would say that that is what should occur.
    Mr. McHugh. Thank you, Admiral.
    Thank you, Madam Chair.
    We will get that information to you.
    Admiral Robinson. Fine, thank you.
    Mrs. Davis. Thank you.
    Mr. Kline.
    Mr. Kline. Thank you, Madam Chair.
    Admiral, I got us kind of twisted around there with the 
Marine Wounded Warrior Regiment. I didn't mean to get us that 
twisted around. Let me just hasten to assure you that I have 
been, over many years of service in the Marine Corps, extremely 
pleased with naval medicine.
    My son was born in a naval hospital. Of course, he is now 
an Army officer. I am not sure where I am going with that, 
except that every time I am with Mr. Wilson, I am thinking 
about if our families weren't as engaged as they were, the 
Department of Defense would have to increase its recruiting 
budget substantially.
    I have three nieces in the Army, one of whom is an Army 
nurse, serving in Baghdad, and all of them very proudly. But, 
again, I didn't mean to imply, and I was talking to Mr. McHugh 
for a minute, come across that I had some criticism of naval 
medicine and, certainly, from my family's perspective, that is 
not so.
    But I do want to get at the relationship between the 
Surgeon General's office and the Wounded Warrior Regiment, not 
here today, because we need to explore that when we have 
somebody from the Marine Corps who can talk about this.
    I want to go back and pick up--I guess I am back in your 
lane again now, General--what Mr. Wilson was talking about, 
these members of the Guard and Reserve who are coming back and 
you expressed that that is a problem that all the services were 
having to face.
    Mr. McHugh was just talking about it sometimes with sailors 
who are discharged. We put in statute now and we have been 
seeing for the last couple of years a pretty aggressive 
reintegration program by the National Guard, expanding to the 
reserves.
    So we bring these soldiers back, we don't just demobilize 
them and sort of say good luck to them, we will see you in a 
few months. We are bringing them back after 30 days, 60 days, 
and 90 days to see how they are doing in a wide range of areas, 
are they getting their jobs back, house, family, life going, 
but part of it is medical, as well, and particularly in view of 
PTSD and perhaps some traumatic brain injury, where symptoms 
are a little bit slower coming.
    How do you see your office, the Surgeon General's office 
relating to that? Do you have a direct input into that, direct 
relation, or is that sort of the guard comes back and then 
those reintegration efforts connect them with the VA? What is 
the relationship? Can you tell me that?
    General Schoomaker. Well, I have a good relationship with 
the leadership of the Guard and Reserve and with their surgeon, 
with whom we work very closely in trying to attend to exactly 
the point that you made here, sir.
    And you have raised some very, very important points about 
the Guard and Reserves challenges once they finish their 
mobilization and are reintegrating.
    The two areas that we see the biggest problems right now, 
first is dental. We have a real problem with dental readiness 
and dental health within the reserve component.
    This is one of our biggest challenges for bringing reserve 
component soldiers into a state in which they can be medically 
deployed.
    And so especially as we turn the reserves from being a 
strategic reserve into an operational reserve, we see their 
service as, in a sense, the preparation, the beginning of the 
preparation for the Army's force generation model of the next 
time that we mobilize and deploy.
    And so it is very important for us to maintain their dental 
health and their dental readiness through programs that we are 
developing.
    The second is, that you alluded to already, our studies now 
have shown, for the last five years of careful cohort studies, 
that the emergence of symptoms of post-traumatic stress of a 
reintegrating soldier don't appear at the moment of 
demobilization or at the moment of redeployment.
    And so we have learned that 30, 90, 60, 180 days out, we 
should be re-interfacing, we should be reexamining, re-
interviewing that soldier to see how they are doing.
    We now have a standing policy across the entire military 
medical system that my colleagues in here and I, we all attend 
to and that is to 90 to 180 days out, perform a post-deployment 
reassessment of health that is focused on those symptoms.
    The National Guard, Reserve and the Army have been very, 
very responsive to that.
    Mr. Kline. Thank you very much, General.
    Madam Chair, I have got another line of questioning having 
to do with what we are doing in terms of research and treatment 
for extremity injuries. But if we don't have another round, I 
will just submit those for the record. If we do, I will raise 
it then.
    Thank you very much. I yield back.
    Mrs. Davis. Thank you.
    Mr. Wilson, you are actually up by when you came in the 
room. So if you would like to ask a question now.
    Mr. Wilson. I would be happy to. Thank you.
    A concern that a lot of people have had, as the National 
Capitol regional medical command is being transformed, a 
concern would be for the ongoing program. What is planned and 
being done to make sure that indeed there is no one left 
behind?
    General Tucker. Sir, if I could take it. I know that the 
Warrior Transition Brigade at Walter Reed, they are 
transforming to what we see as a joint warrior transition unit 
at Bethesda.
    It will also take on units in the National Capitol region. 
There will be a battalion--population size at Fort Belvoir, at 
Fort Meade, at Fort Myer, and at the eight medical treatment 
facilities around the National Capitol region will all have 
smaller, obviously, sub-units of the joint warrior transition 
unit.
    And within that, we would see the Wounded Warrior Regiment, 
the Air Force program and the Army program for this population, 
sir.
    Mr. Wilson. So a concern that occurred last year was that 
as there was a movement of facilities, personnel, organizations 
from Walter Reed to Bethesda, that there, indeed, could be a 
problem. But you feel like this will be addressed.
    General Tucker. In terms of BRAC, yes, sir. Yes, sir. Our 
funding lines have come back up to keep us at full operational 
capability through the entire BRAC process, to the last day 
that we stay open, and we have got hiring authorizations to 
keep our people hired through the process, as well, sir.
    Mr. Wilson. I wish you well, all of your coordinating.
    General Schoomaker. Yes, sir. I will point out that Admiral 
Robinson and I, he at National Naval Medical Center, Bethesda, 
and I at Walter Reed, actually were a part of that process 
before they stood up the joint task force capitol medicine 
under Rear Admiral John Madison and we have already begun 
pretty full integration of clinical services and training 
program, even though we are not collocated yet as a single 
campus.
    And Admiral Madison has had full visibility of our efforts 
to integrate. It is deceptive to many people that even when the 
Secretary of Defense recently broke his shoulder, he may have 
been seen at Bethesda, but he was seen by an orthopedics and 
rehabilitation service that is actually shared between the two 
institutions.
    We have had great success.
    Admiral Robinson. I think that we have, and I just want to 
emphasize that the difference in the area, and I think the 
reason that there won't be anyone left behind, is that as 
Admiral Madison and as the joint task force capitol medicine 
becomes more mature, and it just began a few months ago, but as 
it gets more mature, I think we are making inroads to make sure 
that we have the right services not only at Bethesda, but also 
in the whole capitol area, including Belvoir, so that we end up 
in the National Capitol area, the National Capitol region, with 
a joint run military health system, which would be Air Force, 
Navy and Army.
    And I think that we are, in fact, getting there.
    General Roudebush. Yes, sir. I would add, from the Air 
Force perspective, certainly, with the very focused attention 
of the deputy secretary of defense, Mr. England, and the 
service Secretaries and Vice Chiefs, this has been a very 
focused and collaborative affair, both in BRAC integration and 
assuring that the care that is being provided to these wounded 
individuals coming back, there is not a decrement anywhere in 
that.
    From the Air Force perspective, of course, a lot of focus, 
rightfully so, on Walter Reed, Bethesda and DeWitt, but Andrews 
plays a critically important part in that at Malcolm Grow, both 
in terms of a strategic asset located within the National 
Capitol area, but also as a focal point for ensuring that Air 
Force medical manpower is, in fact, committed and placed 
throughout the region to the best effect of the overall outcome 
of health care.
    So I think this has been a very productive relationship and 
Rear Admiral Madison, I think, has done a very good job of 
assuring that equities are addressed and met in all regards in 
a very demanding situation.
    Mr. Wilson. Well, I wish you well and I know you have a 
success story with the Uniformed Services University being a 
joint facility.
    It truly came to mind when I attended graduation of my son 
and to see persons from every service. It was just such a 
positive experience and the recent movie about the Uniformed 
Services University is just such an inspiration.
    And, again, thank you again for what you have done and 
thank you for what you do for our troops.
    Mrs. Davis. Thank you, Mr. Wilson.
    Mrs. Boyda.
    Mrs. Boyda. Thank you, Madam Chair.
    Last year we had a hearing with Surgeon Generals. It was 
after the Walter Reed had kind of settled into a plan. We just 
generally asked about how things were going and one of the main 
messages that we heard at that point was about the military-to-
civilian conversions.
    And basically their recommendation at that time was that 
those needed to be slowed down or even halted and in the NDAA 
last year, we said that we are going to put a halt to those.
    And, yet, in your 2009 proposed budget, the military-to-
civilian conversions are still in there and budgeted for. If 
you could help me understand what is going on with that. Are 
they going to be planned to be taken out? Do you still feel the 
same way? What impact does military-to-civilian conversion 
have?
    I would like to hear actually from each one of you, if I 
could, each one of the branches.
    General Roudebush. I will begin. The Air Force has been 
very focused on the military-to-civilian conversions and this 
has been going on for some time, really started laying them in 
back in 2004.
    As far as the Air Force is concerned, we have done what we 
are confident in, is very good analysis, where it makes sense 
to do that, where it doesn't make sense, where the capabilities 
are, in fact, available to be hired.
    So that was a part of our analysis and that allowed us to 
go through the subsequent years, four, five, six, seven and 
eight, and certify, according to the direction of this 
committee, in terms of those that we felt were suitable for 
conversion and would not decrement either access or quality of 
care.
    So we, in fact, complied with that. When the Fiscal Year 
2008 NDAA was signed in late January, that did, of course, 
cause us to move into a very concerted effort to be sure that 
we do comply with that law. And working with our Air Force A-1, 
our personnel, as well as our planners and programmers, the Air 
Force is fully committed to complying with the Fiscal Year 2008 
NDAA, as it is written and as it is intended.
    Mrs. Boyda. So you see those budget items being deleted 
then?
    General Roudebush. What you will see is those positions 
will be converted back to military in 2009. Those positions not 
filled will be converted back to military and we are working 
with our planners, programmers, and resourcers to assure that 
that, in fact, occurs.
    Now, I will tell you, there is difficulty in that, because 
as early as 2004, when we began laying those in, our recruiting 
and training pipeline was adjusted accordingly to do that. So 
as we move these back to military positions, it is going to 
take some time to reconfigure both that recruiting and training 
pipeline to deliver those military personnel to fill those 
positions.
    So this is not without challenge and we are looking at 
strategies to address that, as well.
    But the bottom line is the same as the top line--we fully 
intend to comply with the Fiscal Year 2008 NDAA as it has been 
published.
    Mrs. Boyda. I will speak on my behalf and not the entire 
committee perhaps, but that was certainly done--that was what 
came out of the hearing, too.
    So we need to make sure that that is meeting your needs and 
this is not the needs of the committee. We want to make sure 
that we are meeting your needs.
    So, again, I will speak personally, not on behalf of the 
committee, but if there is--if we need to continue to look at 
that, I would be happy to do that.
    General Roudebush. Yes, ma'am. And please rest assured, as 
we have worked very carefully with your staff members, they 
have been very helpful and very forthcoming in working through 
the challenges and working to assure that we understand on both 
sides precisely what the implications of that are.
    Mrs. Boyda. And speaking for myself, the objective is to 
give you the leverage to make the best decisions that you think 
need to be done for our military personnel.
    General Roudebush. Yes, ma'am.
    Mrs. Boyda. General Schoomaker.
    General Schoomaker. Yes, ma'am. We will fully comply, as 
well, with law. There is no question that we will do that.
    We have several challenges. One is to allow us to 
internally restructure our force for the kind of wounds, the 
kind of care, the kind of demands that we see now and we see 
over the horizon.
    So, for example, in the mental health arena, we need the 
latitude to be able to restructure even the uniformed force to 
acquire more mental health support.
    That the Army is allowing us to do and has been allowing us 
to do. We were using the military-to-civilian conversions 
actually to work within that conversion process or that 
remixing process.
    The second is as the Army grows, we need a medical 
supplement, if you will, within our force to meet the Army's 
needs as it grows new modular brigades, as it pushes more 
trainees through its training pipeline and the like and grows 
more families, we need a greater medical force.
    The Army, again, has been very generous in providing us a 
``Grow-the-Army'' slice of the medical.
    So we are complying with the law now. We are also getting 
the force mix conversions that we need to structure our medical 
force for the kind of needs that we have now and that we see on 
the horizon, and we are growing the medical force to respond to 
the growth of the Army.
    Mrs. Boyda. Thank you.
    Admiral, is there anything that we need to add? My time has 
expired.
    Admiral Robinson. Just that both parts of the Air Force and 
the Army are very similar and that we are going to comply with 
the same thing and at Chief of Naval Operations (CNO) and 
Configuration Management Program (CMP), we are fully engaged. 
We are going to do what the law says.
    Mrs. Boyda. All right. Thank you.
    Mrs. Davis. Thank you, Mrs. Boyda.
    I would say, as well, I appreciate the fact Mrs. Boyda 
raised the question, because there was concern that there is a 
disconnect here between what we were seeing coming forward in 
the budget and, in fact, what had been designated in the NDAA.
    So I think we want to obviously work with you. We know that 
there are some needs and some challenges, but the overwhelming 
needs seem to be to have those billets available really to our 
military and to not do anything that would take away the need 
to have the kind of pipeline within the services that is going 
to be so critical to the future. And so I appreciate your 
concern.
    Any additional thoughts on what the problem was, whether 
there was a miscommunication somewhere on whether the needs 
were just so different from what you were seeing?
    General Schoomaker. I think in the case of the Army, what 
we had done is negotiate with the Army to allow them to 
restructure military and civilian workforces, but to give us an 
additional workforce that we could rebalance the way we needed, 
and I think the legislation, ironically, has somewhat forced us 
to go back to the table with the Army and renegotiate how we 
are going to do that.
    That may be what you saw from the Army, that was a part of 
it.
    Mrs. Davis. Okay, thank you.
    General Tucker, for just a second, if you could just talk 
to us a little bit more about how you bring together the 
Warrior Transition Unit cadre.
    I know we have some outstanding men with us today, 
individuals, and women I think I see in the audience. Where are 
they really drawn from? And while I don't think we would have 
any question of their military leadership, I would want to know 
a little bit more about the training or what might be called 
the bedside manner.
    We are dealing with some very vulnerable men and women who 
need that kind of service, and that is not always a natural 
ability that people have.
    General Tucker. Yes, ma'am, and that is a terrific 
question. They do come from all the ranks, all ranks in the 
Army, and they are assessed by human resources command.
    They are two-year stabilized assignment, and we are looking 
for remarkable people, obviously. I often say, when I speak 
with them, that the skills that made you successful as a 
sergeant in an infantry platoon may not be the same skills that 
are going to make you successful in this organization, because 
these people are all individuals with individual needs and they 
are all on a different emotional plane.
    And so we are looking for the sergeant who is probably the 
world's best father, a steady, but firm hand, but compassionate 
and has enormous depth for feeling and understanding and, also, 
to understand that standing behind that wounded soldier is 
probably a parent or a spouse who is going to tell you what 
they are thinking, as we would if someone--if we thought our 
loved one was not being cared for.
    And so they have to absorb that, as well, while still 
maintaining their military bounds. And so we put them through a 
40-hour course currently, we are moving it to a 3-week course, 
a resident course at Fort Sam Houston, the home of the Army 
Medical Center and School. They begin that course in Lewiston 
in October of 2008.
    But right now, they are taking a 40-hour course and it 
takes them through the bedside manner, like you have spoken of, 
ma'am, but there are some things about Army medicine, about 
pharmacology, how to read a profile, how to read a pill bottle 
that says, ``Hey, Jones, you got 30 Percocet on Monday, you 
take two a day or two every two hours and it is Thursday and 
you have one left, what is going on here.''
    So they also understand the effects of medications and what 
you can't have with certain medications and they have to 
understand the physical disability evaluation system, the 
entire world of what a warrior in transition is going through 
and, also, the world of the family and the finances, the 
special hazardous duty pays that they draw, Traumatic Service 
Members' Group Life Insurance (TSGLI), all the things, the 
benefits, so that they become a portal through which to guide 
these soldiers to.
    And because we are looking for these special people and we 
expect them to offer an enormous amount of compassion, they 
spend a lot of hours on duty. And so we have also--another 
piece of busted bureaucracy is we have gotten authorization for 
them to have special duty pay.
    Mrs. Davis. What role do you think that plays? I mean, if 
you didn't have the special duty pay----
    General Tucker. It does two things, ma'am. Number one, it 
tells them they are special. We give drill instructors special 
duty pay. We give recruiters special duty pay. These people are 
doing special duties, as well. They are unlike their peers.
    There are no other units like this in the Army and they are 
doing the Lord's work, so to speak, with people who we should 
be paying pretty close attention to. So we are asking something 
more of them than we would a normal sergeant and they have to 
be trained in special skills.
    And so we give them $225 extra a month for the first six 
months, six months to a year, it is $300, and then $375 after 
the first year.
    And the second thing that it does is it tells the Army that 
these people are enormously special and we are only looking for 
the best you have and that sends a strong message and then 
coupled with that, the Secretary of the Army has instructed the 
Department of Army Secretariat to place special emphasis on 
selection boards and promotion boards to identify these cadre 
members as key and essential to the Army's mission to sustain 
itself.
    General Schoomaker. And if I could just say real quickly, 
Mike himself represents what we are looking for. When I was 
asked to look at candidates by the Vice Chief of Staff of the 
Army for this role, I selected Mike.
    He is a former non-commissioned officer himself. He has 
been a former drill instructor. And I needed someone who could 
look at a process like training soldiers and see a process that 
had regimentation and regularity and standardization, but, at 
the same time, could see human beings inside of that and knew 
that some needed a different kind of motivation than others, 
and you obviously see that in him today.
    Mrs. Davis. Thank you. Are you able to keep the diversity 
in that cadre, as well, that represents the military, men, 
women, minorities, et cetera?
    General Tucker. Yes, ma'am, and also the diversity expands 
into the component.
    They are our National Guard cadre. Half of the cadre are 
active component, one-fourth is National Guard and one-fourth 
is Army Reserve, because the warriors in transition themselves 
are kind of that mix of the population, as well.
    Mrs. Davis. Thank you.
    Mr. McHugh. We ought to be able to get around quickly for 
everybody.
    Mr. McHugh. Thank you, Madam Chairman.
    Just to the point that you and Mrs. Boyda were pursuing a 
couple weeks ago at full committee, we had Secretary DeSantis 
and the Chairman of the Joint Chiefs and the Comptroller 
General, Tina Jones, and we explored that very issue.
    It is obviously a critical one. One of the problems I think 
the services face is, frankly, we didn't do a bill until 
January and they prepared their budgets, as you know, long 
before.
    So they have got a big ship to turn around. I was pleased, 
in my conversations with the Comptroller General, that as a 
lady who kind of keeps her eye on the purse strings, which is 
going to be an important part of the rehiring that is required 
under this provision, if you haven't filled vacancies by, I 
believe, October 1st, that the dollars are going to be there, 
but I just wanted to underscore the concerns this panel has, 
and, Madam Chair, I know you will.
    We are going to have to keep an eye on two balls here, both 
these good folks' efforts to comply with that, but also the 
Department of Defense trying to do some things that help them 
financially, because this has significant monetary impact, as 
well, even though it is absolutely the right thing to do for 
our men and women in uniform.
    So I just want to get that on the record.
    The other thing, General Schoomaker, the NDAA for this year 
gave to the Secretary of Defense the authority to do pilot 
programs to try to explore better ways for the functioning and 
the nexus of the VA and DOD and, in your case, the Army 
disability systems.
    That comment that you made about how you stood as primarily 
a physician in front of people that you were there to help and 
felt as though you were the enemy was a very poignant one and I 
think one of the things that frustrates us all is that you have 
got two good systems manned by the military disability folks, 
who care very deeply about those who have come to them and are 
transitioning through their process, and, of course, the VA 
that is modeled upon helping those who have done so much for 
us.
    And, yet, when you put them together and you try to work, 
the soldier, sailor, Marine or airman or woman, through them, 
it becomes frustrating. All of a sudden, the two systems are 
the enemy.
    So this pilot program I think can hold a lot of promise as 
to how can this system become more user friendly and, 
therefore, in the eyes of those who are using it, become more 
of a solution than a problem.
    As I understand, you are the ball carrier, if you will, for 
the pilot program. Can you give us any insight on how far along 
you are in working out a plan with the VA or is that just too 
early?
    General Schoomaker. No, sir. Actually, the pilot began in 
November. I understand there are 100 soldiers or service 
members in it right now. I think two or three of them have 
cleared the process and have completed their adjudication and 
are into the VA system.
    But I will also say, candidly, sir, that the Congress has 
not fully executed the Dole-Shalala recommendations. I think 
the Dole-Shalala commission and the independent review group 
both very thoroughly looked at the disability adjudication 
process and concluded, I think, what many of us in uniform have 
known for our entire careers.
    We have a system that is over 50 years old that was devised 
for a World War II generation of soldiers, sailors, airmen, 
Marine, Coast Guardsmen, that when we had an all--not an all 
volunteer force, but a conscripted force, when we did not have 
a TRICARE health care benefit, when most of our soldiers, 
sailors, airmen were not married.
    Now, in the Army, we have a largely married force, with an 
extraordinary health benefit called TRICARE that every soldier 
and his or her family is looking to get if they have a medical 
disability.
    And we have a complexity of especially mental health 
challenges that are not well codified within the disability 
process.
    So what we are doing right now through the pilot is 
essentially to speed up a process and reduce bureaucratic 
hurdles in a process which is fundamentally flawed, and the 
fundamental flaw is that the military, under Title 10, has got 
to determine the fitness for duty of the soldier, sailor, 
airman, Marine, Coast Guardsman and should, and it should 
retain that, but then adjudicates on a table very similar, in 
fact, it is an identical table to the VA, what the disability 
for that one disabling condition is.
    And then we turn to the VA, using the same tables and the 
same physical exam, if we get a single exam to do that, and 
allow the VA to then use the whole person concept to determine 
how well will they be able to be employed, what is their 
quality of life.
    And so the typical soldier sees the constellation of 
problems they have, arthritis, sleep apnea, an injury residue, 
determined by the Army, Navy, Air Force or Marines to have a 
disabling condition with a single set point for that disability 
and then go to the VA system, see the same constellation of 
systems, but then looked at from the standpoint of a whole 
person and being given more and ask themselves, ``Why does the 
Army value me less than the VA system does?''
    And especially when a threshold for receiving health care 
benefits is 30 percent, that can be a major difference. I can 
give you cases. A 10-year veteran military policeman trashes 
his ankle through duty while in Korea. He comes back. We can't 
fix his ankle above one that can't run long distances and 
certainly can't ruck 80 pounds for 12 miles.
    And so he is determined to be unfit to serve as a combat 
Military Personnel (MP). He has got three children under the 
age of seven and a non-working wife and he will be separated 
from the Army with an unfitting condition for that ankle.
    He also has shoulder arthritis and sleep apnea, 10 percent, 
10 percent and 20 percent for the ankle. The Army separates him 
at 20 percent disability, no TRICARE benefits.
    He goes to the VA. They say total person concept, 40 
percent disability, but you have already been through the 
military assessment and you don't get TRICARE benefits. You get 
a separation bonus from the Army for $28,000.
    He comes to my office and he says, ``I have got three 
children under the age of seven. I have served ten years. I am 
not going to have a retirement from the Army. I can't do an 
Army job. But what am I going to do with the $28,000 and no 
health benefits?''
    Sir, that is the centerpiece of our problem and that is the 
seam in the seamless system between the DOD and the VA.
    Mr. McHugh. And I appreciate your saying that and it is 
important to say it, and I was heartened by the President's 
comments during his ``State of the Union,'' a rededication of 
Dole-Shalala.
    And I know everyone on this committee, both sides of the 
aisle, feel the same way as the timing came with respect to the 
military-to-civilian move within the medical health corps. The 
Dole-Shalala commission report didn't give us a lot of time to 
look at it.
    But I know we are going to continue to do that. It is 
absolutely critical. The basis by which you are retired out of 
the Army is, as you have noted, far different than out of the 
VA. One is a lack of the ability to serve in a uniform. The 
other is a lack to survive in life.
    But we have got to bring continuity to those two and this 
pilot program, as much as you have pointed out, absolutely 
correctly, the structural challenges that Congress needs to 
change, but the pilot program and the bureaucracy piece of 
that, I would argue, is important, too.
    General Schoomaker. Absolutely.
    Mr. McHugh. We are looking forward to your development on 
that and we have just got to do better. I mean, that is the 
bottom line. And turn our images, if you will, all of our 
images into what we want it to be, and that is collectively 
individuals and organizations that are deeply appreciative for 
the sacrifices these people make and need to share that in very 
real ways.
    General Schoomaker. Yes, sir. My only concern here, I will 
be very straightforward, is when you speed up a bad process, 
all you have is a fast bad process.
    Mr. McHugh. I agree.
    Mrs. Davis. I think we all agree we need to solve this one 
and there isn't a consensus within the communities that are 
affected by it either.
    General Schoomaker. Yes, ma'am.
    Mrs. Davis. We need to work toward that.
    Mr. Kline.
    Mr. Kline. Thank you, Madam Chair.
    I am going to switch directions quite a bit here.
    We as a Nation, you as the Surgeon General have been 
placing a lot of emphasis on traumatic brain injury and PTSD 
and some of the stresses that have been associated with the 
combat in Iraq and Afghanistan, the nature of the weapons, all 
of those things, and I think that is very appropriate.
    I know that members of this committee have also spent a lot 
of time looking at those issues. But, still, we have over 80 
percent of our injuries are extremity injuries. I think 82 
percent was the last number I saw. A lot of cases of legs, 
particularly, but legs and arms.
    And we are putting some resources into that. I was talking 
to General Roudebush beforehand. I know there is some peer 
reviewed sort of joint effort going on between civilian 
orthopedic efforts and military to make sure that we are doing 
the best that we can for these wounded warriors, where so many 
of them have these wounds, and we have seen tremendous examples 
of--in fact, we had in this hearing, I think, a couple of years 
ago, we had a Marine and an airman who had artificial legs and 
they were in uniform and looking great and proud and the Marine 
had just come back from his second tour in Iraq and after he 
served with that artificial leg.
    But my question is, have we let that emphasis on Traumatic 
Brain Injury (TBI) and PTSD pull us away from this orthopedic 
effort and should we look at putting some more emphasis and 
resources into that effort? I will just throw it out for any of 
you who have a comment.
    General Schoomaker. Let me just--and I certainly would 
welcome my colleagues' observations or thoughts about this, but 
let me just say something quickly, sir.
    You often hear people talk about one wound or another wound 
being the signature injury of this war. I am here to tell you 
there is no single signature injury, in my view. There is a 
signature weapon. The signature weapon is blast. The signature 
weapon is blast.
    It is very effectively used by an adaptive enemy and that 
blast takes off limbs. It blinds. It deafens. It burns. It 
causes traumatic brain injury from the mildest concussive form 
to the most severe penetrating form that, frankly, our Navy 
colleagues at Bethesda are leaders in the world in a combined 
team and getting better.
    And the context of all of those physical injuries leads to 
post-traumatic stress later.
    We have in the Department of Defense now, through the help 
of Congress, focused all of the work in blast injury in the 
series of research programs that are being administered through 
the United States Army Medical and Research and Materiel 
Command, under the Assistant Secretary of Defense for Health 
Affairs, the Principal Deputy Assistant Secretary of Defense 
for Force Health Protection, Ms. Ellen Embrey.
    And that program of blast injury I think is answering the 
question that you just asked, and that is are we keeping 
balance, are we looking at all the gaps where research and 
where care needs to be administered and are we doing the 
appropriate things for all of the elements of the signature 
weapon, which is blast.
    Mr. Kline. Anybody else?
    General Roudebush. Yes, sir. Congressman, I think you very 
rightly make a case for being sure that we keep track of all 
elements of the constellation of injuries that we are seeing.
    In terms of the orthopedic extremity trauma research, the 
Army Institute of Surgical Research, with work with Air Force 
surgeons, Navy surgeons, Army surgeons, working collaboratively 
on the joint trauma system which exists today in Iraq and 
Afghanistan, have been instrumental in identifying both the 
wounding patterns, but also the treatment modalities that begin 
to allow us to salvage, if you will, at the first opportunity 
to resuscitate, to look at these injured men and women in a way 
that we begin thinking about recovery at the very first 
opportunity to resuscitate.
    That kind of collaboration has been key. Dr. Andrew 
Pollock, a leading trauma surgeon at Baltimore Shock Trauma and 
a leader within the American Academy of Orthopedics, with a 
particular eye toward trauma, has, in fact, gone downrange to 
our Air Force theater hospital at Balad and participated with 
us in both providing that care, but also helping teach us, 
learning from our experience, collaborating with those folks 
forward.
    It has been a very productive relationship. Now, research 
becomes the crux of this, because if we are, in fact, to take 
that experience and begin to translate that into opportunities 
to help us all do better in taking care of trauma, both in the 
military sense and in the civilian sense, the research is 
critical to that.
    So I think to the extent that we can foster and encourage 
the research activities that are already present and put those 
forward, I think that would serve us all very well.
    Thank you for your interest in that, sir.
    Admiral Robinson. Thank you very much, also, for the 
question. I agree with both colleagues, General Schoomaker and 
General Roudebush.
    I would only point out this one thing. Amputations are--and 
research needs to be done and the research needs to be done 
also in terms of the limbs and the biomechanics and the future 
is really abounding with opportunities.
    So I think that, in the future, people are going to have 
even better modalities of extremity care and prosthetic care 
and both from the impact and both from the surgical research 
and tissue regeneration, these are all things that have to be 
done.
    The emphasis I want to put is I think that, traumatic brain 
injury, and post-traumatic stress disorder is something that is 
unseen and we don't know what we don't know. With a limb, you 
do know there is an amputation. You don't necessarily know how 
far you can take that individual in recovery, but you still are 
starting with a little bit better understanding of what you 
have.
    With post-traumatic stress disorder and with TBI, you don't 
know, and that compounded with the stressors of combat make for 
mental health and mental conditions that we haven't really 
fathomed yet.
    So I would only suggest that--and I would agree with 
General Schoomaker. I think blast is the signature weapon, but 
that is the emphasis and I think we can go back to Vietnam, 
because the PTSD that developed in the veterans who were not 
treated, because we didn't even look at that, and now we are 
seeing 25 and 30 years later, now 35 years later that that was 
a very important thing.
    So I would only point that out.
    Mr. Kline. Thank you very much.
    And thanks for your indulgence, Madam Chair.
    Mrs. Davis. Thanks.
    Mr. Wilson.
    Mr. Wilson. Thank you, Madam Chairwoman.
    Again, I want to thank you and I want to thank you and I 
want to thank your colleagues for your obvious genuine care and 
concern for our soldiers who have made--sailors and Marines who 
have made such a difference and they are heroes for all of us.
    Also, Madam Chairwoman, this has just been a terrific 
meeting. I appreciate your leadership.
    And I want to conclude my part with an invitation and that 
is for our colleagues, for you, for staff people, and that is 
that there is a movie that has been made about uniformed 
services called ``Fighting for Life'' and we have had a 
screening here on Capitol Hill. I was very honored with 
Congressman Chris Van Hollen to have this screening.
    We are going to be doing it again, because it was such a 
wonderful movie and it is going to be released across the 
country. But in the promo, Madam Chairwoman, sometimes it is a 
bit exaggerated.
    This is understated, and I want to read it. It is a new 
film by two-time Academy Award winner Terry Sanders, ``a 
powerful, emotional and dramatic film about the fight that 
begins when the battle ends. It is today's story of young 
wounded soldiers, American military doctors and nurses in a 
time of war, and the West Point of military medicine, USU, the 
best medical school no one has ever heard of.''
    And so it is an extraordinary movie. I am very grateful 
here in the capitol area, at Bethesda, on March the 14th, 
Bethesda Road Theater, in Washington at the E Street Theater, 
and it will be shown across the country.
    But it is an extraordinary, moving film of the success of 
military medicine.
    Thank you very much.
    Mrs. Davis. Thank you.
    And thank you, gentlemen. We certainly want to acknowledge 
the great strides made in medicine, of course, but also in the 
last year in trying to make certain that the men and women who 
serve and who are injured get the kind of support and care that 
they need, and we greatly appreciate that.
    I can assure you that this committee will provide 
continuing oversight on this issue and I am wondering when you 
feel it is an appropriate time to come back and look at some of 
the ongoing challenges, some of the gaps perhaps that you think 
still need to be filled as we continue to move forward, and 
when we might be able to evaluate some of that continuing 
progress.
    Is it six months, a year?
    Admiral Robinson. From the Navy's perspective, I think a 
year is too long. I think a six-month timeframe would be very 
good.
    General Schoomaker. I would concur. I think one of the 
concerns we all have is about the transition that may take 
place in the enduring programs that have been established here. 
I think six months is a very good time. Yes, ma'am.
    Mrs. Davis. Okay, we will certainly do that. And continue, 
please, to ask the questions, questions that we don't know yet, 
but we don't we don't, what we haven't asked, and particularly, 
as we move forward with research, that we are tapping really 
all the tools that we have to answer some of the questions that 
are out there.
    Thank you very much. Thank you all for being here.
    [Whereupon, at 12:02 p.m., the subcommittee was adjourned.]
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