[Senate Hearing 110-198]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 110-198
 
 CARE, LIVING CONDITIONS, AND ADMINISTRATION OF OUTPATIENTS AT WALTER 
                        REED ARMY MEDICAL CENTER 

=======================================================================

                                HEARING

                               before the

                      COMMITTEE ON ARMED SERVICES
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 6, 2007

                               __________

         Printed for the use of the Committee on Armed Services

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                      COMMITTEE ON ARMED SERVICES

                     CARL LEVIN, Michigan, Chairman

EDWARD M. KENNEDY, Massachusetts     JOHN McCAIN, Arizona
ROBERT C. BYRD, West Virginia        JOHN WARNER, Virginia,
JOSEPH I. LIEBERMAN, Connecticut     JAMES M. INHOFE, Oklahoma
JACK REED, Rhode Island              JEFF SESSIONS, Alabama
DANIEL K. AKAKA, Hawaii              SUSAN M. COLLINS, Maine
BILL NELSON, Florida                 JOHN ENSIGN, Nevada
E. BENJAMIN NELSON, Nebraska         SAXBY CHAMBLISS, Georgia
EVAN BAYH, Indiana                   LINDSEY O. GRAHAM, South Carolina
HILLARY RODHAM CLINTON, New York     ELIZABETH DOLE, North Carolina
MARK L. PRYOR, Arkansas              JOHN CORNYN, Texas
JIM WEBB, Virginia                   JOHN THUNE, South Dakota
CLAIRE McCASKILL, Missouri           MEL MARTINEZ, Florida

                   Richard D. DeBobes, Staff Director

             Michael V. Kostiw, Replublican Staff Director

                                  (ii)

  























                            C O N T E N T S

                               __________

                    CHRONOLOGICAL LIST OF WITNESSES

 Care, Living Conditions, and Administration of Outpatients at Walter 
                        Reed Army Medical Center

                             march 6, 2007

                                                                   Page

Chu, Hon. David S.C., Under Secretary of Defense for Personnel 
  and Readiness..................................................     6
Schoomaker, GEN Peter J., USA, Chief of Staff, United States Army    11
Winkenwerder, William, Jr., M.D., Assistant Secretary of Defense 
  for Health Affairs.............................................    14
Kiley, LTG Kevin C., USA, Surgeon General, United States Army....    19

                                 (iii)


 CARE, LIVING CONDITIONS, AND ADMINISTRATION OF OUTPATIENTS AT WALTER 
                        REED ARMY MEDICAL CENTER

                              ----------                              


                         TUESDAY, MARCH 6, 2007

                                       U.S. Senate,
                               Committee on Armed Services,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 9:34 a.m. in room 
SD-106, Dirksen Senate Office Building, Senator Carl Levin 
(chairman) presiding.
    Committee members present: Senators Levin, Kennedy, 
Lieberman, Reed, Akaka, Bill Nelson, E. Benjamin Nelson, Bayh, 
Clinton, Pryor, Webb, McCaskill, McCain, Warner, Inhofe, 
Sessions, Collins, Ensign, Chambliss, Graham, Dole, Cornyn, 
Thune, and Martinez.
    Committee staff members present: Richard D. DeBobes, staff 
director; Leah C. Brewer, nominations and hearings clerk; and 
Gary J. Howard, systems administrator.
    Majority staff members present: Jonathan D. Clark, counsel; 
Gabriella Eisen, professional staff member; Gerald J. Leeling, 
counsel; and Michael J. McCord, professional staff member.
    Minority staff members present: Michael V. Kostiw, 
Republican staff director; David M. Morriss, minority counsel; 
Lucian L. Niemeyer, professional staff member; Diana G. Tabler, 
professional staff member; and Richard F. Walsh, minority 
counsel.
    Staff assistants present: David G. Collins, Kevin A. 
Cronin, and Jessica L. Kingston.
    Committee members' assistants present: Frederick M. Downey, 
assistant to Senator Lieberman; Elizabeth King, assistant to 
Senator Reed; Darcie Tokioka, assistant to Senator Akaka; 
Benjamin Rinaker, assistant to Senator Ben Nelson; Andrew 
Shapiro, assistant to Senator Clinton; Lauren Henry, assistant 
to Senator Pryor; Jason D. Rauch, assistant to Senator 
McCaskill; Richard H. Fontaine, Jr., assistant to Senator 
McCain; Sandra Luff, assistant to Senator Warner; D'Arcy 
Grisier, assistant to Senator Ensign; Bridges Sinyard and Clyde 
A. Taylor IV, assistants to Senator Chambliss; and Adam G. 
Brake, assistant to Senator Graham.

       OPENING STATEMENT OF SENATOR CARL LEVIN, CHAIRMAN

    Chairman Levin. Good morning, everybody. This committee 
meets this morning to address reports of substandard living 
conditions, poor outpatient care, and bureaucratic roadblocks 
and delays for injured soldiers at Walter Reed Army Medical 
Center. We welcome our witnesses here today: Dr. David S.C. 
Chu, Under Secretary of Defense for Personnel and Readiness; 
Dr. William Winkenwerder, Assistant Secretary of Defense for 
Health Affairs; General Peter Schoomaker, Chief of Staff of the 
Army; and Lieutenant General Kevin Kiley, Surgeon General of 
the Army.
    This committee is determined to understand what went wrong 
at Walter Reed Army Medical Center and what we need to do to 
make sure it does not happen again there, or anywhere else. Our 
Nation has a moral obligation to provide quality health care to 
the men and women who put on our Nation's uniform and are 
injured and wounded fighting our Nation's wars. This obligation 
extends from the point of injury through evacuation from the 
battlefield, to first class medical facilities in the United 
States, and ends only when the wounds are healed. Where the 
wounds will never heal, we have an obligation to provide 
quality care throughout the lifetime of the veteran. I am sad 
to say that we are not meeting this obligation, although it is 
an obligation which all Americans accept and insist be met to 
the fullest.
    Today's hearing is about another example of the lack of 
planning for a war that was premised on the assumption that 
combat operations would be swift, casualties would be minimal, 
and that we would be welcomed as liberators instead of being 
attacked by the people we liberated.
    I am proud of the fact that our military doctors, nurses, 
and medics have provided outstanding medical care to those who 
were wounded. Many servicemembers who would have died in 
earlier conflicts survived in Iraq and Afghanistan because of 
the advances in battlefield medical care, and the skill and 
bravery of our combat medical teams. Seriously injured troops 
are rapidly evacuated to world-class medical facilities like 
Walter Reed and Bethesda, where they continue to receive state-
of-the-art care as inpatients.
    It is when they leave inpatient status that the system has 
failed them. A recent series of Washington Post articles 
described deplorable living conditions, failure to account for, 
and bungled administrative processing of injured troops in 
outpatient status at the Walter Reed Army Medical Center. New 
reports indicate that these problems are not confined to Walter 
Reed. They exist elsewhere in the military and Department of 
Veterans Affairs (VA) medical systems. Washington Post 
reporters Dana Priest and Anne Hull are to be commended for 
bringing this tragic situation to light.
    The Army now has acted to move soldiers out of a worn, 
aging facility that should never have been used to house 
wounded soldiers. These heros deserve far better than that. 
They all volunteered for service in our military forces, with 
great hopes and dreams for their futures. Now they are faced 
with the daunting task of figuring out how to live with 
lifetime disability, a condition they incurred in service to 
our Nation.
    It appears that the Army, especially the leadership at 
Walter Reed, was slow to recognize the need to increase the 
number of caseworkers and experienced noncommissioned officers 
(NCOs) to keep pace with the increased number of outpatients 
under their care. These NCOs and case managers are critical for 
assisting injured soldiers in making and keeping medical 
appointments, for accounting for and tracking of these soldiers 
during rehabilitation and recuperation, and assisting them as 
they process through the disability evaluation system.
    The Army is now hiring more case managers and bringing in 
additional NCOs to help these injured soldiers and their 
families navigate the health care system, and to ensure that 
these soldiers have a decent quality-of-life while they 
continue to recover from their injuries. The Army is also 
establishing a new command structure at Walter Reed that will 
be focused on taking care of wounded soldiers in an outpatient 
status. Good leadership should have taken those steps long ago, 
without prompting by a series of embarrassing news articles.
    Senior officers are being held accountable for failures of 
leadership that led to these conditions. Unlike his 
predecessor, who fired only those who disagreed with him, 
Secretary of Defense Robert Gates has moved quickly to remove 
senior officials when he lost confidence in them because their 
actions did not measure up. Our soldiers will benefit as a 
result of Secretary Gates's decisive action to insist on 
accountability.
    While the Army appears to be taking the necessary steps to 
repair and evacuate substandard buildings and hire additional 
staff to assist wounded soldiers, the more daunting task is to 
change an overly complex, bureaucratic, adversarial system used 
to evaluate and rate disabilities of injured servicemembers, 
and we are going to hear more about that this morning.
    Last Friday, four colleagues and I visited Walter Reed and 
talked with a number of these wounded soldiers and their 
families. By and large, they had praise for the inpatient 
health care that they received and, despite our personal 
observation of substandard living conditions for the 
outpatients, they did not complain. What they were most 
concerned about is the military's disability evaluation system. 
Many of these soldiers have extremely complex injuries that 
take many operations and a long time to heal. For some this 
process takes more than a year. Once they get to the point 
where their doctors tell them that further medical care will 
not improve their condition and it is determined that they are 
not fit for duty, most of these wounded soldiers just want to 
go home and get on with their lives.
    It is at this point in their treatment that they encounter 
the Department of Defense (DOD) disability evaluation system. 
This system places these soldiers in the position of having to 
fight for a disability rating that entitles them to medical 
treatment. After all they have been through, these injured 
soldiers should not feel that they have to fight for what we as 
a Nation have a moral obligation to provide.
    One soldier with whom I talked had been injured by an 
improvised explosive device (IED) blast while on his second 
tour of duty in Iraq. He is continuing to receive care for his 
injuries in an outpatient status. He understands that he is no 
longer physically fit for military duty because of the 
seriousness of his injuries. He told me that he is ``scared to 
death'' that the physical disability evaluation system will 
rate his disability at less than 30 percent and therefore he 
would not receive a medical retirement, although he is going to 
be discharged, and that he would be ``put on the street,'' in 
his words, without the ability to take care of his family and 
their medical needs, including his four children.
    How can we as a Nation ask our young men and women to 
serve, and when they are wounded while serving put them in a 
position where they are scared to death that we will not take 
proper care of them and their families? Surely we must change 
such a system.
    The problems are not over for these disabled veterans when 
they leave the military. After a servicemember is medically 
discharged or separated, he or she can apply for disability 
compensation and health care through the VA. The VA conducts 
its own assessment of the degree of disability of the veteran. 
Although the VA and DOD use the same standard for evaluating 
disabilities, their disability ratings often vary significantly 
and in most cases the VA disability rating is higher than the 
military disability rating. Unfortunately, only the military 
disability rating counts when determining whether the member is 
medically retired with family health care benefits or medically 
discharged with no benefits for his or her family, and that is 
extremely frustrating and confusing for our wounded 
servicemembers and their families, who then have to fight the 
system to get the best rating that they can.
    I commend Secretary Gates for quickly recognizing that we 
are falling short in our obligation to our wounded 
servicemembers and, in a unique statement that he made of 
gratitude to the reporters who broke the story, said that he 
was very disappointed that we did not identify it ourselves. He 
added very accurately that our servicemembers ``battled our 
foreign enemies; they should not have to battle an American 
bureaucracy.''
    Senator Akaka, the chairman of the Committee on Veterans 
Affairs, and I and our ranking members, Senator McCain and 
Senator Craig, are determined that our committees will work 
together to improve the care of our veterans throughout their 
continuum of care. We will hold a joint hearing of our two 
committees in the near future to identify the remedies to the 
problems that our wounded soldiers are facing.
    The American people are deeply angry about the shortfalls 
in care. The war in Iraq has divided our Nation, but the cause 
of supporting our troops unites us. We will do everything we 
possibly can do, not as Democrats or Republicans, but as 
grateful Americans, to care for those who have served our 
Nation with such honor and distinction.
    Senator McCain.

                STATEMENT OF SENATOR JOHN McCAIN

    Senator McCain. Mr. Chairman, I want to thank you for 
calling this very important hearing. The revelations over the 
past week have been distressing to the Nation. I am dismayed 
this ever occurred. It was a failure in the most basic tenets 
of command responsibility, to take care of our troops.
    This is even more troubling because we have reason to 
believe that the Army learned from the headlines of poor 
conditions, inadequate medical treatment, and bureaucratic 
delays for the wounded at Fort Stewart 3 years ago. You will 
recall that Acting Secretary of the Army Les Brownlee 
immediately visited Fort Stewart and initiated remedial action 
within the Army. By 2004, hundreds of additional medical and 
administrative personnel had been mobilized and new regional 
centers established throughout the country to accommodate 
soldiers in medical holdover status.
    In 2006, my colleague, Senator Graham, then chairman of the 
Subcommittee on Personnel, sought assurance from two of our 
witnesses today, Doctors Chu and Winkenwerder, that our 
Government was doing everything possible to ensure that 
wounded, once they get off the battlefield with the best 
medicine known in the history of warfare, do not fall through 
the cracks. Today I hope we will hear from Dr. Chu and Dr. 
Winkenwerder where we have failed.
    Our Nation is blessed with a magnificent team of military 
and civilian doctors and nurses who care for our wounded. I 
think it is very important that we recognize and support their 
efforts. At the same time, we must demand accountability for 
the failure to take appropriate actions and move aggressively 
to take corrective action.
    Senior Army leaders were defensive in the face of these 
revelations at Walter Reed, and were quick to lay blame for 
these failures on NCOs. Frankly, I find that appalling.
    To the soldiers who spoke out and their families, you have 
our gratitude for your service and your courage. We should also 
be grateful to the Washington Post reporters who brought this 
to our attention.
    Mr. Chairman, there are more questions to be answered. Is 
Walter Reed just the tip of the iceberg? How many other 
Building 18s are in the Army, the Navy, the Marine Corps, and 
the Air Force? What improvement projects at Walter Reed had a 
higher priority than basic life and safety improvements for 
wounded soldiers? What complaints were received by the Army and 
DOD inspectors general relative to conditions at Walter Reed, 
and what actions were taken? How did the base realignment and 
closure (BRAC) impact the decisions leaders in the Army and at 
Walter Reed made with regard to outpatient facilities?
    We also have a responsibility to ensure that there is a 
future for our wounded that is better than the past. If 
legislation is necessary, we will pursue it. Systems and 
institutions must change. We utilize 21st century medical 
technology to save lives at a rate far greater than at any time 
in our Nation's history, yet Cold War processes to determine 
compensation and the ability to continue to serve. There have 
to be better ways to address the medical and disability 
evaluation systems for those who cannot continue on Active Duty 
due to their disabling conditions.
    The Army leadership must continue to do what it has just 
begun, bring more resources to bear on helping wounded warriors 
and their families. They deserve nothing less.
    Secretary Gates has introduced welcome change to the DOD. 
It is my sincere hope that through his leadership we will build 
on the quality and strength in our system today, but we must 
make right the wrongs that our wounded have endured in what has 
occurred and ensure accountability at all levels, all levels.
    There is no more important responsibility than to act on 
our moral obligation as a Nation to those who are willing to 
give their blood for its freedom. Let us be guided by the words 
of President George Washington in 1789, who said: ``The 
willingness with which our young people are likely to serve in 
any war, no matter how justified, shall be directly 
proportional as to how they perceive that veterans of earlier 
wars were treated and appreciated by their country.''
    Thank you, Mr. Chairman.
    Chairman Levin. Thank you, Senator McCain.
    Secretary Chu.

 STATEMENT OF HON. DAVID S.C. CHU, UNDER SECRETARY OF DEFENSE 
                  FOR PERSONNEL AND READINESS

    Dr. Chu. My colleagues and I have prepared statements that 
I hope you would accept for the record.
    Chairman Levin. We will.
    Dr. Chu. Thank you, sir.
    Mr. Chairman and Senator McCain, I am deeply chagrined by 
the events that bring us to this hearing this morning.
    We set high standards for personnel actions in the DOD, and 
as you have celebrated in the quality of clinical care, 
starting on the battlefield and coming all the way back to our 
inpatient facilities here in the United States. Thanks to that 
care, as you reported, the United States enjoys the lowest 
disease and non-battle injury rate in the history of military 
actions by this Republic, and the highest rate of survival by 
the wounded that we have ever achieved. Indeed, the overall 
TRICARE health program enjoys high positive ratings from its 
beneficiaries and those have led Congress to add additional 
groups to the coverage under that program.
    Where we have fallen short in administration, in billeting, 
in the processing of disability evaluation claims, I want to 
apologize this morning on behalf of DOD to the individuals 
concerned and to the American public. We need to maintain the 
same high standards in these areas that we have achieved in 
others.
    If I may, Mr. Chairman, I would like to defer to my 
colleagues to testify to the medical issues and then return to 
the long-term issue at the conclusion of their opening 
statements that you have raised, and that is the disability 
evaluation system. You and Senator McCain have both spoken to 
this important subject. I think General Schoomaker would be 
next.
    [The prepared statement of Dr. Chu follows:]
               Prepared Statement by Hon. David S.C. Chu
    Mr. Chairman and distinguished members of this committee, thank you 
for this opportunity to discuss care for injured servicemembers and the 
administrative processes for restoration to duty or separation from 
military service.
    We provide extraordinary medical services, on the battlefield, in 
transport to facilities outside of the theater, and in clinical centers 
here in the United States. With the advent of operations in Afghanistan 
and Iraq, our medical care systems mounted an enormously effective 
trauma treatment response. More of those suffering traumatic injuries 
were saved; in years past they might have succumbed to their wounds 
instead.
    I will defer to Dr. Winkenwerder's discussion of the specifics of 
medical care, but I wish to underscore that I share his distress with 
the significant administrative problems at Walter Reed. On behalf of 
the Department, I apologize to the servicemembers and to the American 
public.
    We did not meet our standards as we should. The various review 
panels now being organized will help establish what occurred and the 
adequacy of remedial actions. Permit me to turn to the other issues of 
interest to the committee, starting with the Department's disability 
system.
                department of defense disability system
The Right Paradigm
    Does this Nation have the right paradigm in place military 
disability compensation? We have diverse approaches in the public 
sector to problems that have much in common. Social Security's 
disability payments, the Department of Labor, Workmen's Compensation, 
the Department of Veterans Affairs' (VA) and the Department of 
Defense's (DOD) disability evaluation system (DES) are carried out in 
different ways, against different standards, to achieve different ends. 
Perhaps foreseeing this issue, Congress in 2003 directed the 
establishment of the VA Disability Benefits Commission. Its report is 
expected October 2007, and it may help us understand how to achieve 
unity of effort and purpose.
Department of Defense Disability Evaluation System
    The citizens of the United States have a long and proud history of 
compensating servicemembers whose opportunity to complete a military 
career has been cut short as the result of injuries or illnesses 
incurred in the line of duty. Congress mandated the development of a 
system of rating military disabilities in 1917 and over time that 
system has been further refined to the benefit of servicemembers and 
their families. The Career Compensation Act of 1949 formalized the code 
the military departments utilize today. In addition to DOD disability 
compensation, former servicemembers may be eligible for disability 
compensation benefits through the VA. A key difference between the DOD 
and VA disability systems is that the Services only award disability 
ratings for medical conditions that make the individual unfit for 
continued military service, whereas the VA may rate any change in 
health status that can be linked to the time the member was in Service 
regardless of whether it was disabling enough to preclude continued 
service. Military disability ratings are fixed upon final disposition, 
while VA ratings can increase over time when the condition worsens.
    Now, as in the past, the DOD remains committed to providing a 
comprehensive, fair, and timely medical and administrative processing 
system to evaluate our injured or ill servicemembers' fitness for 
continued service using the DES. The overarching legislative guidance 
for the DOD DES is set forth in statute in chapter 61 of title 10 of 
the U.S.C. Since the inception of chapter 61 in 1949, the Department 
has provided additional policy guidance. Ultimately, Secretaries of the 
military departments have exercised this title 10 authority consistent 
with their roles and missions. However, the Department does mandate 
military department DES include four elements: medical/physical 
evaluation, appellate review, counseling, and final disposition.
    Title 10 mandates that each servicemember determined to be unfit be 
afforded the right to a full and fair personal appearance and hearing. 
To ensure due process, Department policy requires Secretaries concerned 
to utilize a series of medical and administrative boards.
    The evaluation process begins with the medical evaluation board 
(MEB). The MEB is typically generated by a physician when a 
servicemember has an unresolved medical condition or injury which 
precludes him or her from being classified as fit for full duty. The 
MEB documents the medical diagnosis(es), course of treatment, prognosis 
and any duty limitations of the servicemember. The MEB process serves 
to protect the health of the servicemember. But it may be the basis for 
referral to the physical evaluation board (PEB) process if the MEB 
calls into question the individual's fitness for continued military 
service. The PEB is a performance-based process composed of two board 
types referred to as informal and formal PEBs. Formal PEBs typically 
consist of three board members but board composition and membership is 
established by the individual Service Secretaries. The PEBs review a 
variety of medical evidence and performance information to adjudicate 
the impact of the servicemember's medical condition his ability to 
reasonably perform the duties of his or her office, grade, rank, or 
rating. The informal board is a record review process without 
representation whereas the formal board provides a personal appearance 
opportunity with legal representation. If the servicemember's case 
proceeds to a formal hearing, he or she is encouraged to utilize legal 
assistance, provided by the Service or retained by the servicemember at 
personal expense. The formal hearing is a non-adversarial proceeding 
designed to ensure fairness, equity, and due process.
Physical Evaluation Board Adjudication
    On the basis of a preponderance of the evidence, the PEB determines 
whether the individual is fit or unfit (i.e., does not meet medical 
retention standards) for continued military service with one of four 
possible disposition recommendations: return to duty, separate from the 
Service, placement on the temporary disability retired list, or 
permanent disability retirement. As a product of the PEB process and 
according to title 10, servicemembers found unfit for continued 
military service will be awarded a disability rating percentage, for 
the military unfitting condition, in accordance with the rating 
guidance established in the VA Schedule for Rating Disabilities. This 
disability rating determines entitlement to separation or retirement 
benefits.
Timely Disability Evaluation System Adjudication
    The Department's DES timeliness standards were established in 1996 
based on a 1992 DOD Inspector General recommendation. When a physician 
initiates a MEB, the processing time should normally not exceed 30 days 
from the date the MEB report is dictated to the date it is received by 
the PEB. Upon receipt of the MEB or physical examination report by the 
PEB, the processing time to the date of the determination of the final 
reviewing authority as prescribed by the Secretary of the Military 
Department should normally be no more than 40 days. One can easily see 
that the timeliness of the adjudication of each DES case is dependent 
upon a myriad of factors, e.g. the severity of the injury, the recovery 
process, administrative documentation, and due process concerns.
    According to the military departments, the average adjudication 
period for MEB/PEB cases is now longer because the cases are more 
complicated as a result of the types of injuries servicemembers are 
sustaining in current combat operations. In 2004, in order to mitigate 
this formal board phenomenon, the Army Physical Disability Agency 
established a mobile PEB to augment its capacity to conduct formal 
boards at their three fixed PEB sites. This has helped the Army 
accommodate its increased case load. Reserve component servicemembers' 
cases occasionally take longer because private practitioners are 
involved in documenting the cases. The Army reports that its overall 
timeliness rates are above the DOD goal; this is attributed to the 
complexity of injuries and the challenges in collating case files for 
Reserve component soldiers.
    It may be difficult for the individual servicemember to 
differentiate between the medical inpatient/outpatient recovery phase 
and the administrative MEB/PEB processes. This creates the impression 
of long processing times caused by MEBs/PEBs when, actually, the 
servicemembers could still be receiving medical and convalescing care 
for their injuries.
    Let me also emphasize that during this process of health care, 
convalescent care, rehabilitation, and MEB/PEB review, servicemembers 
are in receipt of full pay and allowances. The system is designed not 
to rush a decision. I assure you our servicemembers' best interests are 
at the heart of the system. But we need to communicate better the 
purposeful and deliberate intent of the DES to our servicemembers and 
their families.
Update on the Government Accountability Office findings
    The 2006 Government Accountability Office (GAO) report, ``Military 
Disability System: Improved Oversight Needed to Ensure Consistent and 
Timely Outcomes for Reserve and Active Duty Servicemembers'' concluded 
that disability ratings are consistent between Active and Reserve 
components. The report could not determine if dispositions were 
consistent, and lacking data on preexisting conditions, it called for 
stronger oversight. In response, the Department revitalized its 
Disability Advisory Council (DAC) so that it plays an active and 
strengthened role in molding Department DES policy.
Revitalization Efforts
    In a self-policing effort, the Military Departments' Personnel 
Chiefs and Surgeons General recommended we charge the DAC with updating 
the set of DOD directives/instructions that promulgate disability 
policies. The Department has also tasked this group with strengthening 
oversight processes and making recommendations on program effectiveness 
measures. The Department has established working groups, under the 
Disability Advisory Council, consisting of senior human resource and 
medical subject matter experts from the military departments and OSD 
agencies to address the GAO recommendations on training, oversight and 
consistency of application. We anticipate revised DOD instructions will 
be completed in May 2007.
    In addition to our DOD-level initiatives, the military departments 
are also continually reviewing their processes to make them more 
effective. For example, Army leadership recently established a Physical 
DES Transformation Initiative which integrates multiple major commands 
and the VA. This combined effort targets improving process efficiency 
and timeliness in areas such as: MEB and PEB processes, automation of 
disability data, counseling and training, and transition assistance. 
Additionally, in November 2006, the Army directed an internal Inspector 
General review of its DES process. I understand that the report is due 
out this fall.
             quality-of-life programs for severely injured
Military Severely Injured Center
    The Department is committed to providing the assistance and support 
required to meet the challenges that confront our severely injured and 
wounded servicemembers and their families during the difficult time of 
transition. Each Service has programs to serve severely wounded from 
the war: the Army Wounded Warrior Program (AW2), the Navy Safe Harbor 
program, the Air Force Helping Airmen Recover Together (Palace HART) 
program, and the Marine4Life (M4L) Injured Support Program. DOD's 
Military Severely Injured Center augments the support provided by the 
Services. It reaches beyond the DOD to coordinate with other agencies, 
to the nonprofit world, and to corporate America. It serves as a fusion 
point for four Federal agencies--DOD, the VA, the Department of 
Homeland Security's Transportation Security Administration (TSA), and 
the Department of Labor.
Federal Partners
    The Military Severely Injured (MSI) Center unites Federal agencies 
through a common mission: to assist the severely injured and their 
families.

        The VA Office of Seamless Transition has a full-time liaison 
        assigned to the center to address VA benefits issues ranging 
        from expediting claims, facilitating VA ratings, connecting 
        servicemembers to local VA offices, and coordinating the 
        transition between the Military and the VA systems.
        The Department of Labor has assigned three liaisons from its 
        REALifelines program which offers personalized employment 
        assistance to injured servicemembers to find careers in the 
        field and geographic area of their choice. REALifelines works 
        closely with the VA's Vocational Rehabilitation program to 
        ensure servicemembers have the skills, training, and education 
        required to pursue their desired career field.
        The Department of Homeland Security's TSA has a 
        transportation specialist assigned to the center to facilitate 
        travel of severely injured members and their families through 
        our Nation's airports. The Center's TSA liaison coordinates 
        with local airport TSA officials to ensure that each member is 
        assisted throughout the airport and given a facilitated (or 
        private) security screening that takes into account the 
        member's individual injuries.

Nonprofit Coordination
    The MSI Center has coordinated with over 40 nonprofit 
organizations, all of which have a mission is to assist injured 
servicemembers and their families. These nonprofits offer assistance in 
a number of areas from financial to employment to transportation to 
goods and services. Many are national organizations, but some are 
local, serving Service men and women in a specific region or at a 
specific Military Treatment Facility. Some of the many organizations 
that are providing assistance are the Wounded Warrior Project, the 
Injured Marine Semper Fi Fund, the Veterans of Foreign Wars, the 
American Legion, Disabled American Veterans, the Coalition to Salute 
America's Heroes, and, of course, the Service Relief Societies. There 
are hundreds of other non-profits who offer assistance to military 
families in general that are part of the America Supports You network 
(www.americasupportsyou.mil).
Operation Warfighter
    DOD sponsors Operation Warfighter (OWF), a temporary assignment or 
internship program for servicemembers who are convalescing at military 
treatment facilities in the National Capital Region. This program is 
designed to provide recuperating servicemembers with meaningful 
activity outside of the hospital environment that assists in their 
wellness and offers a formal means of transition back to the military 
or civilian workforce. The program's goal is to match servicemembers 
with opportunities that consider their interests and utilize both their 
military and non-military skills, thereby creating productive 
assignments that are beneficial to the recuperation of the 
servicemember and their views of the future. Servicemembers must be 
medically cleared to participate in OWF, and work schedules need to be 
flexible and considerate of the candidate's medical appointments. Under 
no circumstance will any OWF assignment interfere with a 
servicemember's medical treatment or adversely affect the well-being 
and recuperation of OWF participants.
    In 2006, 140 participants were successfully placed in OWF. Through 
this program, these servicemembers were able to build their resumes, 
explore employment interests, develop job skills, and gain valuable 
Federal Government work experience to help prepare them for the future. 
The 80 Federal agencies and sub-components acting as employers in the 
program were able to benefit from the considerable talent and 
dedication of these recuperating servicemembers. Approximately 20 
permanent job placements resulted from OWF assignments upon the 
servicemember's medical retirement and separation from military 
service.
    The core of OWF is not about employment, however; placing 
servicemembers in supportive work settings that positively assist their 
recuperation is the underlying purpose of the program.
Heroes to Hometowns
    The American public's strong support for our troops shows 
especially in their willingness to help servicemembers who are severely 
injured in the war and their ever-supportive families, as they 
transition from the hospital environment and return to civilian life. 
Heroes to Hometowns' focus is on reintegration back home, with networks 
established at the national and State levels to better identify the 
extraordinary needs of returning families before they return home. They 
work with local communities to coordinate government and nongovernment 
resources necessary for long-term success.
    The Department has partnered with the National Guard Bureau and the 
American Legion, and most recently the National Association of State 
Directors of Veterans Affairs, to tap into their national, state, and 
local support systems to provide essential links to government, 
corporate, and nonprofit resources at all levels and to garner 
community support. Support has included help with paying the bills, 
adapting homes, finding jobs, arranging welcome home celebrations, help 
working through bureaucracy, holiday dinners, entertainment options, 
mentoring, and very importantly, coordinated hometown support. 
Currently, Heroes to Hometowns assistance has been provided to 156 
families in 37 States and 2 territories.
    Many private and nonprofit organizations have set their primary 
mission to support severely injured veterans. The Sentinels of Freedom 
in San Ramon, California, for example, recruits qualifying severely 
injured to their community with ``scholarships'' that include free 
housing for 4 years, an adaptive vehicle, a career enhancing job, 
educational opportunities, and comprehensive community mentoring. 
Through a coordinated effort among local governments, corporations, 
businesses, nonprofits, and the general public, six scholarships have 
already been provided in the San Ramon Valley and plans are to expand 
the program nationwide.
Paralympics
    The ability of injured servicemembers to engage in recreational 
activities is a very important component of recovery. We continue to 
work with the United States Paralympics Committee and other 
organizations so that our severely injured have opportunities to 
participate in adaptive sports programs, whether those are skiing, 
running, hiking, horseback riding, rafting, or kayaking. We are also 
mindful of the need to ensure installation morale, welfare, and 
recreation (MWR) fitness and sports programs can accommodate the 
recreational needs of our severely injured servicemembers. At 
congressional request, we are studying current capabilities of MWR 
programs to provide access and accommodate eligible disabled personnel.
    The United States Olympic Committee Paralympics organization is 
also coordinating with key Military Treatment Facilities to see how 
severely injured sports and recreational opportunities can be expanded 
and incorporated into all aspects of the recovery, rehabilitation, and 
reintegration process. The Department is coordinating with other 
organizations such as the Armed Forces Recreation Society to provide 
similar opportunities to severely injured veterans on the municipal and 
local levels, even possibly partnering with colleges and universities 
to take advantage of those facilities and recreational programs.
                             the way ahead
    Earlier I requested the DOD Inspector General (IG) perform an 
independent review, evaluating our policies and processes for injured 
Operations Enduring Freedom/Iraqi Freedom servicemembers. The objective 
is to ensure they are provided effective, transparent, and expeditious 
access to health care and other benefits when identified for separation 
or retirement due to their injuries. I expect to receive the IG report 
by July 2007.
    In compliance with the National Defense Authorization Act for 
Fiscal Year 2005, the Joint Medical Readiness Oversight Committee 
(JMROC) was established to improve medical readiness throughout the DOD 
and enhance servicemember health status tracking before, during, and 
after military operations. The JMROC oversees medical readiness issues 
by using a Comprehensive Medical Readiness Plan. Initially consisting 
of the 22 actions required by the National Defense Authorization Act 
for Fiscal Year 2005, the Department is expanding that list to include 
readiness initiatives emanating from the National Defense Authorization 
Acts for Fiscal Years 2006 and 2007. I believe the JMROC can assist the 
Department in implementing improvements to support our injured 
servicemembers.
    As the various reviews reach their conclusions, I hope that we can 
reach a national consensus on the integration of Federal disability 
systems affecting our Nation's veterans and how they can be improved. I 
look forward to working with you to develop the best way to provide for 
the men and women who stepped forward to defend this Nation and were 
injured in its service.

    Chairman Levin. General Schoomaker.

  STATEMENT OF GEN PETER J. SCHOOMAKER, USA, CHIEF OF STAFF, 
                       UNITED STATES ARMY

    General Schoomaker. Mr. Chairman and distinguished members 
of the committee, I cannot tell you how disappointed and how 
absolutely angry I am to have to sit before you today and to 
stand accountable for what has occurred in the United States 
Army. I agree with your statement and the statement of the 
ranking member. I think that the military health care system, 
particularly the Army, one I am very familiar with, is full of 
the most professional, most caring medical professionals in the 
world, and I hope that we make sure that as we address the 
shortcomings here that we recognize the heroic work that is 
taking place by all of the men and women who are taking care of 
our wounded warriors and their families throughout this 
process.
    Now, we have discovered shortcomings that were brought to 
our attention by the media. We should have known about these 
things ourselves and we are finding out why we did not. But I 
will tell you that I accept full responsibility and 
accountability for these shortcomings because I am the senior 
uniformed officer in the Army, just like I accept 
responsibility for everything that happens in the Army and 
fails to happen. That is the tradition of military service and 
accountability, and I stand before you accountable for what has 
occurred.
    I will tell you that we all run in a bureaucratic morass. 
Life every day in this system is like running in hip boots in a 
swamp. It sucks the energy out of you every day, and not just 
in the medical system, but in everything else that we do. I 
hope that as we take a look at this that we look broadly at the 
kinds of things that we can do to bring all of this into the 
21st century, because that is the challenge that I believe we 
all face and I believe it is a national security issue.
    I would like to describe very quickly the things that we 
have done and are doing immediately to rectify and bring into 
standards and tolerance the situation that we find not only at 
Walter Reed, but across the United States Army system. First of 
all, we put a new leader in command at Walter Reed, Major 
General Eric Schoomaker. He took command last Friday and was on 
the ground within hours of taking charge. His deputy commander 
will be announced. He is being selected as I speak, and will be 
announced this week. He will be a combat arms brigadier general 
that will work for Major General Schoomaker and will assist in 
making sure that the proper care is being taken in an 
administrative and military way for our soldiers.
    The Wounded Warrior Transition Brigade commander and 
command sergeant major, both combat arms soldiers-leaders, have 
been selected and are on the ground, and are taking charge of 
accountability for health and welfare issues. The new brigade 
structure that we have approved out there is being manned.
    A one-stop soldier and family assistance center has been 
established at Walter Reed and this brings together in one 
place the case managers, family coordinators, personnel and 
finance experts, Army Wounded Warrior Program representatives, 
Red Cross, Army community services, Army emergency relief, and 
VA representatives.
    Additionally, we are establishing a hot line from across 
the Army directly into the Army operations center, which means 
that anybody can call in on a toll-free number and report 
directly into our operations center problems that they are 
having within the system so that the leadership will have 
direct access and immediate knowledge of what is occurring.
    We have launched a tiger team of medical installation 
professionals to our major medical treatment facilities Army-
wide to assess the outpatient care and to report back to the 
Army leadership within 30 days. We will launch a similar team 
early next week to assess outpatient care at our eight 
community-based health care organizations, which are locations 
where our Reserve component soldiers are given the opportunity 
to recover and rehabilitate closer to their families and their 
homes.
    The Vice Chief of Staff of the Army will host a video 
teleconference this Friday with hospital commanders of those 
treatment facilities with major outpatient populations to get 
an assessment of their programs and need for resources.
    All wounded soldiers, save those on leave or that are 
departing within the next few days, have been moved to Building 
14, which was renovated in July 2005, on the Walter Reed 
campus. This will put all wounded soldiers on the Walter Reed 
compound. State-of-the-art Internet capability computers, 
television, and phones are being added to each room in Building 
14 and those same accessories will be provided to all wounded 
soldiers out there.
    We are pursuing a patient advocate, an ombudsman, program 
at Walter Reed and other major installations for soldiers. 
Additionally, for the soldiers we have a central issue point 
for uniforms for all wounded soldiers, centralized distribution 
system for all donated goods, have made improvements to the 
dining facility so that wounded soldiers can more easily access 
it, and are ensuring that awards that have been earned are 
expeditiously presented and as rapidly as possible.
    There are many other things that we are doing outside 
Walter Reed specifically and for the purposes of brevity I will 
stop here. Again I want to recount that I stand accountable for 
what has occurred in the Army and all of our energy is going 
into make sure that the proper actions are being taken to 
correct it.
    Thank you very much.
    [The prepared statement of General Schoomaker follows:]
           Prepared Statement by GEN Peter J. Schoomaker, USA
    Mr. Chairman, Senator McCain, and distinguished members of the 
committee, thank you for this opportunity to discuss the outpatient 
care of our Nation's wounded warriors at Walter Reed Army Medical 
Center, and throughout our Army. Every leader in our force is committed 
to ensuring that Army health care for America's soldiers is the best 
this Nation can provide. From the battlefield through a soldier's 
return home, our priority is the expedient delivery of compassionate 
and comprehensive world class medical care.
    I am here today as the Chief of Staff of the U.S. Army. I can tell 
you, I have never been prouder than I am today to serve with our 
incredible soldiers, who motivate me every day and who remain the focus 
of everything we do as an Army.
    As Americans, we treasure the members of our All-Volunteer Force 
who have raised their right hand to say, ``America, in your time of 
need, send me. I will serve.'' We instinctively understand that in 
return for their service and sacrifice, especially in a time of war and 
demanding operational tempo, we owe them a quality of care that is at 
least equal to the quality of service they have provided to us.
    I have visited Army medical facilities around the world, and I have 
met with soldiers, staff, and patients in Iraq and Afghanistan; at 
Landstuhl, Germany; at installations across the United States, to 
include Walter Reed and Brooke Army Medical Centers. Without exception, 
the people I encounter inevitably remind me that the United States is a 
special Nation, blessed with incredible sons and daughters who are 
willing to serve. From the wounded soldiers I meet, whose bodies have 
been hurt, but whose spirits remain strong, to loved ones whose tender 
attention and tireless dedication are easing our warriors' path to 
recovery, to the medical staff who have devoted themselves to 
fulfilling the promise of our Army's Warrior Ethos that we will never 
leave a fallen soldier; I have witnessed unparalleled strength, 
resilience, and generosity, and I am humbled by their bravery. Even if 
all of our facilities were the best in the world, and every process, 
policy, and system were streamlined perfectly, our solders and families 
would still deserve better. Without a doubt, they deserve better than 
we have been providing to date.
    Today we have 248,000 soldiers deployed in more than 80 countries 
around the world. When injured or wounded, every one of those soldiers 
begins a journey through our medical treatment facilities with the top-
notch care delivered by Army medics, surgeons, nurses, and civilians in 
the forward operating facilities. There, our soldiers receive 
extraordinary acute care that has drastically lowered our died-of-
wounds rate, and is regularly cited as being without peer.
    But it is after the incredible lifesaving work has been done, and 
the recovery process begins, that our soldiers are subjected to medical 
processes that can be difficult to negotiate and manage. Due to a 
patchwork of regulations, policies, and rules--many of which need 
updating--soldiers and staff alike are faced with the confusing and 
frequently demoralizing task of sifting through too much information 
and too many interdependent decisions. To compound this challenge, we 
have not optimally managed Army human and capital resources to assist 
wounded soldiers and their families. Some of our counselors and case 
managers are overworked and have not received enough training yet. At 
times, we do not adequately communicate necessary information. We must 
make better progress in improving our administrative processes. Some of 
our medical holding units are not manned to the proper level and some 
of our leaders have failed to ensure accountability, discipline, and 
the well-being of our wounded soldiers. We need to improve our 
maintenance of some of our facilities. Most of these issues we can 
repair ourselves, and we are working aggressively to do so. Some others 
may require your support and assistance to resolve.
    We have identified and fixed a number of problems, but there is 
still much to do. The Army has launched a wide-ranging and aggressive 
action plan to address current shortfalls, both at Walter Reed and 
across our Army. We are committed to rapidly fixing these problems, and 
are focusing our efforts in four key areas: soldier welfare, 
infrastructure, medical administrative processing, and information 
dissemination.
    At Walter Reed, we have made significant progress in repairing and 
improving conditions at Building 18. We have also accelerated 
improvements to the medical hold organizations and medical processes 
and are expediting the identification and implementation of ways to 
improve the Physical Disability Evaluation System across the force.
    We are reorganizing the Walter Reed medical hold unit by 
establishing a wounded warrior transition brigade, creating an 
additional medical hold company, and increasing its permanent party 
personnel to ensure we have the right numbers of leaders with the right 
skills to properly take care of our outpatient wounded soldiers and 
their families. We have selected a command-experienced, promotable 
lieutenant colonel and command sergeant major who will lead this 
organization. We are assigning more platoon sergeants who possess 
greater tactical leadership experience and are re-establishing the 
Walter Reed Garrison Command Sergeant Major position to provide the 
right level of skilled, caring leadership our wounded soldiers and 
their families deserve.
    To assist with outpatient care and reduce the delays in the medical 
and physical evaluation process, we are adding more personnel, 
improving their training, and adjusting our medical and administrative 
processes. We are expediting the reassignment and hiring of an 
additional 34 case managers and 10 physical evaluation board liaison 
officers to handle the increased patient load at Walter Reed. We have 
improved the physical, administrative, and medical transition of 
patients between the hospital and the medical-hold task force, and have 
implemented a revamped clinic appointment system for our outpatient 
wounded warriors. Additionally, a complete review of the medical and 
physical evaluation process is underway.
    Addressing the emotional, physical, and administrative challenges 
our wounded warriors and their families face is a major area of 
emphasis. In addition to the improvements to our outpatient care and 
administrative processes, we have assigned Army officers to meet and 
escort the families of our wounded warriors from local airports to 
Walter Reed. To assist with their needs at Walter Reed, we are creating 
a streamlined ``one-stop shop'' Soldier and Family Assistance Center, 
have hired additional bilingual staff, and have increased counselor 
availability at the Mologne House. Finally, the Army has implemented 
the U.S. Army Wounded Warrior Program, which provides long-term support 
of our seriously wounded soldiers to help them be self-sufficient, 
contributing members of their communities.
    Let me conclude by reiterating that Army Medical care is the best 
in the world. Each day selfless, dedicated Army doctors, nurses, and 
support staff perform miracles to save lives and limbs, and provide the 
best possible care for our wounded warriors and their families. We will 
do what is right for our soldiers and their families. They can be 
assured that the Army leadership is committed and dedicated to ensuring 
that their quality of life and the quality of their medical care is 
equal to the quality of their service and sacrifice.
    On behalf of the nearly 1,000,000 soldiers that comprise our Army--
and our wounded warriors and their families in particular--I appreciate 
the committee's concern for these critical issues, and for Congress' 
continuing support of soldiers and their families. Army Strong!

    Chairman Levin. Thank you very much, General Schoomaker.
    Now, Secretary Chu, who did you plan on speaking next?
    Dr. Chu. Dr. Winkenwerder, next General Kiley, then I will 
come back on the disability evaluation system issue.
    Chairman Levin. Dr. Winkenwerder, thank you.
    Secretary Winkenwerder.

    STATEMENT OF WILLIAM WINKENWERDER, JR., M.D., ASSISTANT 
            SECRETARY OF DEFENSE FOR HEALTH AFFAIRS

    Dr. Winkenwerder. Yes, sir, Mr. Chairman. Mr. Chairman, 
distinguished members of this committee, thank you for the 
opportunity to be here today to talk about the serious concerns 
that have been raised with regard to housing conditions and 
inappropriate bureaucratic delays and hurdles for our 
servicemembers at Walter Reed and for others that might be 
caught up in a similar circumstance elsewhere.
    Our wounded servicemembers and their families expect and 
they deserve quality housing and family member support, along 
with well-coordinated services. In the case of the incidents at 
Walter Reed, we failed them. Today I welcome the chance to talk 
about these issues and what DOD is doing to move forward.
    As you have just heard, corrective action plans in the Army 
and DOD are already initiated, but they will take the following 
approach. First, the top priority is on finding and fixing 
problems. Where policy or process or administrative change is 
required, DOD will do it.
    Second, we welcome public scrutiny, even when it is 
critical and it is painful to hear. Problems cannot be solved 
and the people cannot be properly served if issues are not 
brought to light, and this process is doing that. I think all 
of us here endorse the statements of Secretary Gates. He has 
made it clear that defensiveness and explanations are not the 
route to getting things done. Standing up, making things happen 
to meet the needs of our servicemembers and their families is 
our only responsibility right now.
    I would assess the problems before us as follows. There are 
the physical facility issues we have heard about, there is a 
process of disability determinations, and then there is the 
process of care coordination. I will not speak about the 
substandard housing because, as you have just heard, the Army 
has already begun to correct that problem. Obviously, a wider 
review is needed across all Services and I think that is 
already underway.
    With respect to disability determinations, let me just say 
that the servicemembers deserve fair, consistent, and timely 
determinations. Complex procedures must be streamlined or they 
have to be removed. The system must not be adversarial. I think 
you made an excellent point. It should not be adversarial, and 
the system has just got to improve.
    Likewise, coordination of services. There must be a higher 
ratio of case managers to wounded servicemembers to ensure 
personalized care, better support, communication with families, 
and simpler processes. No servicemember should ever have to 
work through a maze or a gauntlet, or be on his or her own to 
figure things out. That is just unacceptable.
    Let me address one thing, importantly, and make this clear. 
The problems cited in the press reports are not the result of 
unavailable or insufficient resources, nor are they in any way 
related to the BRAC decisions to close the Walter Reed campus 
as part of the planned consolidation with the National Naval 
Medical Center in Bethesda. I know there is a concern about 
that and we will be happy to answer questions during this 
hearing about that.
    Significant resources have always been available and we 
continue to invest at Walter Reed for whatever is needed. For 
example, there were some, I might note, who questioned the 
decision in 2005 to fund $10 million to construct a new Walter 
Reed amputee center. Yet we proceeded with this, and the new 
center will open in a few months. That was absolutely the right 
decision. We will not allow the plans for the new medical 
center to interfere with ongoing issues of care or needed 
improvements.
    Secretary Gates's decision to establish an independent 
review group to evaluate and make recommendations on this 
matter will be very beneficial in my judgment. The group is 
highly qualified, it is a bipartisan team of former 
Congressmen, line, medical, and enlisted leaders. They have 
already begun their work.
    Let me just say this. The entire Department has been 
informed of the review group's charter. Group members can go to 
any installation, talk to any personnel, and review any policy 
to get the information and answers they need. They will have 
the Department's full support.
    DOD will be driven for results in its actions in the weeks 
ahead, engaged, action-oriented, and focused on making real and 
permanent improvements. Findings and actions will be shared 
with the public, the people we serve, the servicemembers, their 
families, military leaders, Congress, the Secretary of Defense, 
and the President. They all deserve to know that the job is 
getting done.
    We have attacked problems in the past, solved them, and 
come out stronger as a result, and we can do that again. We 
have established, as Dr. Chu has noted, new standards in 
virtually every category of wartime medicine and also, I might 
add, in other areas of everyday medicine in America. The 
quality of our medical care for our servicemembers is 
excellent. There is no question about that.
    But with regard to these issues, which are quality-of-
life--and in my judgment they are equally important as quality 
of care, equally important--we have not met our own standards. 
In the current reports on Walter Reed, the trust that has been 
earned through our great achievements has been damaged. We have 
to re-earn that trust and that is our job.
    Let me just say one final thing in closing and that is that 
as we all work together on these issues, maintaining the morale 
of those who care for our warriors and maintaining the 
confidence of our entire military in this system is critically 
important. It is important that people believe that they are 
going to get the care that they need, no matter if it is on the 
battlefield, in the hospital, after the hospital, or when they 
are in the VA. I just urge that we are sensitive and careful 
about that concern of keeping up our morale.
    I look forward to working together with you, Mr. Chairman, 
and with leaders within the Services and DOD in the remaining 
weeks of my tenure in this important effort. I am grateful, 
really grateful, to have had the opportunity to have worked 
with the selfless and committed professionals and patriots who 
care for and support our Nation's heroes. These heroes deserve 
our very best.
    Thank you, Mr. Chairman.
    [The prepared statement of Dr. Winkenwerder follows:]
     Prepared Statement by Hon. William Winkenwerder, Jr., MD, MBA
    Mr. Chairman, distinguished members of this committee, thank you 
for the opportunity to discuss the Military Health System, and in 
particular to address the concerns raised in recent news media reports 
regarding treatment of servicemembers at Walter Reed Army Medical 
Center.
    Our wounded servicemembers and their families deserve coordinated 
professional health care services--both clinical and administrative--
together with quality housing and family member support. In the case of 
the incidents cited at Walter Reed, the Department did not meet our 
patients' expectations, and we did not meet our own expectations.
    I want to address the events associated with the media reports and 
internal findings regarding substandard housing for some of the 
servicemembers receiving outpatient, long-term rehabilitative care, and 
the administrative delays and hassles associated with the military's 
disability process.
    I would first like to outline the principles that underlie the 
Department's approach in addressing this problem.

         We welcome public scrutiny, even when it is critical. Perhaps 
        especially when it is critical. In this case, the Department 
        accepts the fundamental premise of the reports by the 
        Washington Post that unacceptable conditions existed at Walter 
        Reed for some of our servicemembers.
         Where change is required, the Department will make it. The 
        focus will be on understanding and fixing the problems using a 
        systems approach. As Secretary Gates has stated, persons who 
        allowed these conditions to persist will be held accountable. 
        Yet, several of the issues identified cut across organizational 
        boundaries, and our greatest attention will be to introduce 
        change to the processes by which we support our servicemembers 
        and families.
         Our military health system is a unique, national asset. It 
        must be preserved. As we engage on this issue using the skills 
        and talents of our people to solve the problems, we must act 
        carefully to preserve the morale and trust of our dedicated 
        caregivers.
 context within the larger military health system: medical support to 
                             servicemembers
    We serve over 2.2 million members in the Active, Reserve, and Guard 
components, to include over 251,000 servicemembers deployed overseas, 
and another 7 million families, and retirees. Over 9 million Americans 
are entrusted to our care--and in both battlefield medicine and 
traditional health care delivery here at home, we are excelling in our 
mission. Based on data, measures, and independent assessments by health 
care organizations around the country, the performance of our military 
medical personnel on the battlefield and in our medical facilities in 
the United States has been extraordinary. We have established new 
standards in virtually every major category of wartime medicine, and 
many areas of peacetime medicine:

         Lowest Disease, Non Battle Injury Rate. A testament to our 
        medical readiness and preparedness, our preventive medicine 
        approaches and our occupational health capabilities, we are 
        successfully addressing the single largest contributor to loss 
        of forces--disease.
         Lowest Death to Wounded Ratio. Our agility in reaching 
        wounded servicemembers, and capability in treating them, has 
        altered our perspective on what constitutes timeliness in 
        lifesaving care from the ``golden hour'' to the ``platinum 15 
        minutes.'' We are saving servicemembers with grievous wounds 
        that were likely not survivable even 10 years ago.
         Reduced Time to Evacuation. We now expedite the evacuation of 
        servicemembers following forward-deployed surgery to stateside 
        definitive care using airborne intensive care units and the 
        latest technology, we have been able to move wounded 
        servicemembers from the battlefield to hospitals in the United 
        States in as little as 48 hours.
         Our medical professionals have provided high quality medical 
        care, and indicators of quality compare very favorably with 
        national benchmarks. The Department of Defense (DOD) Patient 
        Safety Program is a national model, and efforts to reduce and 
        eliminate medical errors have achieved ground breaking results.

    We are also ensuring our servicemembers are assessed before 
deployments, upon return and then again 90-180 days after deployment. 
These health assessments provide a comprehensive picture of the fitness 
of our forces, and highlight areas where intervention is indicated. For 
example, we've learned that servicemembers do not always recognize or 
voice health concerns at the time they return from deployment. By 
checking with them 3 to 6 months later, we've found that about half of 
them report physical concerns, such as back or joint pain, and a third 
of them have mental health concerns. As of January 31, 2007, 212,498 
servicemembers have completed a post-deployment health reassessment 
with 31 percent of these individuals receiving at least one referral 
for additional evaluation.
    We have introduced an Individual Medical Readiness measure that 
provides commanders with a picture of the medical readiness of their 
soldier, sailor, airman, and marine down to the individual level.
    We have worked closely with our partners in the Department of 
Veterans' Affairs (VA), in our shared commitment to provide our 
servicemembers a seamless transition from the mility health system to 
the VA. DOD implemented a policy entitled ``Expediting Veterans 
Benefits to Members with Serious Injuries and Illness,'' which provides 
guidance on the collection and transmission of critical data elements 
for servicemembers involved in a medical or physical evaluation board. 
DOD began electronically transmitting pertinent data to the VA in 
October 2005 and continues to provide monthly updates, allowing the VA 
to better project future workload and resource needs. Receiving this 
data directly from DOD before these servicemembers separate eliminates 
potential delays in developing a claim for benefits by ensuring that VA 
has all the necessary information to award all appropriate benefits and 
services at the earliest possible time.
    Here in the United States, our beneficiaries continue to give the 
TRICARE program high marks in satisfaction. Military health system 
beneficiaries' overall satisfaction with medical care in the outpatient 
and inpatient settings compares very favorably against national 
civilian benchmarks. The quality of our medical care is further 
attested to by such organizations as the Joint Commission on 
Accreditation of Healthcare Organizations that has recognized the 
excellence in our medical treatment facilities with ratings well above 
civilian averages.
    Internationally, our medical forces have deployed with great speed, 
skill, and compassion. Their accomplishments in responding to 
international disasters has furthered our national security objectives; 
allowed us to constructively engage with a number of foreign nations; 
and saved civilian lives throughout the world.
    Operating on the global stage, our medics--from the youngest 
technicians to the most experience neurosurgeons--have performed in an 
exemplary manner in service to this country. We will make the necessary 
changes to our policies and processes, while remaining mindful of the 
skills, dedication, and courage of our medical forces.
                      identifying the way forward
    The set of issues addressed recently in the Washington Post deserve 
our immediate and focused attention. The Army and the Department have 
taken swift action to improve existing conditions, and enhance services 
provided at Walter Reed, and identify areas meriting further study and 
improvement. Army leadership initiated immediate steps to control 
security, improve access, and complete repairs at identified facilities 
and sought to hold accountable those personnel responsible to provide 
for the health and welfare of our Nation's heroes.
    Most recently, Secretary Gates commissioned an independent review 
group (IRG) on March 1, 2007, to evaluate and make recommendations on 
this matter. The IRG shall conduct its work and report its findings to 
the Secretary of the Army, the Secretary of the Navy, and the Assistant 
Secretary of Defense for Health Affairs no later than April 16, 2007. 
The report will include:

         Findings of an assessment of current procedures involved in 
        the rehabilitative care, administrative processes, and quality 
        of life for injured and ill members, including analysis of what 
        these heroes and their families consider essential for a high 
        quality experience during recovery, rehabilitation, and 
        transition.
         Alternatives and recommendations, as appropriate to correct 
        deficiencies and prevent them from occurring in the future.

    The Department will be relentless in its actions--engaged, action-
oriented and focused on making measurable improvements. Goals will be 
clear and milestones will be established.We will regularly inform the 
people we serve--the soldiers, the families, military leaders, 
Congress, the Secretary, and President--on our progress. Findings and 
actions will be shared with the public.
    We know that this approach works. It has been successfully employed 
in attacking other issues over the past--the development and 
implementation of pre- and post-deployment health assessments; clinical 
guidelines for psychiatric care; the development of stringent health 
information security measures and reporting processes; and the 
electronic collection of deployment health data.
                      an assessment of the issues
    There are a number of disturbing elements to the conditions at 
Walter Reed, yet I am confident that each of these items is fixable 
with sustained leadership and oversight.The Department, with the 
assistance of the Secretary's IRG, will come forward with revised 
approaches to addressing the more complex personnel and medical issues. 
I would categorize and assess the problems before us as follows:
Physical Facility Issues
    In the case of substandard housing, the Army has been able to 
quickly implement a corrective action plan. Some of those actions have 
already occurred with facility repair and improvements. Clearly, other 
facility improvements may require more comprehensive repairs that may 
take longer. I am confident the Army and the Navy are taking steps to 
ensure that any needed improvements will be made.
Process of Disability Determinations
    The critical first step in assessing this process will be to 
identify the desired outcome. We know that there are expectations that 
both the servicemember and the Department want:

         Full rehabilitation of the servicemember to the greatest 
        degree medically possible;
         A fair and consistent adjudication of disability; and
         A timely adjudication of disability requests--neither hurried 
        nor slowed due to bureaucratic processes.

    The fundamental problems did not result from a lack of available 
resources. The main effort here must be focused on the processes being 
analyzed and assessed for their value and alternatives. The processes 
must be redrawn with the outcomes we have in mind, with as much 
simplicity and timeliness as possible.
Process of Care Coordination
    Again, the quality of medical care delivered to our servicemembers 
is exceptional. This assertion is supported by independent review. Yet, 
the process of coordinating delivery of care to servicemembers in long-
term outpatient, residential rehabilitation needs attention. The Army 
will assess, and my office will review, the proper ratio of case 
managers to wounded servicemembers. The administrative and information 
systems in place to properly manage workload in support of the soldiers 
will also be assessed.
    The planned consolidation of health services and facilities in the 
National Capital Region will enable the Department to best address the 
changing nature of inpatient and outpatient health care requirements, 
specifically the unique health needs of our wounded servicemembers and 
the needs of our population in this community. The BRAC decision also 
preserves a precious national asset by sustaining a high quality, 
world-class military medical center with a robust graduate medical 
education program in the Nation's Capital. The plan is to open this 
facility by 2011. In the interim, we will not deprive Walter Reed of 
resources to function as the premier medical center it is. In fact, in 
2005 we funded $10 million in capital improvements at Walter Reed's 
Amputee Center--recognizing the immediate needs of our warrior 
population. We are proud of that investment in capacity and 
technology.We simply will not allow the plans for a new medical center 
to interfere with the ongoing facility improvements needed in the 
current hospital.
The Legacy of Military Medicine
    Sustaining a medically ready military force and providing world-
class health services for those injured and wounded in combat remains 
our primary mission.
    In the current spate of news reports on Walter Reed, the trust that 
we have earned through our other many medical achievements has been 
damaged. Everyone's efforts will be focused on repairing and re-earning 
that trust.
    Our civilian and military leaders have remained steadfast in both 
their support of what we have accomplished, and their belief that these 
matters can be fixed. U.S. military medicine and our medical personnel 
are a national asset, representing a readiness capability that does not 
exist anywhere else, and--if allowed to dwindle--could not be easily 
reconstituted.We must preserve this asset.
    As the problems that lie at the intersection of personnel issues 
with health care delivery are addressed, it is our shared 
responsibility to focus on the specific problems, and not the people 
who have done so much to improve the health of our military 
servicemembers. We are blessed with a rich cadre of dedicated, hard-
working, skilled professionals. I have complete confidence that they 
will rise to the occasion again, as they have done in the past, learn 
from what went wrong, and build an even stronger, more responsive 
system for all.
    After more than 5\1/2\ years of service as the Assistant Secretary 
of Defense for Health Affairs, I look forward to working together with 
you and with the leaders within the Services and DOD in the remaining 
weeks of my tenure to begin this effort at rebuilding this important 
part of our system that needs attention. I remain grateful for the 
opportunity to have worked with such selfless servants that comprise 
the military health system.

    Chairman Levin. Thank you, Secretary Winkenwerder.
    General Kiley, you are next, and then we will go back to 
Dr. Chu.

 STATEMENT OF LTG KEVIN C. KILEY, USA, SURGEON GENERAL, UNITED 
                          STATES ARMY

    General Kiley. Thank you, Mr. Chairman, distinguished 
members of the committee. I am Lieutenant General Kevin Kiley, 
the Army Surgeon General, Commander of U.S. Army Medical 
Command (MEDCOM), and I am accountable for health care in the 
U.S. Army MEDCOM. A commander's first responsibility is the 
health and welfare of his soldiers. A physician's first 
responsibility is the health and welfare of his patients. As we 
have seen in the last couple weeks, we have failed to meet our 
own standards at Walter Reed. For that I am both personally and 
professionally sorry and I offer my apologies to the soldiers 
and families, the civilian and military leadership of the Army 
and DOD, and to the American people.
    It is also clear that this complex, bureaucratic, 
administrative medical evaluation board (MEB), physical 
evaluation board (PEB) process is in need of urgent 
simplification and I am dedicated to doing whatever in my power 
and authority to make positive change to this process. Simply 
put, I am in command. I am accountable, and I share in the 
failures, and I also accept the responsibility and the 
challenges for rapid corrective action.
    As General Schoomaker has already outlined, the living 
conditions and welfare of soldiers, the responsiveness of our 
leaders and enhanced support services for our families are in 
evolution and in place as we speak. We are also beginning to 
put into effect long-term change to help with some of the 
bureaucratic medical evaluation processes that are impacting on 
our soldiers.
    We have addressed the living conditions at Walter Reed. 
General Bob Wilson and my team are out, as the chief has 
alluded to, inspecting other installations to assure we do not 
have these similar issues at other installations. But we do 
have human problems, too, human systems problems, and that is 
about soldiers and families. American soldiers go to war with 
the confidence that if they are injured they can come back 
through a system that will care for them every step of the way, 
to include in particular Walter Reed Army Medical Center, and 
in fact, to date, that record has been outstanding.
    They say a soldier will not take an objective out of sight 
of a medic, and by extension Walter Reed, both inpatient and 
outpatient care, is an extension of our trust with our combat 
soldiers, and nothing can be allowed to shake that confidence. 
Secretary Gates has made it very clear that he expects decisive 
action. He and our soldiers will get it.
    As we have heard, the disability compensation and 
transition system is complex, confusing, and frustrating. It is 
further compounded by the exceedingly complex nature of the 
injuries that our young men and women are suffering, and the 
Army MEDCOM has been working with the Army to begin changing it 
to make it more responsive to soldiers and to reduce the 
confrontational and adversarial form that it presently has.
    We are making the adjustments at Walter Reed. As we have 
announced, we are increasing staff to improve ratios and 
communications. But we really need to reinvent this entire 
process and we are in the process of doing that now. We want to 
take care of our soldiers fully, giving them time to heal and 
then carefully documenting their conditions to give them best 
outcomes through the disability process.
    Our Army's medical professionals have earned a tremendous 
reputation during this war and this is a result of three 
factors: first, the dedicated, talented, caring professionals 
at our facilities, to include and in particular Walter Reed, 
and across the rest of the military system, many of whom have 
already served in Iraq and Afghanistan.
    Second is the application of cutting edge technology to 
save lives on the battlefield and return them home safely.
    Third and equally important has been the exceptionally 
strong support of Congress and the American people in this 
effort.
    It is regrettable that you and the American people have had 
to learn these issues at Walter Reed through the Washington 
Post. That is something we should have known, I should have 
known, and we should have been working on it immediately. But 
the light has been shed on this and, to be clear, having made 
those mistakes, we are taking immediate action and establishing 
future actions to correct it and prevent it from happening 
again.
    I am committed to fixing it. I am personally committed to 
regaining the trust and confidence that our soldiers 
everywhere, and I, and the American people have had in Army 
medicine.
    I appreciate the opportunity to speak to the committee 
today. Mr. Chairman, I look forward to answering your 
questions.
    [The prepared statement of General Kiley follows:]
             Prepared Statement by LTG Kevin C. Kiley, USA
    Mr. Chairman, Senator McCain, and distinguished members of the 
subcommittee, thank you for the opportunity to discuss recent media 
reports about the living conditions, accountability procedures, medical 
care, and administrative processing of soldier-patients receiving 
recuperative or rehabilitative care at Walter Reed Army Medical Center 
(WRAMC) as outpatients. The leadership and staff of WRAMC are committed 
to providing world-class care for our wounded warriors and we are all 
upset by the problems detailed in the Washington Post series.
    Let me begin by informing you that in the past 2 weeks I have 
directed three separate investigations into various problems raised by 
the Washington Post articles. First, prior to the articles being 
published, I asked the U.S. Army Criminal Investigation Division to 
open an investigation into allegations of improper conduct by Dr. 
Michael Wagner, the former Director of WRAMC's Medical and Family 
Assistance Center (MEDFAC). The Washington Post published these 
allegations on Tuesday, 21 February 2007. In addition, I directed two 
more investigations. The second investigation will look specifically at 
the execution of command responsibility by the WRAMC Medical Center 
Brigade and the WRAMC Garrison Command to ensure safe, healthy living 
conditions for our recovering Warriors. The final investigation will 
look into WRAMC's internal Medical Evaluation Board (MEB)/Physical 
Evaluation Board (PEB) processing. The intent of these investigations 
is to uncover systemic breakdowns in our processes and to improve our 
system of care for wounded warriors. Once these investigations are 
complete, we will report back to you on our findings and our actions.
    Since 2002, WRAMC has provided highly personalized health care by 
treating more than 6,000 soldiers from Operation Enduring Freedom (OEF) 
and Operation Iraqi Freedom (OIF). Nearly 2,000 of these soldiers 
suffered battle injuries, more than 1,650 of whom started their care at 
WRAMC as inpatients--receiving lifesaving medical treatments, needed 
surgeries and physical therapy then progressed to outpatient status 
living near the hospital. A team of 4,200 medical professionals treat 
these wounded warriors and dedicate their lives and hearts to helping 
our soldiers. On average, more than 200 family members also join them 
to help with recovery, provide emotional support, and offer a strong 
hand or a warm hug to carry them through difficult days.
    The requirement to assign soldiers to Medical Holding Units (MHU) 
is dictated by internal Department of Defense (DOD) regulations. The 
Army policy for assigning soldiers to MHUs is intended to support the 
needs of the individual soldier and his/her family. Soldiers with long-
term debilitating conditions such as spinal cord and brain injuries or 
terminal cancer fall into this category and require intensive medical 
and administrative management only available at the MHU. In certain 
circumstances a soldier may be assigned to a MHU while undergoing 
outpatient treatment when the Military Treatment Facility Commander 
determines that continuous treatment is required and that the soldier 
cannot be managed by his or her unit, i.e., is unable to perform even 
limited duty at the unit.
    Army military treatment facilities have two types of MHU. Active 
component soldiers whose medical condition prevents them from 
performing even limited duty within their unit are assigned to a 
medical hold company. Each Army hospital with inpatient capability is 
authorized a medical hold company. Generally speaking, a majority of 
soldiers assigned to medical hold companies have medical conditions 
that will eventually lead to separation from Service or medical 
retirement. Since 2003, Reserve component soldiers who cannot deploy, 
are evacuated back to the U.S. during their units' deployment, or 
return home with a medical condition are assigned to a medical holdover 
company. At WRAMC, both companies are organized under the Medical 
Center Brigade, which also has command responsibility for permanent 
party and students assigned or attached to WRAMC.
    The current conflict is the longest in U.S. history fought by 
volunteers since the Revolution. Two dozen soldiers arrive each week 
and remain on the campus an average of 297 days for active duty, and 
317 days for Reserve and National Guard. Often the very first thing 
they ask when they are able to speak is ``when can I get back to my 
guys?''
    The rehabilitation process at Walter Reed is also unique in its 
focus to restore these wounded soldiers not just to a functioning level 
in society, but to return them to the high level of athletic 
performance they had before they were wounded for continued service in 
the U.S. military if possible. This is the stated goal of the WRAMC 
program, as well as the newer program at the Center for the Intrepid 
which was modeled after the Walter Reed successes.
    The amputee population deserves special note as an example of these 
initiatives. There have been a total of 552 soldier members who have 
suffered major limb amputation in the war. Of these, 432 of the 
patients were cared for at WRAMC: 394 servicemembers from OIF (68 with 
multiple amputations) and 38 servicemembers from OEF (6 with multiple 
amputations). There have been 35 amputee patients with major limb loss 
who were found fit for duty (17 that are Continuation on Active Duty/
Continuation on Active Reserve and 18 remaining to complete the Medical 
Board process). Five of the 17 soldiers have returned to serve on the 
front lines in Central Command. All of the soldiers were monitored and 
supported by medical hold or medical holdover companies during their 
rehabilitation at Walter Reed.
    It is important to note that, with the exception of burn patients, 
WRAMC cares for most of the critically injured soldiers. Our Brooke 
Army Medical Center and its new state-of-the art rehabilitation center, 
cares for many critically injured soldiers with units or home of record 
in the southwest. The complexity of the injuries and illnesses suffered 
by these soldiers often results in a recovery period that is longer and 
more challenging than those cared for at most other DOD facilities. 
This places significant stress on the soldier-patient, their families, 
and the staff providing care. The media reports about inadequate living 
conditions brought to light frustrations with billeting and the 
administrative processes necessary to return these warriors to duty or 
to expeditiously and compassionately transition them to civilian life. 
I would like to address three problem areas reported in the Washington 
Post series: Living conditions in Building 18; accountability 
management of outpatient-soldiers; and, administrative processing of 
MEBs and PEBs.
         billeting issues and living conditions in building 18
    As soldiers are discharged from inpatient status, many need to 
remain at WRAMC for continued care. Historically, the combination of 
permanent party soldier barracks, off-post lodging, and three Fisher 
Houses have been sufficient to meet the normal demand for billeting 
soldiers assigned to the MHU at WRAMC. Beginning in 2003, the 
population of Active and Reserve component soldiers assigned to WRAMC's 
MHU increased from 100-120 before the war to a high of 874 in the 
summer of 2005. To accommodate this increase in outpatient-soldiers, 
WRAMC made use of all 199 rooms in the Mologne House--a nonappropriated 
fund hotel on the installation opened in 1996; 86 rooms in 2 buildings 
operated by the Mologne House; 30 rooms in 3 Fisher Houses; and, 15 
contract hotel rooms in the Silver Spring Hilton. With the exception of 
Building 18, all of these facilities have had extensive renovations 
performed over the last 10 years and have amenities similar to many 
modern hotels.
    In the summer of 2005, WRAMC began housing the healthiest of the 
outpatient-soldiers in Building 18--a former civilian hotel across the 
street from the main WRAMC campus. Building 18 was constructed in 1969 
and leased periodically by WRAMC until the government acquired the 
building in 1984. Between 2001 and 2005, more than $400,000 in 
renovations were made to Building 18. In 2005, a $269,000 renovation 
project made various improvements in all 54 rooms to include replacing 
carpeting and vinyl flooring. Additional upgrades to the central day 
room included a donation of a pool table and the command purchase of 
couches and a large flat screen TV.
    The healthiest of our outpatient-soldiers are assigned rooms in 
Building 18 after careful screening by the chain of command, case 
managers, and treating physicians. Patients who have trouble walking 
distances, have post-traumatic stress disorder, or have traumatic brain 
injuries are not allowed to live in Building 18.
    Building 18 has 54 rooms. Whenever a new soldier was assigned a 
room, the building manager directed the soldier and his/her supervisor 
to identify any deficiencies or damage in the room and initiates work 
orders to repair identified problems. Additionally, residents and their 
chain of command may submit work orders through the building manager at 
any time. This entire process is being reassessed to ensure proper 
accountability. Since February 2006, more than 200 repairs were 
completed on rooms in Building 18, repairs continue to be made, and a 
rapid renovation is planned.
    In spite of efforts to maintain Building 18, the building will 
require extensive repairs if it is going to continue to remain in 
service. Upon reading the Washington Post articles, I personally 
inspected Building 18. As noted in the article, the elevator and 
security gate to the parking garage are not operational. Twenty-six 
rooms had one or more deficiencies which require repair. Two of these 
rooms had mold growth on walls. Thirty outstanding workorders have been 
prioritized and our Base Operations contractor has already completed a 
number of repairs. We are also working closely with U.S. Army 
Installation Management Command, the Army Corps of Engineers, and our 
health facility planners to replace the roof and renovate each room.
    There are currently no signs of rodents or cockroaches in any 
rooms. In October 2006, the hospital started an aggressive campaign to 
deal with a mice infestation after complaints from soldiers. Preventive 
medicine specialists inspected the building and found rooms with 
exposed food that attracted vermin. Removing the food sources and 
increased oversight by the chain of command has since brought this 
problem under control, although such problems require vigilant 
monitoring, which is ongoing.
       accountability and information flow to outpatient-soldiers
    As of 16 February 2007 WRAMC had a total of 652 Active and Reserve 
component soldiers assigned or attached to two MHUs. Currently there 
are 450 Active component soldiers assigned or attached to WRAMC's 
Medical Center Brigade. There are 202 Reserve component soldiers 
assigned or attached. Platoon sergeants and care managers are key to 
accounting for, tracking, and assisting soldiers as they rehabilitate, 
recuperate, and process through the disability evaluation system. Prior 
to January 2006, WRAMC only had a single medical-hold company to 
provide command and control, and accountability for all of those 
soldiers. Since January 2006, the hospital created new organizational 
structures to decrease the soldier-to-platoon sergeant and soldier-to-
case manager ratio from 1 staff member for every 125 soldiers, to 1 
platoon sergeant and 1 case manager for approximately 30 soldiers.
    Platoon sergeants and case managers attend staff training every 
Thursday. The training consists of various topics ranging from resource 
availability to soldier services. Weekly Thursday training is 
supplemented with a platoon sergeant/case manager orientation program. 
Departing platoon sergeants work along side their replacement for 
approximately 1 week. Reserve component case managers attend a 1-week 
training program at Fort Sam Houston Texas for an overview of the 
Medical Holdover Program, MEB/PEB process, customer service training 
and the duties of a case manager. Upon arrival at WRAMC, these case 
managers undergo a month-long preceptor program. Once hired by WRAMC, 
these case managers undergo a 1-week training program to address 
organizational structure, MEB/PEB process, case manager roles and 
responsibilities, use of data systems, administrative documentation, 
convalescent leave and available resources in the hospital and on the 
installation, as well as expectations and standards. There is also a 
weekly clinical meeting held with physician advisory board and case 
managers for chart reviews and recommendation for the MEB process. 
Where ever possible we are working to streamline and merge platoon 
sergeant and case manager training to make it identical for all new 
personnel such as incorporating the preceptor concept for both Medical 
Hold and Medical Holdover units. We will also enhance the weekly 
training to introduce topics that are not only important to the platoon 
sergeant and case manager but address recurring issues/concerns raised 
by soldiers and family members.
    We are conducting a 100-percent review of the discharge planning 
and handoff process to ensure the transition from inpatient to 
outpatient is seamless and patients understand the next step in their 
recovery. This discharge will now include a battle handoff to a platoon 
sergeant. We are also in the process of hiring additional case managers 
and will submit plans to increase other critical positions in the 
Medical Center Brigade, which will reduce the current staff to 
outpatient ratio to more manageable levels, allowing more personalized 
service to the recovering soldier and family member in making 
appointments, completing necessary paperwork, and navigating the 
complex disability evaluation systems.
    The MEDFAC will colocate functions performed by Human Resources 
Command, Finance, and Casualty Assistance into the MEDFAC allowing 
service in one location. In the near term, WRAMC will expand the staff 
to support the family members and relocate the operations to a more 
centralized 3,000 square feet space in the hospital providing an 
improved environment for the families to obtain assistance.
    The Medical Center Brigade recently established a Soldier and 
Family Member Liaison Cell to receive feedback from soldiers and family 
members. A recent survey of soldiers and family members in January 2007 
indicated that less than 3 percent of the outpatient-soldier population 
voiced complaints about administrative processes. The command will 
continue to enhance the structure of the soldier and family member 
liaison cell. We have requested three family life consultants from the 
Family Support Branch of the Community and Family Support Center, 
Installation Management Command to expand the resources available to 
identify areas of interest as well as provide counseling support to 
soldiers and family members. We also will expand the current survey 
feedback process to include an intake survey for soldiers and family 
members, a monthly town hall meeting and survey for ongoing issues, and 
an outtake survey upon the departure of soldiers and family members. 
This feedback will be reviewed by the WRAMC Commander and other key 
leaders.
    The Mologne House has approximately 30 personnel on staff that 
speak Spanish. These personnel work in all departments and a number of 
them are in management positions. These personnel have been assisting 
the Spanish speaking soldiers and their families since the hotel 
opened. The Mologne House is taking steps to ensure the desk has a 
Spanish speaking staff member on call 24 hours a day to assist those in 
need of translation services.
    Patients arrive at WRAMC by aero-medical evacuation flights three 
times a week--Tuesday, Friday, and Sunday. Additionally, some patients 
arrive at WRAMC on commercial flights for medical care. Family members 
may arrive with the soldier or through their own travel itinerary. 
Soldiers and family members who arrive on medical evacuation flights 
are met by an integrated team of clinical staff, MEDFAC, Red Cross, 
Patient Administration, Unit Liaison Noncommissioned Officers, and 
Medical Center Brigade representatives. Inpatients are triaged for 
further evaluation and disposition. Outpatients remain on the ambulance 
bus and are sent to the Mologne House with a representative from the 
Medical Center Brigade for billeting. Family members are met by MEDFAC 
and Red Cross and are escorted to the Mologne House for lodging.
    Currently, there are 51 global war on terrorism inpatient 
casualties. Our census ranges between 30 and 50 depending on the volume 
of air evacuations (high of 359 in July 2003 to low since OIF began of 
64 in November 2005). Roughly half of the patients come as inpatients, 
and half as outpatients. Outpatients are processed through the Medical 
Center Brigade for accountability and billeting when they arrive. 
Inpatients are accounted for by the hospital's patient administration 
office. We believe as many as one in five patients may be at risk to 
miss some of the administrative in processing at the Medical Center 
Brigade when they are discharged from the hospital, because of the 
timing of their discharge, their underlying medical condition, or 
miscommunication. I have directed a complete review of the discharge 
planning and the development of a new handoff process between the 
hospital and the Medical Center Brigade. This will include the 
development of a ``Global War on Terrosim Discharge Validation 
Inventory'' that will be completed by the attending physician, 
discharging nurse, discharging pharmacist, social worker, brigade 
staff, and hospital patient administration. The checklist will be 
validated by the Nursing Supervisor, Attending Physician, Deputy 
Commander for Clinical Services (DCCS) or Deputy Commander for Nursing.
    Each soldier receives a handbook upon assignment or attachment to 
Med Hold or Med Holdover. The Med Hold handbook is provided to soldiers 
when they are assigned or attached by their respective platoon 
sergeant. Newly arriving family members receive a Hero Handbook as well 
as a newcomer's orientation binder. Family members attend a weekly new 
arrival meeting, and a weekly townhall meeting where information is 
exchanged to answer questions or discuss ideas. PEB Liaison Officers 
(LOs) conduct monthly training sessions on the MEB/PEB process for 
soldiers and family members. A Case Management booklet with frequently 
asked questions is also provided to soldiers.
               administrative processing of mebs and pebs
    The MEB/PEB process is designed with two goals in mind: (1) to 
ensure the Army has a medically fit and ready force; and (2) to protect 
the rights of soldiers who may not be deemed medically fit for 
continued service. This process was designed to support a volunteer 
Army with routine health occurrences and it is essentially a paper 
process. We can and will improve this process in order to ensure that 
it can support a wartime Army experiencing large numbers of serious 
casualties.
    The average Reserve component soldier assigned to Medical Holdover 
at WRAMC has been with us for approximately 289 days. We know from past 
experience they will be with us, on average, for 317 days from the time 
they are assigned to the Medical Holdover Company. The primary reason 
for this lengthy stay is the requirement that each soldier be allowed 
to achieve ``optimal medical benefit''--in other words, heal to the 
point that further medical care will not improve the soldier's 
condition. All humans heal at different rates and this accounts for the 
longest part of the process.
    Once the treating provider determines the soldier has reached the 
point of optimal medical benefit the provider will initiate an MEB. 
This is a thorough documentation of all medical conditions incurred or 
aggravated by military service, and ultimately concludes with a 
determination of whether the soldier meets medical fitness standards 
for retention. If the treating provider and the hospital's DCCS agree 
the soldier does not meet medical fitness standards, the case is 
referred to the PEB.
    The PEB is managed by U.S. Army Human Resources Command and is 
comprised of a board of officers, including physicians, who review each 
MEB. The role of the PEB is to evaluate each medical condition, 
determine if the soldier can be retained in service, and, if not 
retainable, assign a disability percentage to each condition. The total 
disability percentage assigned determines the amount of military 
compensation received upon separation. It is important to note that the 
MEB/PEB process has no bearing on disability ratings assigned by the 
Department of Veterans Affairs (VA), but thorough and complete 
documentation of medical conditions is essential for expeditious review 
by the PEB and will also aid the soldier in completing VA documentation 
requirements.
    The Washington Post articles provide anecdotal experiences of 
soldiers and families who have had medical records and other paperwork 
lost during the MEB/PEB process. All medical records at WRAMC are 
generated electronically. However, paper copies must be printed since 
the PEB cannot access the electronic medical record used by DOD 
hospitals.
    There are currently 376 active MEB/PEB cases being processed by the 
WRAMC PEB LOs. The average time from initiation of a permanent profile 
to the PEB is 156 days. The MEB is processed through the PEB and 
Physical Disability Agency for an average of 52 days (including the 15 
percent of cases returned to the hospital for further information). 
Thus, the total time from permanent profile to final disability rating 
is currently 208 days. At present, WRAMC has 12 trained PEB LO 
counselors. We are hiring an additional 10 counselors and 4 MEB review 
physicians to expedite the medical board process. It takes at least 3 
months to train a PEB LO counselor and these employees are the main 
interface between the soldier and the MEB/PEB system. As you might 
imagine, PEB LO counselors need to have excellent interpersonal and 
communication skills to perform well in a system that can be very 
stressful for the soldier, family, and counselor.
    In closing, let me again emphasize my appreciation for your 
continued support of WRAMC and Army medicine. The failures highlighted 
in the Washington Post articles are not due to a lack of funding or 
support from Congress, the administration, or the DOD. Nor are they 
indicative of the standards I have set for my command. Walter Reed 
represents a legacy of excellence in patient care, medical research, 
and medical education. I can assure you that the quality of medical 
care and the compassion of our staff continue to uphold Walter Reed's 
legacy. But it is also evident that we must improve our facilities, 
accountability, and administrative processes to ensure these systems 
meet the high standards of excellence that our men and women in uniform 
so richly deserve. Thank you again for your concern regarding this 
series of articles.

    Chairman Levin. General Kiley, thank you very much.
    Back to you, Dr. Chu.
    Dr. Chu. Sir, thank you. Let me underscore at the outset a 
point that General Schoomaker made, and that is we recognize 
that to deal properly with these cases we need several echelons 
of support in DOD. That is the reason a year ago we established 
the Military Severely Injured Center as a backstop to the 
Services' programs. It has a 1-800 number which any family or 
any servicemember can call 24 hours a day, 7 days a week. It is 
the place in which we try to bring together the Services and 
the several government agencies that deal with these issues--
Department of Labor, Transportation Security Agency, and the 
VA. It has been one of the elements we have used to ensure 
there are VA representatives in our major clinical centers.
    It has been our agent in helping establish the Heroes to 
Hometowns program, in which we partner with local 
organizations, with the American Legion, with the State VA 
apparatus, to ensure that when the service person returns home 
there is a sponsor, there is the kind of support the country 
properly expects.
    I want to thank Congress for its actions in support of 
these multi-echelon efforts. As one example, in your National 
Defense Authorization Act for Fiscal Year 2007 you granted the 
authority we sought to allow us to award to the service person 
the equipment that we provide them on Active Duty under our 
computer electronics accommodations program.
    But you raised, Mr. Chairman and Senator McCain as well, I 
think the fundamental issue that I hope this debate will allow 
us to address. That is the adequacy, the structure, the nature 
of the Nation's disability programs for injured servicemembers. 
As you appreciate, we have a variety of different programs that 
support these members, the principal ones being those in the 
DOD, but also, as you cited, the VA and the Social Security 
Administration. These proceed from different statutory 
authorities. They have somewhat different purposes and, as you 
have noted, they reach somewhat different conclusions about 
individual cases.
    It is not surprising to us that individuals in the system 
find it frustrating and difficult to navigate. I believe the 
ultimate question here is whether the country has the right 
paradigm or whether we should try to bring these programs 
together. That is the question ahead of us; answering that 
question I believe we will benefit from the several review 
groups that have been appointed, both those constituted within 
the last several days and those appointed earlier.
    As you recall, sir, Congress mandated there be a commission 
on veterans disability benefits. It is scheduled to report in 
October of this year with its findings and we have been 
supporting its deliberations.
    Within the existing system, DOD has begun revitalizing how 
we deal with these issues. We are in the process of revising 
the instructions that apply to the program as it stands today, 
the program that we administer, and the Services are addressing 
their issues, because these programs are run by each military 
department on a decentralized basis, I would point particularly 
to the Army's transformation initiative in this regard.
    I am confident, with the energy, the attention, the 
interest that is being paid to these programs, with your 
support for necessary statutory changes, that we can replicate 
for disability and disability evaluation the same success for 
the Nation that we have already achieved in our clinical 
services.
    I thank you, sir, and look forward to your questions.
    Chairman Levin. Thank you, Secretary Chu.
    There has been a statement submitted for the record by the 
Veterans for America and that statement will be made part of 
the record.
    [The information referred to follows:]
     
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
     
    Chairman Levin. Senator Pryor, I believe, has to chair a 
committee hearing and he wants to make a unanimous consent 
request.
    Senator Pryor.
    Senator Pryor. I do have a statement for the record that I 
would just ask be entered into the record. Also I have a letter 
from a soldier from Arkansas who spent in and out about 2 years 
in Walter Reed after being injured in Iraq. Mr. Chairman, I 
just ask that be submitted for the record, and I want to thank 
you and Senator McCain for your leadership on this issue.
    Chairman Levin. Thank you, and they will be made part of 
the record.
    Senator Pryor. Thank you.
    [The prepared statement of Senator Pryor follows:]
              Prepared Statement by Senator Mark L. Pryor
    I would like to start by apologizing to our service men and women 
and their families--not just those who have suffered due to the 
conditions at Walter Reed, but all of our veterans and servicemembers 
across the country. This is unacceptable, period. It will be remedied, 
and remedied soon. That is why I joined my colleague, Senator Obama, in 
co-sponsoring the Dignity for Wounded Warriors Act. This legislation is 
an important first step, and I encourage this committee to mark it up 
and the full Senate to pass it soon.
    When I read the Washington Post series, I couldn't help but think 
that we've failed our brave service men and women. Like my colleagues 
and most Americans, I was outraged and surprised to learn of the 
unacceptable conditions in Building 18 of the Walter Reed Army Medical 
Center. I've visited Walter Reed many times, even as recently as last 
month, and was never informed of the poor condition of Building 18. I 
didn't even know of the existence of Building 18. I guess I know why 
Building 18 was left off of my tour.
    What kind of message are we sending to these young soldiers and 
their families when the hospital or medical facility has holes in the 
ceiling and black mold growing on the walls? These men and women have 
sacrificed so much to keep this nation safe and free. We owe it to them 
and their families to provide the very best medical care and treatment 
that this country has to offer. I refuse to believe that this is the 
best we can do.
    As the President proposes to send another 21,500 brave American 
service men and women to serve overseas in Iraq and thousands of others 
prepare to serve our country elsewhere around the world, the condition 
of our medical facilities is even more crucial. We need to implement 
change quickly--not just at Walter Reed but at any and all of our 
Department of Veterans Affairs (VA) facilities that are in need of 
upgrades or repairs, in addition to our battlefield facilities. 
Although I've been to the VA facilities in Arkansas many times, after 
hearing the revelations about Walter Reed, I plan to visit again at the 
next available opportunity to ensure that I have the full picture of 
the facilities' strengths and shortcomings.
    I am somewhat heartened to see that the Army is taking some 
responsibility for the failures at Walter Reed. Defense Secretary Gates 
has expressed his commitment to resolving this issue, and several 
officers with direct oversight of Walter Reed have either resigned or 
been fired. I would like everyone to know that I intend on holding 
Secretary Gates to his word, and I took forward to working with my 
colleagues to provide active oversight to ensure that this never 
happens again. I know my colleagues are as anxious as I am to move 
forward and find solutions to ensure that our overburdened VA system is 
able to care for all of our veterans--those just returning home and 
those who served us in previous military conflicts.
    I want to thank the chairman and ranking member for holding this 
very important hearing. I want to thank our witnesses for being here. I 
know that you'll be asked some tough questions, but hopefully we can 
get to the bottom of this to make sure our service men and women get 
the best medical care our government can provide.
    Letter from a constituent who spent roughly 2 years at Walter Reed 
Army Medical Facility.
     
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
     
    
    Letter from a constituent detailing his experience at an active 
duty facility.
     
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    

    Chairman Levin. We will have an 8-minute first round.
    When we visited Building 18 last week we were told that 
there were too few NCOs to take care of the assignment of the 
medical needs of the outpatient soldiers under their 
supervision and to do other things that needed to be done that 
they were required to do, including the health and welfare 
inspection of soldiers' rooms. We also learned when we visited 
Walter Reed last week that there was a backlog in work orders 
for the maintenance and repair in Building 18.
    General Schoomaker, let me ask you, who in the chain of 
command should have been aware that there were no inspections 
going on of soldiers' rooms and that there was a backlog in the 
work orders for maintenance and repair?
    General Schoomaker. At Walter Reed, the commander of Walter 
Reed is the ultimate authority there that should have known 
that. He is supported by a chain of command that supervise the 
soldiers on a day-to-day basis and he is supported by a 
garrison command whose job it is to manage the maintenance, et 
cetera, out there. So he had in my view adequate assistance on 
the ground out there, and in the exercise of commandership and 
leadership out there should have known this.
    So should the Army have known it, though. I will tell you, 
I went through Building 18. Never even heard of it before. I 
went through it myself. There is nothing out there we could not 
have corrected with the proper attention, and we should never 
have had that problem.
    Chairman Levin. General Kiley, were you aware of those two 
specific shortfalls, that they were not being conducted, the 
inspections of the soldiers' room, and that there was a backlog 
of workorders for maintenance of Building 18? Were you aware of 
those?
    General Kiley. No, sir, I was not.
    Chairman Levin. All right.
    Dr. Winkenwerder, were you aware of those two shortfalls?
    Dr. Winkenwerder. No, sir, I was not.
    Chairman Levin. Should you have been?
    Dr. Winkenwerder. Yes.
    Chairman Levin. General, should you have been?
    General Kiley. Certainly if the Walter Reed commander was 
having any difficulty executing the repairs of those I should 
have been aware of that. If General Weightman felt that I 
needed to know that, I should have been aware of it. But I am 
still accountable as his next higher commander.
    Chairman Levin. General Kiley, General Weightman testified 
yesterday before the House that, ``We had a system that 
probably was accurate about 80 percent of the time'' as to the 
handing off of inpatients to outpatient care. That was the 
figure he used. About 20 percent of the time, he said, we did 
not do a good handoff of those patients from inpatient to 
outpatient. Would you agree with that percentage?
    General Kiley. Sir, based on what he told me, yes, sir, 
because I would believe him.
    Chairman Levin. Were you aware of it at the time?
    General Kiley. No, sir.
    Chairman Levin. Should you have been aware of it?
    General Kiley. Yes, sir, as the commander I should be aware 
of that, particularly if it is an issue for General Weightman, 
to bring more resources to bear.
    Chairman Levin. General Kiley, veterans advocates, lawyers, 
and servicemembers say that the Army is shortchanging our 
troops on the disability retirement ratings and they point to 
the fact that the same soldiers are more often being given 
higher disability percentages by the VA than they are by DOD, 
and this is particularly true, but not limited to, post-
traumatic stress disorder (PTSD) and traumatic brain injuries 
(TBI).
    Would you agree that we have been shortchanging troops in 
that area, those two areas particularly?
    General Kiley. Senator, I have said on multiple occasions 
that the emergence of PTSD and the emergence of particularly 
mild TBI is a very complex process that we are only now in the 
last year or 2 beginning to realize how to diagnose and treat. 
I would agree that it is very difficult for the disability 
system of DOD to recognize the nuances, if I can use that term. 
It is very clear to me in talking to soldiers even as recently 
as last week that the present disability system recognizes 
something as fundamental as a missing limb, but does not 
appreciate or take into account the whole man theory, that the 
PTSD this soldier may have, or TBI, may be as significant or 
more significant for their future.
    So I agree that we have an issue there and I think we need 
to take that on.
    Chairman Levin. In that respect, our failure to take those 
problems into account, would you say we have been shortchanging 
some soldiers?
    General Kiley. Yes, sir, I think we have.
    Chairman Levin. We are going to take every step we can 
possibly change to correct that, working with you folks, 
because it is a huge issue.
    General, do you want to add a quick word there?
    General Schoomaker. Sir, I do, if you do not mind. One of 
the things I learned and I did not know before is, of course 
there are two different laws, and I am not trying to--just for 
clarity. The military system operates under a different law 
than the VA system does, and I was very surprised to see that 
where a soldier would be rated, say, at 40 percent in the 
military system that the VA may rate that very same soldier at 
70 percent.
    This kind of problem is fundamental to people's 
understanding and trust and confidence in the system, and it is 
very difficult to explain.
    Chairman Levin. It is not only difficult to explain, it is 
unexplainable, it is inexplicable, and it is unacceptable, and 
that is one of the reasons why these two committees are going 
to be meeting together. We are going to try to end that 
separation, that difference, the crack that exists between the 
DOD and the VA.
    There was a recent article that was written about PTSD by 
Mark Bowell. He quotes Lieutenant Colonel Dr. Charles Engell, 
who is the Director of Deployment Health Clinical Center at 
Walter Reed, as saying that military doctors are reluctant to 
diagnose soldiers with PTSD because it would, ``stigmatize the 
person or bring harm to their careers.''
    General Kiley, should military doctors be reluctant to 
diagnose soldiers with PTSD to avoid stigmatizing them?
    General Kiley. Mr. Chairman, I do not believe they should 
be reluctant to, but I think that is absolutely the reality. As 
part of the mental health task force that Congress has directed 
and that I am co-chairing, we have visited Army, Navy, Air 
Force, and Marine bases around the world. It is very clear that 
our soldiers, sailors, airmen, and marines are very concerned 
about being diagnosed with PTSD as it relates to security 
clearances, as it relates to a perception among their peers and 
their superiors that they are somehow inadequate or not capable 
of being soldiers and leaders. I think it is one of the great 
challenges in military medicine and in the Nation to move past 
that.
    Chairman Levin. But should doctors be reluctant?
    General Kiley. What I believe happens is that the 
individual soldiers are reluctant to talk to doctors about it 
and the doctors know they are reluctant and so they attempt to 
deal with it. There is a difference between helping soldiers--
but I do not think they should be reluctant. I think if a 
soldier has a diagnosis of PTSD it should be documented.
    Chairman Levin. There was a National Public Radio story 
about Fort Carson, Colorado, where it was alleged that there 
was a failure to provide adequate treatment for soldiers 
suffering from PTSD and other service-connected mental health 
problems. Are you, Dr. Winkenwerder, aware of that story? I 
think you have looked into allegations; I believe you have now 
undertaken an investigation at Fort Carson. What have you found 
there?
    Dr. Winkenwerder. Mr. Chairman, I did learn about that and 
I learned about it during the interview. I had not been aware 
that there were problems. I was disturbed to hear about the 
individual cases because, as I heard about them, they had merit 
in my judgment. It appeared to me that people had been 
potentially improperly discharged or discharged without the 
proper medical diagnosis, and it appeared that there might have 
been some instances of retribution or just not the right 
behavior.
    I have worked very hard over the last 4 to 5 years to send 
the signal and to work with all of our leaders, both medical 
and non-medical, to destigmatize mental health issues and to 
make caring for mental health part of the routine of what we 
do.
    Chairman Levin. We have a long way to go.
    Dr. Winkenwerder. Yes, we do.
    Chairman Levin. One final question has to do with the 
funding. The fiscal year 2008 budget request actually has less 
funding requested for the sustainment of defense facilities, 
defense health facilities, than the fiscal year 2007 budget. 
The fiscal year 2007 budget has $341 million. The fiscal year 
2008 budget request has $335 million. Now, sustainment is the 
funding that is used to maintain buildings at their current 
level of quality. This is the fixing of roofs, air 
conditioning, the kind of things that they are doing at 
Building 18, and this includes preventative maintenance.
    One hundred percent funding simply means you are doing 
enough maintenance to keep your facilities at the same quality 
as last year to prevent deterioration. This is 87 percent 
request of this year's funding. How does the administration, 
Dr. Chu, possibly justify requesting 13 percent less than is 
needed to sustain our medical facilities at this year's level?
    Dr. Chu. I think, Mr. Chairman, when you come to the budget 
figures you have to take into account not only the base budget, 
but also what is in any supplemental request.
    Chairman Levin. You are saying there is a supplemental 
request in this area, sustainment of medical buildings?
    Dr. Chu. I think, if I may, sir, to get the full picture we 
have to look at what was spent this year in 2007 and where that 
is going to be, also what was spent in 2006, as well as what is 
planned for 2008 to understand the condition of the actual 
facilities. Obviously, it is our intent to request what is 
necessary to keep those facilities in a good condition and 
where they are inadequate to make sure they come up to the 
right standard.
    Chairman Levin. But your budget request does not keep the 
dollars even at last year's level. I am just telling you that.
    Dr. Winkenwerder. I will be glad to help answer this. The 
figures I have are that in 2006.
    Chairman Levin. There was a hurricane issue in 2006. That 
is why I left it out. There was a big issue about hurricane 
damage to one particular facility. So start in 2007: $341 
million for sustainment; the request for 2008, $335 million. 
That is a reduction. By your own figures, if you look at the 
bottom line, it was 96 percent in 2007 of the level needed to 
maintain it at the previous year's level; 87 percent; and in 
2009 goes down to 77 percent. How do you justify budget 
requests that are that reduced?
    Dr. Winkenwerder. Sir, we will take a look at that. I just 
would note for you that, not just in 2006 but 2005, the 
sustainment and modernization budget for the entire military 
health system was at 150 percent and 172 percent of the 
requirement. There is no reluctance to provide whatever is 
needed. There is just not an issue there, I can assure you 
about that.
    Chairman Levin. Well, the numbers do present an issue. You 
will have to take a look at that.
    Dr. Winkenwerder. We will look at them.
    Chairman Levin. Thank you.
    Dr. Winkenwerder. That should not be an issue.
    Chairman Levin. It should not be.
    Dr. Winkenwerder. Yes, sir.
    [Additional information provided for the record follows:]

    The fiscal year 2008 budget request of $335 million for the 
sustainment of Defense Health Program (DHP) facilities is $7 million 
less than the fiscal year 2007 budget of $342 million. This reduction 
results from a detailed scrub of programs within each of the Budget 
Activity Groups (BAGs). As a result, there was realignment of programs 
and the associated funding among several of the BAGs; one such 
realignment resulted in an overall decrease to sustainment funding 
between fiscal year 2007 and fiscal year 2008. The primary decrease was 
attributable to the realignment of funding to the In-house Care BAG for 
patient appointing, a patient related cost.
    The fiscal year 2006 budget request of $324 million for sustainment 
of DHP facilities was $18 million less than the fiscal year 2007 budget 
of $342 million. As a result of funding that became available during 
the year, total fiscal year 2006 expenditures for sustainment of 
facilities equaled $512 million. Funding may become available during 
fiscal year 2007 to perform additional facility sustainment 
requirements (see table below).

                                       Facilities Sustainment Model (FSM)
----------------------------------------------------------------------------------------------------------------
                                                                                  Fiscal Year
                                                              --------------------------------------------------
                                                                     2006             2007             2008
----------------------------------------------------------------------------------------------------------------
                                                                       Actual         Estimate         EstimateFSM Requirement..............................................       $ 351,385        $ 356,302        $ 387,890
Budgeted.....................................................         323,859          341,937          334,858
Funded.......................................................         512,072          341,937          334,858
Funded to FSM Rate...........................................          145.7%            96.0%            87.0%
----------------------------------------------------------------------------------------------------------------


    Chairman Levin. Senator McCain.
    Senator McCain. Thank you very much, Mr. Chairman.
    I would like to note the presence today of members of our 
veterans service organizations, the Veterans of Foreign Wars, 
American Legion, and others, who are with us, who I have had 
the honor of working with for the last 25 years. I think there 
is no one more capable of providing us the advice and counsel 
on these issues than our veterans organizations, who themselves 
have served. So I am glad to have them here with us.
    Chairman Levin. Thank you, Senator McCain, for pointing 
that out, and I know you do that on behalf of the whole 
committee. We join you in that.
    Senator McCain. General Schoomaker, do you think that the 
Washington Post articles fairly characterize the problems at 
Walter Reed?
    General Schoomaker. I believe they did, especially in 
regards to the frustration of the soldiers. I think Building 18 
became a metaphor for a bigger problem, and that is the 
frustration that we have been discussing and the bureaucracy, 
and the inexplicable rules and the bureaucracy that surrounds 
it. So in that regard I would say yes.
    Senator McCain. So how do you evaluate Lieutenant General 
Kiley's responsibility for the problems at Building 18 and the 
lack of resources assigned to medical hold personnel?
    General Schoomaker. General Kiley is the Surgeon General of 
the Army and he is the principal, he is dual-hatted. He is both 
the medical command commander--he commands the entire medical 
command across the whole United States Army, as well as being 
the principal medical adviser to the chief of staff of the Army 
and the Secretary of the Army. So from the standpoint of 
knowing something specifically that had not been brought to his 
attention in a single barracks someplace, I would say that is a 
stretch.
    However, the system should elevate the kinds of things that 
require resources and they get fixed. I will say that what is 
inexplicable is that we, for 3 years, have been putting 
hundreds of millions of dollars into substandard barracks. I 
have been in the Army for almost 4 decades. We have never 
funded barracks, housing, and things the way they should be 
funded, either in terms of numbers or in terms of maintenance. 
It has always been a stretch.
    We tried to correct that in the last 3 years by making some 
major shifts. You can find years where we are funding 
maintenance at less than 50 percent of what was required. That 
is not unknown to people. So to have--with all of the energy 
that we put into trying to fix this problem Army-wide, it is a 
surprise to me that we would have any reluctance to get 
Building 18 fixed. So what I am telling you is that the 
commander on the ground there clearly should have had it fixed 
and been accountable for it. We should have known about it if 
it was a problem.
    Senator McCain. I appreciate that, General. But already 
there are stories, there are complaints about conditions at 
Fort Lewis, Fort Dix, Fort Knox, Fort Bragg, and Fort Irwin 
according to published stories today. What credence do you give 
those complaints?
    General Schoomaker. We are going to check, and we are going 
to find out, and we will correct those that we have.
    Senator McCain. So it is not just a Building 18, maybe?
    General Schoomaker. Maybe not, that is correct. Again, I 
want to reemphasize something, that this has been a challenge 
for decades. We have short-shifted maintenance because we had 
to carry readiness accounts, we had to train, we have had to 
repair equipment. That has always been a challenge.
    Senator McCain. General, with all due respect, I know of no 
time in the 24 years that I have been a Member of Congress that 
the DOD has come over and asked for funding for this kind of 
needs for the military it has ever been turned down. So I 
understand your statement and I think there may be something to 
it, but every time there has ever been a request that has to do 
with personnel matters in 24 years that I have been in Congress 
we have always not only granted those funds, but we have tried 
to exceed them.
    So maybe there is something wrong in the system that has 
caused, maybe at Secretary Chu's level and Secretary 
Winkenwerder's level, that we have not funded these facilities, 
because it certainly is not a reluctance on the part of 
Congress and the American people.
    General Schoomaker. Sir, I certainly was not saying that 
that was the problem. I was stating the facts, that in my 
entire experience this has always been a challenge and I think 
we all know that. So it is not an excuse, either. It is just a 
fact. So I only bring it up because with the emphasis that we 
have put on trying to rectify this and improve the quality-of-
life of our soldiers and their families that there is really no 
excuse for this kind of thing not to have surfaced and been 
rectified.
    Senator McCain. Again I would assert that these kinds of 
problems are viewed as unacceptable by everyone, and they 
exist, apparently they exist in other bases around the Nation 
as well.
    General Kiley, I want to read you a quote from the 
Washington Post on February 23, 2007, where you conducted a 
tour by the press in Building 18. `` `In the next room there is 
a little water drop in the ceiling. You can get a nice shot of 
it,' Kiley joked.'' According to the report, there was water 
dripping into a wastebasket in the game room used by recovering 
soldiers in Building 18.
    If that quote is accurate, what does that say about your 
attitude to this problem, General?
    General Kiley. Sir, I do not believe that quote is 
accurate. It was in room 416. It was in a double, a two-room 
suite on the fourth floor of that building. I had been in that 
room earlier in the day and had talked to the sergeant who 
lived in there about the leak. They had offered to move him out 
and he was okay with it. He was getting ready to leave the 
area.
    I was attempting to provide full disclosure to the press 
about what we had found in terms of our walkthrough. I was not 
joking about anything. This is very serious. It had rained a 
little bit earlier in the afternoon before the press corps get 
in there. We went up, I walked into the room and one of the 
reporters asked me to point out the drop. So I put my finger up 
at the drop and it disappeared and we waited for another drop. 
But there was nothing humorous. We were not in the process of 
making jokes about this process.
    Senator McCain. Dr. Winkenwerder, beginning last year your 
office initiated a so-called ``efficiency wedge,'' which is a 
deduction from the service medical budgets. Both the Army and 
Navy Surgeons General have indicated that these reductions are 
unexecutable. What is the value of the efficiency wedge 
reductions across the Army, Navy, and the Air Force between 
2007 and 2009?
    Dr. Winkenwerder. I do not have that figure right in front 
of me, but it is several hundreds of millions of dollars over 
that span of time.
    [Additional information provided for the record follows:]

    The table below provides details of the reduction to the Services' 
budgets for the period fiscal years 2007-2009 as a result of the 
efficiency wedge:

                                            [In millions of dollars]
----------------------------------------------------------------------------------------------------------------
                                                                                    Fiscal Year
                                                                 -----------------------------------------------
                                                                     2006        2007        2008        2009
----------------------------------------------------------------------------------------------------------------
Army:
  DHP O&M.......................................................     4,970.6     4,635.8     4,867.5     4,963.9
  DHP Procurement...............................................        66.0        73.8        78.8        73.0
  DHP RDT&E.....................................................       354.0       222.5         5.0         5.0
  Medical Milpers...............................................     2,114.2     2,232.2     2,141.4     2,190.0
                                                                 -----------------------------------------------
    Total.......................................................     7,504.8     7,164.4     7,092.7     7,231.9
                                                                 -----------------------------------------------
  MTF Efficiencies..............................................        29.8        82.1       142.3       227.3
  Percent of Total..............................................         0.4         1.1         2.0         3.0
----------------------------------------------------------------------------------------------------------------
Navy:
  DHP O&M.......................................................     2,877.9     2,862.4     2,657.3     2,737.0
  DHP Procurement...............................................        61.5        53.2        50.8        52.7
  DHP RDT&E.....................................................        46.9        29.8        23.8        24.3
  Medical Milpers...............................................     2,435.8     2,431.6     2,420.5     2,400.6
                                                                 -----------------------------------------------
    Total.......................................................     5,422.1     5,377.0     5,152.3     5,214.6
                                                                 -----------------------------------------------
  MTF Efficiencies..............................................        30.6        84.4       146.5       234.2
  Percent of Total..............................................         0.6         1.5         2.8         4.3
----------------------------------------------------------------------------------------------------------------
Air Force:
  DHP O&M.......................................................     2,506.0     2,477.6     2,377.8     2,528.6
  DHP Procurement...............................................       104.5        66.2        63.0        52.2
  DHP RDT&E.....................................................        54.2        19.0        22.0        22.5
  Medical Milpers...............................................     2,810.9     2,717.9     2,812.9     2,828.4
                                                                 -----------------------------------------------
    Total.......................................................     5,475.6     5,280.6     5,275.7     5,431.7
                                                                 -----------------------------------------------
  MTF Efficiencies..............................................        33.6        92.5       197.5       323.7
  Percent of Total..............................................         0.6         1.7         3.6         5.6
----------------------------------------------------------------------------------------------------------------


                        [In millions of dollars]
------------------------------------------------------------------------
                                                  Fiscal Year
                                     -----------------------------------
                                         2007        2008        2009
------------------------------------------------------------------------
Army................................      -$82.1     -$142.3     -$227.3
Navy................................      -$84.4     -$146.5     -$234.2
Air Force...........................      -$92.5     -$197.5     -$323.7
                                     -----------------------------------
  Defense Health Program Total......     -$259.0     -$486.3     -$785.2
------------------------------------------------------------------------


    Senator McCain. What was your rationale in imposing a tax 
on medical operating budgets of hundreds of millions of dollars 
in time of war?
    Dr. Winkenwerder. This was part of a long-term budget plan 
that had been developed about 3 years ago in conjunction with 
the then surgeons general, and the vice chiefs, and the leaders 
from all of the Services about what was believed to be more 
efficient, effective delivery of health care that could take 
place as part of that. Some of that led into some of the BRAC 
decisions, for example, with closing small community hospitals 
so that we could, in turn, use care that would be out in our 
network that would be equally, if in some cases better, 
received by our beneficiaries, but would be a dollar savings to 
the DOD.
    We are charged with trying to do the right thing in terms 
of managing the budget. I think you raise a very good question 
that I think that needs to be reevaluated in the context of 
everything that we are dealing with right now.
    Senator McCain. If a plan was developed 3 years ago, I 
would have hoped you would not wait until this hearing to 
evaluate it, given the level of conflict that we are in 
throughout the world today in Afghanistan and Iraq.
    Dr. Winkenwerder. We do evaluate things each year. So it is 
not like we make a decision and forget about it. But I take 
your point and we will be doing that.
    Senator McCain. I hope you will inform this committee as to 
what the needs are, because clearly any proposal to reduce 
spending, as the chairman just pointed out, given the level of 
casualties that we are receiving, is also hard to fathom.
    Dr. Winkenwerder. I will. I would, Senator, if I might, 
note that our aggregate budget--Congress has been very 
supportive. One of my goals coming on board 5\1/2\ years ago 
was to ensure that we never ended up in a position where, 
frankly, DOD and the military health system had been before, 
where we were coming to Congress year after year, falling 
short, needing supplemental funds and we had to fight, frankly, 
to ensure that the out growth projections were accurate based 
on what the increased cost of health care is.
    So our budget has more than doubled. It was about $18 
billion in 2001. It is approximately $40 billion today. So we 
are spending a lot more money, but we need to spend money to 
make sure that we get the job done right.
    Senator McCain. Mr. Chairman, I want to thank you for the 
additional hearings we are going to hold with the Veterans 
Affairs Committee, because one of the major policy issues that 
needs to be addressed by Congress is this disconnect, which you 
have already talked about and is being discussed, between our 
VA care, treatment, hospitalization, et cetera, and those who 
are on Active Duty.
    It seems that the experts I have talked to believe that 
there needs to be a seamless transition here and clearly that 
is not taking place and is a cause of a lot of the very 
significant difficulties, the manifestations of which we are 
exploring today.
    I thank you, Mr. Chairman, for holding these hearings and 
the future ones we will hold with the Veterans Affairs 
Committee.
    Chairman Levin. Thank you, Senator McCain.
    Senator Lieberman.
    Senator Lieberman. Thanks. Mr. Chairman, I thank you and 
Senator McCain as well for what you are doing here.
    General Schoomaker, you made a comment that I think ought 
to resonate and ring through our brains and hearts and souls as 
we go on with our response to the Washington Post series on 
Walter Reed, which is that what was happening in Building 18 
really is a metaphor for a lot else that is wrong with the 
system. I think you are right. It is a metaphor, it is a wakeup 
call.
    I think what is important is to focus on the fact that the 
element of the story that infuriated most of us, embarrassed us 
most--the rodents on the floor, the mold on the walls, which 
none of us want our veterans, particularly those injured, to 
have to cope with, those problems can be resolved rapidly. They 
have been resolved. The mold has been taken away, the rodents 
have been eliminated. But what remains both in the DOD and I 
think increasingly we will find in the VA is a system that 
simply shortchanges those who have served us, both because of 
the bureaucratic red tape that is part of it--I thought, 
General, as you approach the conclusion of your great career of 
service to our country, your statement earlier about the red 
tape that surrounds so much of what you try to do to protect 
our national security--I think you used the metaphor there of 
feeling like you were going constantly through a swamp--is 
something that also ought to ring bells in a lot more that we 
do and that is done within the Pentagon.
    But let me come back to it. The mold on the walls, the 
rodents on the floor, they are taken care of. But what remains 
is a system in the DOD and the VA particularly, I think, that 
is too bureaucratic, and that in that bureaucratic red tape 
frustrates and in some sense insults the veterans because of 
what it puts them and their families through.
    But also I believe as I have gotten into this deeper and 
deeper that what we all have to come to conclude--let me just 
speak for myself; I conclude--we have not made a national 
commitment to our veterans in this war on treatment, including 
particularly Iraq and Afghanistan, commensurate, as great as 
the service and sacrifice that we are asking them every day to 
give.
    We have simply got to close that gap between what we are 
asking them to do for us on the battlefield and what we as a 
Nation are doing for them when they come home. The fact is, and 
the other thing that we ought not to let the mold and the 
rodents conceal, is that the battlefield medical care, the 
acute care they are getting, and the care that they are getting 
as inpatients, so much of which is going on at Walter Reed and 
Bethesda, is the best in the world. But in a lot of other ways, 
in the outpatient services and in the red tape about 
disability, we are really failing them.
    That is where I echo what has been said. I think Senator 
Levin and Senator McCain are doing something very important in 
bringing us together with our colleagues on the Veterans 
Affairs Committee. There are hundreds of thousands of claims 
for disability that are pending today in the VA. They are 
waiting 6 months to as long as 2 years. It is just shocking and 
unacceptable.
    Whatever it takes--and I think it is going to take some 
money in addition to reorganization--we have to resolve to end 
that gap and take care of our veterans in some way approaching 
the way they have taken care of us.
    General Kiley, you indicated in response to earlier 
questions that there were some things going on that you did not 
know in your role as Army Surgeon General. I want to ask you 
what your conclusion is about why you did not know them and 
what you are going to do now to correct that situation so you 
will know anything that is wrong with the system henceforth?
    General Kiley. Senator, if you are referring to this 
complex bureaucratic process of the MEB and PEB process, I 
think I probably should have known more, and what is going on 
at Walter Reed in terms of the frustration of the staffs and 
the patients is probably mirrored to some extent in most of our 
other facilities, as I hear commanders talk to us about these 
issues. I think it is amplified a little at Walter Reed because 
of the sheer numbers. There are a lot of soldiers at Walter 
Reed that are going through that process.
    We clearly need to take a look at everything from what we 
call quick fixes that we could suggest to the Department of the 
Army that we eliminate as part of the 22 different forms. We 
need to reenergize, I need to reenergize, commanders to 
understand that they have all the resources they need. They can 
hire all the case managers and doctors, not just at Walter 
Reed, but across MEDCOM, to get these conditions corrected if 
they are there.
    I think we still need to recognize that soldiers still need 
time to heal and that in that healing process there is 
consultation and time. So I am always faced with the challenges 
as the commander of MEDCOM through my commanders. We want to 
give soldiers enough time without delaying it, and some feel 
that their processing is being delayed. As we try to expedite 
that care, soldiers feel we are rushing them out of the system, 
that we are not giving them time to heal. It is a very tight 
rope that the commanders, the attending physicians, the case 
managers across MEDCOM have to walk.
    We talk to them at commanders conferences. I talk to the 
senior leaders on video-teleconferences (VTCs), if not weekly, 
monthly about these kinds of issues. When there are special 
issues or problems associated, for example, with deployment or 
redeployment of major combat units into installations, we keep 
an eye on the med holdover and med hold soldiers. So there is a 
lot going on.
    Senator Lieberman. General, let me ask you this personal 
question. From 2002 to 2004 you were the commander of the 
Walter Reed Army Medical Center.
    General Kiley. Yes, sir.
    Senator Lieberman. I do not know, I presume you do not 
know, whether the conditions at Building 18 during that period 
of time were what they were when the Washington Post did the 
investigation. But presumably the red tape problems that a lot 
of the soldiers are finding did exist. As you look back, do you 
hold yourself accountable for the development of some of the 
shortcomings or do you hold others under you accountable?
    General Kiley. I hold myself accountable. As I relinquished 
command in 2004, the number of soldiers on the post was 
increasing. We were filling up all the rooms in the Mologne 
House. We had just begun the case manager process. I think we 
still had, if I remember correctly, patients serving as platoon 
sergeants, and we were starting to hear that was not fair to 
the sergeants and it was not fair to the rest of the soldiers.
    I probably could have, and should have, taken action 
earlier, trying to learn lessons from that installation and the 
other installations in my North Atlantic Region, to include 
Forts Dix, Drum, Knox, Attaberry, and McCoy. We were out 
looking at this all the time, attempting to improve it, never 
wanting for resources, but sometimes difficult in execution.
    General Schoomaker. Senator Lieberman, if I could add 
something here.
    Senator Lieberman. Yes, sir.
    General Schoomaker. Building 18 I have now learned has gone 
through--it went through a renovation in 2001. It went through 
another renovation in 2005. But there is a metaphor within the 
metaphor here. We fixed the mold, we fixed the things that you 
talked about, but the roof is not fixed. If you do not fix the 
roof, these things are going to be back if that is the problem.
    Senator Lieberman. Right.
    General Schoomaker. It really is a metaphor for a much 
bigger challenge that we have. I will tell you: How much energy 
have all of us here spent on the VA, MILCON, BRAC bill this 
year? We are 6 months into the fiscal year and we do not have a 
bill.
    Senator Lieberman. Right.
    General Schoomaker. We spent a lot of energy, and we are 
about $2 billion short on the BRAC, on the deal which is going 
to be--this is not pointing fingers. Last year we worked--we 
did not get our first funding until December 30, a quarter into 
the fiscal year. We did not get our other increment until the 
end of June, only 90 days left. So we are running through this 
swamp, spending our energy in a huge way at the senior level, 
and that energy could be so much better spent trying to be more 
effective leaders and managers down there. But that is just the 
reality. That is the bureaucracy.
    Senator Lieberman. It is a point well-taken.
    My time is up. I do not want to ask a question, but I just 
want to ask you to please think about something, whether we 
ought to go back and take a second look at the BRAC 
recommendation to close the Walter Reed Army Medical Center. It 
just seems to me that when we know there is going to be an 
increasing demand from veterans for services, medical services, 
to close this facility that has some state-of-the-art services, 
I am not sure it makes sense.
    It may be that you want to concentrate certain medical 
services there to veterans, not just in the Army, or soldiers 
not just in the Army, but across the four Services and to 
concentrate some more in Bethesda. I am having second thoughts 
about the wisdom of that.
    General Schoomaker. First of all, the BRAC thing is way 
above my pay grade, but I will say is that we need that 
hospital at Fort Belvoir, because that is where the center has 
moved. The transportation system supports it. We need to get 
better medical care for the broader community.
    Second, we need to improve Bethesda and get the Uniformed 
Health Services University, get the research center and 
everything set up.
    Third, I have concerns as we go through this long war about 
taking down capacity that may be needed. So I am not suggesting 
opening BRAC or anything else, but I think we ought to be very, 
very careful about disconnecting certain things with the 
realities that we face today.
    Senator Lieberman. I totally agree with you and that is why 
I think we ought to take a second look at that decision about 
Walter Reed.
    Mr. Chairman, I have gone over my time.
    Chairman Levin. Secretary Winkenwerder did want to comment, 
apparently, on that.
    Dr. Winkenwerder. Yes, I would like to comment on that as 
well. I do think it is the right decision to bring these two 
great facilities together. We will be stronger. Military health 
care will be stronger. We will be more joint.
    Chairman Levin. If we do what?
    Dr. Winkenwerder. Bring these two institutions, Walter Reed 
and Bethesda, to the new Walter Reed National Military Medical 
Center.
    Chairman Levin. To the Walter Reed?
    Dr. Winkenwerder. The new, the new Walter Reed; move 
forward with the BRAC recommendations.
    For all the reasons that are talked about, there is the 
opportunity to get all of our great expertise in one place with 
our medical school, the research, and the National Institutes 
of Health is right across the street with the great research 
programs there. There is an opportunity to invest a large sum 
of money. We are talking approximately $2 billion that is to be 
spent on state-of-the-art facilities.
    The people are the key and the people obviously are not 
going away. The programs are not going away. It is the facility 
at that location that I think is the right thing.
    Now, having said that, I totally agree with you that we all 
need to be absolutely careful, scrutiny to the highest degree, 
to make sure that nothing falls through the crack, nothing is 
left undone, until the day that that move occurs. We absolutely 
have to continue everything just as if Walter Reed were going 
to continue for another 15 years until that move occurs.
    So that is my view. I know that there will be other 
discussions on it.
    Chairman Levin. Thank you.
    Senator Warner.
    Senator Warner. Thank you, Mr. Chairman.
    Mr. Chairman, I have to reflect that in the 29 years that 
you and I have been together on this committee, as I approached 
this hearing this morning it was with a feeling of great 
distress. This is one of the most distressing situations that 
we have ever seen in the time that we have been here together. 
I commend you and Senator McCain and others at the 
forthrightness with which this committee is going to address 
it.
    I think as we listen to the accountability unhesitatingly 
coming forward from this group of witnesses we should also 
examine our own oversight process and to see how a situation of 
this magnitude in many ways was not brought to our attention. 
Of course, our oversight is performed not only through the 
hearings and the witnesses, but from constituent inquiries, and 
when I visited Walter Reed, which was just the Friday following 
the disclosure of the very valuable investigative report in the 
Washington Post. I was present when Secretary Gates came out 
and spoke at Walter Reed about this situation and his first 
steps that he took, and I commend him for the expeditious 
manner in which he stepped up to accept his share of 
responsibility as we deal with this question.
    But I want to bring to the attention of our witnesses again 
the value of constituents contacting us. When I was out there I 
visited with a staff sergeant--I will withhold his name, 
although if necessary I will make it disclosed--and his 
commander out there, a colonel, full colonel, who dealt with 
this issue.
    My first question goes to General Schoomaker. I have had 
the privilege of being associated with the military for many 
years and the limited contribution I may have made came up 
through the Reserve side of our military. I have always been 
concerned about the differential treatment between the Reserves 
and the regulars. In the context of the problem we have here 
today, constituent inquiries on this issue bring this question 
to mind.
    I go back to the famous slogan that the Army had for many 
years, ``An Army of One.'' What did that mean, General? I 
interpret it as meaning that Reserves and regulars are to be 
treated as one. Is that correct?
    General Schoomaker. That would--sir, really we talk about a 
total Army.
    Senator Warner. Total Army.
    General Schoomaker. I think you know that throughout my 
entire tenure I have made that one of my highest priorities.
    Senator Warner. No question about it.
    General Schoomaker. Made this one Army. I will tell you 
that I believe that we are on the path to do that.
    Senator Warner. I want to say as you begin to draw to a 
close your distinguished career, as you say, of 40 years, it 
has been a privilege to work with you. You are a man not only 
of proven combat courage, but a man of enormous compassion for 
your soldiers of all ranks and their families, and I know this 
situation you find very distressing. As a matter of fact, when 
you greeted me here at the dais this morning I think those were 
the words that you used.
    But let us go back to that ``Army of One,'' because part of 
the oversight performed by this committee was in the context of 
our National Defense Authorization Act of Fiscal Year 2006, and 
in it we directed the Government Accountability Office (GAO) to 
review the results of the military disability and evaluation 
system, the very thing that is before us today. That report 
when it was released said as follows: ``GAO's analysis of the 
military disability benefit decisions for soldiers who were 
determined to be unfit for duty were less definitive, but 
suggests that the Army reservists were less likely to receive 
permanent disability retirement or lump sum disability 
severance pay than their Active Duty counterparts.''
    It is interesting. Just yesterday I was visited by a member 
of the Veterans of Foreign Wars (VFW) here in Washington for 
the conference, as Senator McCain mentioned, and there is 
another means by which members of this committee receive 
valuable information to work on our legislative and oversight 
responsibilities.
    But let us go and address that, because this sergeant whom 
I visited on Friday, February 23--it was the afternoon of the 
press conference by the Secretary of Defense. As I mentioned, 
he stepped up and accepted his accountability; very prompt and 
decisive direction in that conference. But this sergeant 
brought that up, and he had with him a full colonel who was in 
charge of the cadre of soldiers in the Reserve and the Guard, 
and he confirmed what this sergeant had said.
    If you look back on this extraordinary chapter of military 
history here in regard to Afghanistan and Iraq, we have relied 
upon the Guard and Reserve to a greater extent than ever in I 
suppose the contemporary history of our military.
    So can you, General, talk to the question of the 
credibility of these comments with regard to different 
treatment between the Reserve and the Guard? A wound is a wound 
whether it is borne by a guardsman, reservist, or a regular 
Army soldier.
    General Schoomaker. Sir, first of all, I agree with you. In 
fact, I do not think our system at the medical--the doctors do 
not differentiate. I certainly do not when I go around and 
visit these patients. Now, the realities are as they go back 
out through the system there are other challenges. Whereas an 
Active component member comes from an installation that has a 
support base that is coherent and cohesive in a certain sense 
many of our Reserve component members go back out into smaller 
communities and the Guard Bureau and the Army Reserve Command 
have other systems to help make up for that.
    But one of the points is, is there a difference in the 
disability ratings, et cetera, and I would be glad to provide 
for the record some figures here that I got out of our 
personnel and medical command that shows that in fact the 
Reserve component soldiers have gotten a higher percent--in 
2005-2006, actually received a higher percentage of permanently 
retired and temporary disability retirement list ratings than 
the Active component did.
    I think it indicates that Reserve component soldiers are 
not being disadvantaged in terms of how they are being 
evaluated.
    Senator Warner. Yet the GAO seemed to have found that there 
was a disparity.
    General Schoomaker. We will provide the figures.
    [The information referred to follows:]

    U.S. Army Medical command does not discriminate among patients 
based on component. The only factor considered in scheduling 
appointments or the administrative processing of soldiers is the 
clinical requirements of the patient as determined by the treating 
health care providers. A review of scheduling information for clinics 
at Walter Reed Army Medical Center and across U.S. Army Medical Command 
indicates no differences between Active and Reserve component soldiers 
in access or timeliness of appointments.

    Senator Warner. All right. Let us ask the Surgeon General. 
Incidentally, on my visit on February 23 following Secretary 
Gates' press conference you and I met. You took me through 
Building 18 and I think we discussed that issue, and what was 
your observation as to any disparity of treatment between the 
Reserve and the regular?
    General Kiley. Senator, in the 4 years from Walter Reed to 
my command of MEDCOM there clearly has been a concern among 
Reserve and National Guard soldiers that they perceive that 
they are not getting timely enough care quickly enough, and 
consistently our message to commanders, to clinicians, is not 
only are they to get the same access, but because of some of 
the uniqueness, unique administrative requirements for Reserve 
and National Guard soldiers as they work their way through the 
process of the MEB-PEB, I have asked commanders to move Reserve 
and National Guard to the front.
    Senator Warner. My time is coming to a conclusion.
    General Kiley. Yes, sir.
    Senator Warner. I would like to have you join with the 
Chief of Staff of the Army in reporting to this committee.
    General Kiley. Yes, sir.
    Senator Warner. I would like to return to the issue of this 
BRAC issue. I have been looking into it. Indeed, following a 
hearing in the House there were similar representations by the 
Subcommittee of the Appropriations on Defense. Indeed, General 
Cody said the following: ``I think we need to take a look at 
and address whether we should sanctuary Walter Reed during this 
long war.'' I think he meant by ``sanctuary'' put it in some 
holding status, which would require going in and amending--only 
by law could we do it--the BRAC process.
    I urge that we, if we wish to look at that, certainly we 
should, but on the other hand it seems to me, Mr. Chairman and 
Senator McCain, it would be incumbent on this committee perhaps 
to reach a recommendation that we should begin to expedite the 
funding profile to do the augmentation at Bethesda and to begin 
to break ground and proceed with the new hospital. Is it to be 
called Walter Reed, the follow-on? Fine.
    Dr. Winkenwerder. Yes, sir.
    Senator Warner. Which is at Fort Belvoir. Now, I am going 
to address those questions, but I think those who want to try 
and reinvigorate Walter Reed should look at the volume of 
expenditures required. Did you not mention that to me on 
Friday, General Kiley, your estimate of the amount of MILCON 
that would be required to put Walter Reed back into a situation 
where it is a front-line military facility?
    General Kiley. Sir, I think it is a front-line military 
facility. But there is a master plan that at its maximum called 
for multiple hundreds of millions of dollars for renovation 
projects, yes, sir.
    Senator Warner. So we have to balance that. Thank you. When 
I used the word ``front-line'' I meant to put it in condition 
so that it can continue to do the work.
    By the way, the medical attention received by individuals 
in the course of this very tragic dispute has not been 
questioned. I think that should be made clear for the record.
    All right. I do hope that we look at the BRAC in the 
context of moving ahead, keeping the BRAC decision with the new 
facility.
    Chairman Levin. Thank you, Senator Warner.
    By the way, General, you have used the term twice now, 
``PEB'' and ``MEB''. I think we know what they are, but for the 
record you should state.
    General Kiley. ``MEB'' is the Medical Evaluation Board and 
``PEB'' is the ``Physical Evaluation Board.''
    Chairman Levin. The MEB comes first and then the PEB?
    General Kiley. Correct, Senator.
    Chairman Levin. Thank you.
    I am glad I asked that question. I do not know if Senator 
Bill Nelson is happy, but Senator Reed is next.
    Senator Reed. Thank you, Mr. Chairman.
    Thank you, gentlemen. Dr. Chu, there are two icebergs that 
are looming as the administration steams ahead. One is the 
adequacy of the DOD medical system itself, the hospitals, the 
capacity, the human capacity, doctors, et cetera; and the other 
one is the capacity of the VA to handle all these young 
Americans, probably for 50 years. Specifically, you mentioned 
the coordination, but do you have a sense right now which you 
communicate to the VA where these people are going, their costs 
over time? Because this is not a transitory issue.
    Are you providing the kind of coordination or do you have 
the authority to coordinate so that you can assure these young 
people right now that, not just through their military service 
and their first few years in the VA, but for 50 years that they 
are going to be cared for with the same level of concern we 
have all expressed here tonight, or today rather?
    Dr. Chu. Senator, thank you. That is I think a significant 
issue. We believe that the procedures and processes in place 
will sustain these veterans over the long-term. We meet 
regularly with our VA counterparts. We have constituted, in 
addition to a health executive council that Bill Winkenwerder 
co-chairs with Dr. Kussman, his VA counterpart, a benefits 
executive council, and the VA deputy secretary and I co-chair a 
joint executive council that meets quarterly to confront 
exactly these issues.
    Do we have all the authority we need? I am not confident 
that that is the case, although I would like to wait for 
several reviews that are ongoing, including one that I have 
asked our own inspector general (IG) to do. Let me just point 
to one of the same issues, which is as long as they are on 
Active Duty there are certain things they cannot get from title 
38, the VA statute. We may want to come back to Congress and 
ask to allow an overlap here.
    A similar issue, for example, with support for the families 
of injured veterans. This is not so much the long-term. This is 
more the short-term. We can, under statutes this committee has 
granted, provide support to families to visit the bedside and 
so on and so forth. VA does not have, as I understand it, 
similar authorities. So one transition issue is, back to 
Senator Levin's question, when they move from us to the VA 
there is under American law a different set of rules of the 
game.
    We can ameliorate that with voluntary organizations, 
support from America at large, and we do mobilize that. Again, 
it is premature for me to make a recommendation at this stage, 
but I do hope within a few months we will come to the 
conclusion, what do we need to do, perhaps less on the long-
term, more on the, as Senator Levin pointed, short-term 
transition issue from DOD to VA.
    Senator Reed. How many billions of dollars do you estimate 
it will cost just at this point to care for these young people 
over the course of their lives?
    Dr. Chu. I do not have an estimate at the top of my head, 
sir.
    Senator Reed. Will you get that estimate?
    Dr. Chu. I would be delighted to work on one, yes, sir.
    [The information referred to follows:]

    This question addresses lifetime costs of caring for Iraq/
Afghanistan veterans, the biggest piece of which will be Department of 
Veterans Affairs (VA) costs. Since we do not possess VA cost data, we 
respectfully defer to the VA on this question.

    Senator Reed. Let me ask another question. For years now 
many members of this committee and other colleagues have called 
for the increase of the Army's end strength, and until a few 
months ago the administration rejected in a serious way those 
proposals. My understanding is that during that period of time 
the Army was trying to constitute maneuver brigades by taking 
people out of overhead. Did that overhead include either the 
medical system by not adding additional positions or by taking 
people away from the medical detachments and the medical 
service corps elements?
    Dr. Chu. I do not believe so, sir. I will let Dr. 
Winkenwerder and General Schoomaker speak to the specifics of 
Army medical manning. It is the case that the Army has 
converted some military billets to civilian status within its 
system, although its conversions are generally more modest than 
those of the other military departments because it started with 
a higher civilian content than the others. But I believe the 
staffing is stable or possibly growing, sir.
    Senator Reed. I will ask General Schoomaker. But what 
prompts the question is that before the conflict in Iraq and 
Afghanistan the inpatient population of Walter Reed I am told 
was roughly about 100 people. It swelled in 2005 to 874. They 
now have 674. Average patient stay is 45 days. Outpatient stay 
is 300 days. Yet I do not think there is any concomitant 
increase in the number of people in the medical hold detachment 
and in those nonclinical areas.
    General, as we talked about this issue before, the Army was 
desperately trying to pull people out of TRADOC and other 
places. If not directly contributing to this problem, was there 
the implicit notion that you could not ask for more people to 
go up and staff a medical detachment at Walter Reed?
    General Schoomaker. The answer, sir, is no, I do not think 
that there is any connection between the two. I think that we 
were successful in growing the operational portion of the Army 
through some moves. We are constantly looking at it because we 
are concerned about what institutional risks we take. We have 
been aggressive on the military to civilian change. But we have 
also mobilized a great many medical professionals, reservists, 
and we have looked at joint solutions.
    I will give you a good example. Landstuhl largely has been 
staffed by Reserve component soldiers over there. Today--in 
fact, I think it took place when I was there at Christmas time. 
They had just turned over. We have about 300 to 350 naval 
medical personnel now that are staffing Landstuhl. So there 
have been joint solutions to this. There have been Reserve 
component solutions. Quite frankly, in our structure we have 
actually grown medical capacity for the battlefield on that in 
terms of our structure.
    Senator Reed. General Kiley?
    General Kiley. Sir, I agree with the Chief. We have watched 
that military-to-civilian conversion very carefully in MEDCOM. 
It is spread across all our facilities, not just at Walter 
Reed. The risk that we take at a place like Walter Reed is 
where for other medical services and capabilities we can 
contract or hire civilians, you cannot put civilians in as 
platoon sergeants and company commanders.
    Where we failed is in not asking the Army for help, which 
is now what we are doing, bringing in soldiers from the line 
Army to stand up this task force. So that in that respect I 
failed in terms of realizing the potential impact on that.
    Senator Reed. I think that is an accurate after-the-fact 
evaluation, because I think obviously, we recognize there has 
been a failure there. Interestingly enough, and I will not 
dispute your analysis, General Schoomaker, but so many times 
when we find a problem the solution seems to be, well, put more 
people there, where before the problem was discovered obviously 
we did not have enough people.
    Just one final area of concern and that is the culture of 
the organization. Most major medical organizations I know are 
not run by doctors any longer. They are run by Masters of 
Business Administration (MBAs). Yet in the military system it 
seems all these major facilities are run by physicians, who 
have great clinical training, great care, great compassion. Are 
we going to look seriously at a new model of running 
institutions like this, doctor, secretary?
    Dr. Winkenwerder. That is a great question and I welcome 
that. Just for the benefit of your background--I spent most of 
my--I am a physician, trained, an internist. I also trained in 
business and have a business degree, and fortunate enough to 
have worked with some great health care organizations in the 
private sector.
    One thing I will say just is this is the toughest 
organization. I totally echo General Schoomaker's remarks. We 
are a very complex, very large organization, tremendous 
management challenge. One of the things I see a need for--and 
we have talked about this, but again this may take legislative 
change or regulation change--is a need for strong civilian 
administrative capability in these locations. All of the 
military treatment facilities are managed through the Services.
    One of the issues we face is turnover of people, changes of 
command and leadership. Our people work hard. They are 
wonderful people, committed and talented managers. I think if I 
am to compare from my private sector experience, we have some 
great managers. But I think we would be well-served to have, if 
you will, some leadership that is administrative that provides 
some continuity, so that things do not fall through the gaps 
and that we can make sure we get it right.
    Senator Reed. Thank you, Mr. Chairman.
    Chairman Levin. Thank you, Senator Reed.
    Senator Inhofe.
    Senator Inhofe. Thank you, Mr. Chairman.
    First of all, I thank both Secretary Chu and General 
Schoomaker for beginning your remarks complimenting the people 
who are offering care at our various institutions. I have been 
to all of them and you have, too. But I think when you look at 
some of the statistics, World War II, 30 percent of those who 
were injured died. In Vietnam it was 24 percent. Now it is 9 
percent. A lot of that is due to better equipment, I understand 
that, but also better treatment.
    What I get, whether it is Landstuhl or Walter Reed, in 
making my visits I hear from the troops who are injured and 
their first concern is--they are very complimentary on the 
treatment they are getting and the first thing they want to do 
is get back to their unit. So I am glad that we are all 
recognizing that. There is a lot of people watching us now that 
are thinking it is the quality of treatment in areas where it 
is not.
    I do want to get to the PEB and the MEB thing. I think that 
is very important. Each one of us up here has cases where we 
have been called by veterans. I have one where a soldier had 
lost his leg actually to cancer, but it was diagnosed as an 
aggressive cancer and he did qualify. Then when that paperwork 
reached Washington they rediagnosed it and decided it was a 
slower growing cancer and he was not qualified. We corrected 
that problem. But I thought that was an isolated case until I 
have been hearing some of the testimonials in conjunction with 
this hearing.
    Now, General Schoomaker, I cannot figure this out, but when 
you look at the GAO report, unless I misread it, it talks about 
the Marines, the Air Force, and the Army. Thirty percent of the 
cases before the Marine PEB have been granted permanent 
disability, 24 percent of the Air Force, and only 4 percent of 
the Army. I have to ask what could be the reason for that?
    General Schoomaker. Sir, I have asked the same question. I 
cannot figure it out either. Some people have said, we are 
talking about in many cases a younger population that does not 
have the years of service and therefore there is a different 
deal. But I am not satisfied that we know the answer. In fact, 
General Kiley and I were having this conversation. So I think 
we owe you an answer and we will probably have to do it for the 
record, but it does not make sense.
    [The information referred to follows:]

    The 4 percent figure and disparity with other Services comes from a 
quote on February 25, 2007, in The Washington Post Magazine: ``The 
Defense Department reports that the Army, which handles more than half 
of the military's disability cases, put less than 4 percent of the 
10,460 active duty soldiers and reservists it evaluated last year on 
permanent disability retirement and less than 15 percent on the 
temporary list. (Temporary retirees undergo periodic reassessments of 
their condition for as much as 5 years before a final decision.) By 
comparison, the Navy (including the Marine Corps) retired about 35 
percent of its injured, temporarily or permanently, and the Air Force 
about 24 percent the Defense Department says.'' Although not stated in 
the article, these Department of Defense figures are only from fiscal 
year 2006.
    Approximately 19 percent (4 percent + 15 percent mentioned above) 
is the appropriate Army disability retirement figure to compare to Navy 
and Air Force. Further refinement of the Army disability retirements: 
fiscal year 2006--18.70 percent; fiscal year 2007 through February 28, 
2007--21.36 percent.

    Senator Inhofe. That is fine for the record, but I was 
wondering. I was an Army guy myself and I always look out and 
see the differences in treatment, and I want to make sure that 
is not the case. I would not want the Army to be out of step 
with the other Services.
    Now, Senator Lieberman said that Walter Reed is kind of a 
metaphor or a wakeup call for other institutions and, General 
Kiley, you talked about directing three investigations. One of 
those investigations was the MEB and PEB insofar as Walter Reed 
is concerned. Now, are you also taking into consideration 
looking into all the other institutions as well?
    General Kiley. Senator, we are doing an in-depth analysis 
of how the medical board process works inside Walter Reed, so 
that we can streamline it, iterative-reiterative process of 
looking at how the doctors and the soldiers--that is one.
    The second process is this team that I have sent out with 
Bob Wilson and the professionals who are looking across all the 
installations for communications, infrastructure, bureaucracy 
issues, to make sure we do not have duplication. Then I have a 
series of investigations going on, one by CID and two what we 
call AR-15-60s.
    Senator Inhofe. I see, okay. The GAO, in the same report, 
reported that the PEB caseload grew from 7,200 cases in 2001 to 
13,700 in 2005. The number of soldiers waiting to go through 
the process across the country averages 5,000 cases.
    I am not saying this critically, but I know that the Army 
particularly, and other Services too to a lesser degree, during 
the drawdown of the 1990s--I can remember going to the floor 
many times and talking about we are going to come back and pay 
for a lot of this, because it was a reality at that time. Now, 
if funding is the problem we really need to know it. Mr. 
Secretary, you mentioned I think--maybe I misunderstood you, 
but you did not think it was. You think you have had all the 
resources you need. When you said that, I did not quite agree 
with it, because it appears to me that funding is a problem.
    We all know what we went through recently. General Cody, 
who I thought was originally going to be on this panel, his 
concern at one time, it looked like we were not going to be 
able to pay reenlistment bonuses, we were not going to pay 
widows benefits, and things that would really be a disaster 
unless we have the proper funding. Then of course they pulled 
$3.1 billion out of the BRAC account, which is I think really a 
disaster and it needs to come back in, not at the expense of 
something else, because there is no fat left out there. It 
cannot come out of modernization, it cannot come out of Future 
Combat System, it cannot come out of the RPM accounts, or 
whatever they call those accounts now.
    But I seem to think this is a problem. I would like to have 
you, each one of you, address this, because I think we are 
looking at a funding problem. Here is a quote that I have from 
General Cody. He said: ``Our counselors and case managers are 
overworked. They do not receive enough training. Our medical 
holding units are not manned at the proper level.''
    Do you have any comments?
    General Schoomaker. Sir, that is precisely what we are 
fixing.
    Senator Inhofe. You cannot fix it without adequate 
resources and money.
    General Schoomaker. That is correct, and so I want to 
address that. One of the things that I think I have to say 
here, because I think maybe we are overlooking it, and that is 
even before the war we had thousands of people that were going 
through the MEB-PEB process. Every soldier, regardless of 
whether they are injured in battle, whether they are injured in 
training, whether they are injured through whatever, deserves 
exactly the same treatment.
    I looked at some figures the other day. Seven of the 
soldiers at Building 18 that were living in there, were battle-
injured soldiers. The others were not battle-injured soldiers 
that were living there. So there is a baseline of soldiers that 
have always been in this system. Part of our problem is that as 
we go through the budget deliberations and get in these 
arguments everybody talks about how much more money we have 
today than we had before. The issue--we have always had too 
little money. I have testified here too much about the 
underfunding of the United States Army historically.
    This is about how much we should have and how much the 
Nation can afford to do. So we need to take a look at it in a 
direction that says this is the standard for these soldiers, 
regardless of whether battle-injured, non-battle-injured, 
whether they are sick, cancer like your constituent, et cetera, 
and we need to fund this correctly. We need to make sure the 
pay systems interact, that the VA-DOD health system interacts.
    This country can do this. But you cannot do it when our 
energy is not being spent on doing it and we are arguing over 
stuff that we should not have to argue over. I say this because 
I do believe we have to put it in perspective.
    The last thing I would like to say is we all have 
constituents. My constituents are soldiers and their families, 
and when I have gone around, everywhere I have gone they have 
complimented the health care providers in our system. If we are 
guilty of one thing, it is we have been drinking our own bath 
water about how well we have been treating everybody. Everybody 
is giving us thumbs up on it, and we have overlooked something 
that we should not have overlooked. Digging down inside the 
bureaucracy, and there is this category of soldiers that we owe 
exactly the same kind of care to, and we have just let them 
down.
    I just needed to get that out and make sure that we do not 
run down a rabbit hole here, because we still have this big 
context and this future, not only the long war, but the future 
volunteer force, must be resourced properly.
    Senator Inhofe. That is why I asked the question. This is a 
good forum to bring it out, and I knew you would and I 
appreciate it very much.
    By the way, when Senator Warner talked about you will be 
before long going into retirement, you have already been there, 
and you have come back and answered the call for service. I 
want to tell you how much I appreciate the service.
    My time has expired. Just I only want to ask, Mr. Chairman, 
the Building 14 that you mentioned that you are moving some of 
this to, what is in that building now? Is somebody else going 
to have to be kicked out in order to utilize that?
    General Kiley. Sir, there were permanent party soldiers 
that were in there. They had empty rooms. We moved some of the 
soldiers from Building 14 into some very nice apartments.
    Senator Inhofe. So it was more of a barracks operation?
    General Kiley. Yes, sir. Building 14 is a barracks. It is 
an exceptionally outstanding, just renovated, $25 million 
barracks at Walter Reed. There are individual rooms for 
soldiers. That is where those soldiers from Building 18 are now 
sitting, are now housed. They are living there now.
    Senator Inhofe. Thank you very much.
    Thank you, Mr. Chairman.
    Chairman Levin. Thank you, Senator Inhofe.
    Senator Bill Nelson.
    Senator Bill Nelson. General, you said unfortunately we 
have let them down. I am going to point out another area where 
it appears that we have let them down and I would like to know 
what you can do about it. One of the most serious injuries that 
we are seeing in Iraq is TBI and it is often caused by the 
explosions coming out of those IEDs. There are four TBI centers 
in this country. They are set up under the VA hospitals. 
Medical experts tell us if there are any delays in the 
initiation of the comprehensive rehabilitation for those 
soldiers who suffer the brain injuries then they are going to 
have a long-term problem of long-term recovery. In other words, 
the delays in treatment lessen the chances of recovery for our 
soldiers.
    Now, this was of concern last summer to the VA's IG and he 
wrote a comprehensive report on this. He pointed out--and I am 
just going to read from the report--that he found that ``Groups 
differed substantially with respect to the median length of 
time from injury to initiation of comprehensive TBI 
rehabilitation.'' He pointed out that in model systems the 
delay was only 2.1 weeks and in the VA it was 6.1 weeks.
    Now, the IG also found out that remaining on Active Duty--
this is where you come in--was a barrier to soldiers receiving 
more timely rehabilitative care from a veterans facility. He 
further pointed out--I am quoting here from the IG report: ``We 
identified one soldier on duty at a military post who had had 
little constructive activity for several months while she 
waited to be discharged. Another patient''--I am still quoting 
``still on Active Duty spent 4 months without rehabilitation 
after the lead center staff had told them to go on and get that 
soldier taken care of.'' At that veteran's medical facility he 
was told he would not be eligible for care until he was retired 
or discharged.
    Further, in talking with some of these soldiers the IG 
found that 40 percent of them said that they felt uncertain 
about whether they were receiving quality care. This is the 
TBI. Seventeen percent said they lacked the money to pay for 
the medical services and rehab and 8 percent said they were 
receiving no medical care.
    Beyond that report, I have received complaints and one of 
the complaints just received a day or so ago, now that this 
Building 18 issue has raised the visibility. Familiar with a 
particular brain injury facility, decried the conditions, and I 
quote, as ``horrible.''
    So we have two issues here with regard to you. Where there 
are Active Duty soldiers on a VA facility receiving care, that 
is good if the facility is not ``horrible.'' So there has to be 
some interagency cooperation between you to see that our 
soldiers are being taken care of. Or, number two, of processing 
those soldiers faster so that they are not a ping-pong ball, 
being referred to the VA facility, which has happened in the 
case of some of these four brain injury centers in this 
country, then to be bounced back by saying, we cannot take care 
of you in this VA facility because you have not been processed 
out of the military.
    Now, that is just, as we have heard the word used over and 
over here, inexcusable. So what can you do and what have you 
already done to ensure that the rehabilitation and the lifelong 
care for these brain injured soldiers are initiated quickly and 
without regard to Active Duty status, where they get delayed as 
that one soldier was in this IG report for 4 months or they get 
to be a ping-pong ball because they have not been outprocessed 
by the military?
    General Schoomaker. Sir, Kevin will handle this, but let me 
just say something. Everything you describe there is totally--
number one, it is unacceptable. But number two, it is all 
feasible; there is no argument that that occurs. There are 
people that have experienced TBI, kinds of concussive events 
that do not end up with any shrapnel holes in them or bullet 
holes and they continue with duty, and many of them--and I 
think you would have to agree--do not even know they had this 
injury until later. It is like a boxer, a football player, a 
bull rider and everybody else who gets knocked in the head. 
Sometimes this stuff is--so that is one thing.
    You have the situation where we are rapidly evacuating 
people through the system and they get the very best of care 
and the medical process works perfectly. I have been to one of 
those four hospitals, the one in Tampa, the Polytrauma 
Rehabilitation Center down there, VA center, which is an 
extraordinary facility, and everybody wants people to get that 
kind of care.
    So what I guess is part of the problem we have here is the 
fact that every one of these is an individual story, that is 
what I am trying to say.
    Senator Bill Nelson. Of course the IG was not addressing 
that. The IG was addressing the deficiencies.
    General Schoomaker. Yes.
    Senator Bill Nelson. That is the question, what are you 
going to do about the deficiencies?
    General Schoomaker. The problem is that the solutions have 
to--as we try to solve these challenges, we have to solve them 
understanding that there are so many individual kinds of 
solutions that will be required.
    Senator Bill Nelson. I do not doubt that. But a soldier 
should not be a ping-pong ball----
    General Schoomaker. He should not.
    Senator Bill Nelson.--needing that rehabilitative care for 
a brain injury, and saying we cannot treat you because you are 
still on Active Duty status.
    General Schoomaker. That is right. All I am trying to say--
I am not trying to defend the system. I am saying as we move to 
solve it how we start to solve it is going to have a lot to do 
with where we end up. If we do not understand that this is a 
very complex thing and approach it with its complexity, we will 
miss the boat and come up with some generic cookie cutter 
solution that is going to disadvantage people.
    Senator Bill Nelson. What is the solution? That is what I 
am asking.
    Dr. Chu. Senator, if I may, it is exactly----
    Senator Bill Nelson. I want to hear General Kiley and then 
I will come to you, Secretary Chu.
    General Kiley. Senator, I agree with you completely in all 
these comments, and I recognized this last summer as a major 
issue that had not been addressed. I thought we were doing 
fairly well with amputee work. The mental health task force was 
coming to closure. I asked one of my senior medical leaders to 
establish a task force to look at every piece of TBI, from 
research to ongoing diagnosis to therapy to follow to long-term 
follow-up.
    Over 2 years ago or at least a year and a half ago, I put 
Active Duty ombudsmen into the four VA Polytrauma centers in an 
effort to coordinate the same kind of care soldiers coming to 
Walter Reed and Brook get at Tampa, Minnesota, Palo Alto, and 
Richmond. I was in Iraq in January and the senior medical 
leadership in Iraq informed me that they have established a TBI 
protocol over there for the practitioners.
    I think we are just recognizing the depth and extent of the 
challenges associated with these very mild but extremely 
important conditions. As the Chief has said--in fact, Senator, 
we got into a discussion about, frankly, should a TBI qualify 
for a Purple Heart. I mean, there are some criteria for that. 
This is the level of intense interest the medical community has 
in this.
    The capability to take care of an Active Duty soldier in 
the VA should be transparent to the soldier. Refer back to my 
comments about the complexity and the frustrations associated 
with taking care of soldiers. That is something that we will 
have to work out between the two Departments, I agree with you. 
Some soldiers do not want to be retired, feel like they are 
forced into retirement simply so they can get this health care. 
We have to fix that.
    Senator Bill Nelson. It ought to be transparent. But there 
is an IG report from June of last year that says it is not.
    General Kiley. Yes, sir.
    Senator Bill Nelson. So what are we going to do, Secretary 
Chu?
    Dr. Chu. We already did something and therefore I am 
puzzled by the IG's finding. I am not familiar with this 
report. I will look into it, obviously.
    [The information referred to follows:]

    In general, the Department of Veterans Affairs (VA) requires proof 
of separation to care for servicemembers, unless they are acting in the 
role of supplemental care provider. Supplemental care is a system to 
pay for care for Active Duty servicemembers when local military health 
care is not available. VA medical centers are often providers under the 
supplemental care system. In the case described in the VA Inspector 
General report, it appears that the patient should have received 
services through supplemental care either at the local VA or through 
another local provider, if these services were required and the 
servicemember was at home for convalescence after discharge from a VA 
Lead Center.
    There appeared to be some confusion on the part of the Lead Center 
staff, who apparently told the servicemember to go directly to the 
local VA medical center for care. In fact, the military medical 
treatment facility responsible for case managing (from the military 
viewpoint) the care at the Lead Center should have made arrangements 
for his local VA medical center to supply that care under the 
supplemental care program, and should have made arrangements for a 
coordinated transition of that care (from supplemental care to VA 
authorized care) upon return home and upon separation from service.
    The confusion in this case needs to be addressed, and we will do so 
as part of our larger effort to simplify and streamline current 
processes.

    Dr. Chu. Exactly for this reason, several years ago, after 
great effort by Dr. Winkenwerder and company, we signed an 
agreement with the VA that we would treat each other's patients 
on a standard reimbursement schedule. So I do not understand 
how a patient was ``refused'' because they were still Active 
Duty. We will look into it, try to understand why that 
occurred. It should not have happened, bottom line.
    Chairman Levin. Thank you.
    Thank you very much, Senator Nelson.
    Senator Collins.
    Senator Collins. Thank you.
    General Schoomaker, I received a letter from a mother in 
Portland, Maine, whose son was injured in Iraq. I want to read 
to you part of this letter because it is so disturbing to me 
because it suggests that the problems we are facing with 
military health care go far beyond one facility at Walter Reed. 
This mother writes about the horrors that her son David faced 
while trying to recover over the past few months. She says:

          ``The recently published Washington Post articles on 
        Walter Reed detail conditions and treatment that are 
        appalling. I can assure you that the issues were 
        virtually the same at Fort Hood, Texas, where my son 
        was stationed. I can also assure you that the public is 
        just starting to become aware of the problems and anger 
        is building.
          ``David had nothing but great things to say about the 
        doctors and nurses and med-evac flight crew that 
        transported him to Germany. His complaints stem largely 
        from an Army bureaucracy culturally unprepared to 
        handle the wounded and sick, an Army so desperate for 
        manpower that many NCOs are poorly suited for authority 
        and commissioned officers are fearful of being removed 
        from career tracks if they try and change the system. 
        It is also a system that wastes money daily while 
        charging wounded soldiers for the most basic of 
        needs.''

    This is a disturbing indictment because it suggests that we 
are facing far greater problems than just the physical 
conditions at Walter Reed or even the battles that soldiers are 
having trying to get disability payments. What is your reaction 
to what I just read you?
    General Schoomaker. I am disappointed that that was the 
experience, and I think that as we go down looking 
comprehensively through the thing we ought to be seeking out 
these kinds of anecdotes and find out what is the root cause of 
it.
    I will tell you that the Army has undergone more change in 
the last 4 or 5 years than it has in over a quarter of a 
century. The fact of the matter is while we are fighting a war 
we are radically changing not only the culture, but the 
organization and the doctrine and everything else that we are 
doing. So I would tell you that change is very much part of our 
culture right now.
    But nevertheless, these kinds of anecdotes are 
extraordinarily disappointing. They should be pursued. We 
should find out what the problem is and make sure that they are 
not perpetuated for more people.
    Senator Collins. I guess what troubles me is this mother's 
conclusion that there is an Army bureaucracy culturally 
unprepared to handle wounded and sick soldiers. That suggests 
that we need to do way more than remove molds or repair a roof. 
I wonder if we should take a look at the entire way that we are 
delivering health care in the VA system and in our military 
system. I am not sure that that is the answer, but I was 
thinking this morning about the fact that the GI bill is 
unanimously acclaimed. It has been very successful. It 
essentially gives a voucher to a retired soldier to pursue his 
education. That contrasts with the VA system and the military 
system we have. We are trying to do better with community-based 
clinics, but I still have World War II elderly veterans 
traveling 5 hours to get to the one VA hospital in Maine.
    Should we take a look at our VA and military health care 
system and consider a whole different approach of delivering 
services?
    General Schoomaker. Ma'am, I think that--and I will just 
give you my opinion, but I want to throw a caution out here. 
The military health care system in this country is the best in 
the world. There is no other country in the world that has it. 
Every one of our allies are looking at us and are--``jealous'' 
is not the right word; or ``desirous''--but they really like 
what they see.
    For instance, my British counterpart. The British have no 
corresponding system. They have military wings in civilian 
hospitals. They are very critical of what they are going 
through by going to commercial initiatives on these kinds of 
things, and they have virtually no follow-up in the manner that 
we are talking about right here.
    So with all our warts, we better be careful that we do not 
really damage what is an extraordinary system that has 
problems. We need to correct the problems.
    Dr. Winkenwerder. If I might add as well, Senator.
    Senator Collins. Yes, doctor.
    Dr. Winkenwerder. I would echo General Schoomaker's 
remarks. There are so many areas in which the system broadly is 
working very, very well. The TRICARE health plan is one of the 
top-rated plans. We know that, consistent increased 
satisfaction. Things work. Battlefield medicine works. Acute 
care works. Outpatient care across the board tends to work 
well.
    But the issue, if I can hone it in to where I think, to 
answer your question where is the problem or problems, it is 
those who have been injured and wounded after their acute care 
in this phase, the seam, the transition, and the disability 
determination process and the coordination, at that point, 
which is critical because those individuals deserve our very 
best. That is where our focus should be, I believe, because so 
many other things are working well.
    The other thing I would say is that we have great capacity 
in this TRICARE network. We have the ability for any of our 
Active Duty and our retirees to see over 240,000 physicians 
across the United States, that network, in nearly every 
civilian hospital.
    So there is a lot of capacity in this system. I am not sure 
we have used it properly between that and the jointness. We 
have not talked today about using Air Force, using Navy when 
Army is overstressed, and that has happened in the theater. The 
Blalad facility is staffed by the Air Force, so we have to 
think better about how to manage those resources.
    Senator Collins. We do. But there is clearly a problem. 
These are not isolated stories or anecdotes. There is a pattern 
here of very good care on the battlefield and inpatient and 
then it seems to fall apart after that. I think we have to 
remember that these in many cases are soldiers who are going to 
have life-long problems as a result of the injuries. So the 
aftercare is as important.
    General Kiley, I want to bring up a comment that you are 
reported to have said at the House hearing yesterday because I 
really found it disturbing, assuming you were quoted correctly. 
You were asked why you were unaware of the living conditions 
across the street from your own home and according to the paper 
you replied: ``I don't do barrack inspections at Walter Reed.''
    I must say that I found that to be a stunning and troubling 
response. The maxim of the military has always been that you 
get what you inspect, not what you expect. I realize that you 
personally do not go and do barracks inspections, but you are 
responsible for ensuring that they--or you were responsible for 
ensuring that they do get done. I just would like to hear 
further from you because it struck me as such a disclaiming of 
responsibility that it was enormously troubling.
    General Kiley. I am sorry if I misled anyone in that 
hearing. It was not my intent to somehow shed responsibility 
for that. What I was attempting to explain, and I did not do a 
very good job of it, was that, consistent with the chain of 
command, there are company commanders and first sergeants, 
colonels and a general on the post whose primary responsibility 
is to inspect barracks. I would inspect barracks. I have 
inspected barracks. I understand that is part of command 
responsibility and accountability. Just as we have talked 
earlier, barracks inspection, the health and wellness of 
soldiers is critically important.
    I only meant by the comment, because it was pointed out 
that I live right across the street and somehow that I should 
have been inspecting, it was not that I would not inspect it if 
someone came to me, particularly General Weightman, and said, 
you need to go see these, or if somehow talking to a soldier it 
came to my attention that there were mold or rats or problems 
in the barracks. I would have been right over there looking at 
it. I certainly would have alerted the chain of command that I 
was going to look at it.
    I do apologize if I misled you or misled anybody on that. I 
simply was attempting to articulate the concept of the chain of 
command and authority in the sense that commanders have 
responsibilities. In this case I obviously did not check enough 
on what was going on at Walter Reed. But I do inspect barracks. 
I have inspected barracks. I inspect hospitals. I visit 
hospitals and walk through hospitals. I visit new medical 
facilities that we are building as part of our Army 
transformation.
    Senator Collins. Thank you.
    Chairman Levin. Thank you very much, Senator Collins.
    Senator Ben Nelson has very generously agreed to switch 
places with Senator McCaskill, so that the order now on this 
side will be Senators McCaskill, Clinton, and then Ben Nelson.
    Senator McCaskill.
    Senator McCaskill. Thank you, Mr. Chairman, and thank you, 
Senator Nelson, very much.
    General Kiley, you just referenced, in response to Senator 
Collins's questions, about the chain of command. But you are in 
fact responsible for the culture of command within the MEDCOM 
of the United States Army, is that not correct?
    General Kiley. Yes, ma'am.
    Senator McCaskill. I am here today to try to--and what I am 
going to say is going to make probably some uncomfortable and 
it is going to be awkward, but I think it has to be said about 
your command of the MEDCOM unit. I would like to speak on 
behalf of a sergeant from Missouri who is at Walter Reed. He 
has been there since he lost both of his legs on the 
battlefield 10 months ago. I had the opportunity to meet him 
when I went to Walter Reed and spent 3 hours last week.
    I have tried to communicate with him since then. At 8 
o'clock last night he sent me an e-mail and I would like to 
read what this sergeant said:

          ``General Kiley had the opportunity during his time 
        as Walter Reed commander to identify and begin 
        correcting the issues that were evident. Rather than 
        addressing those issues, General Kiley simply swept 
        them under the rug. General Kiley received more avenues 
        to dispose of the issues once he was appointed as the 
        Army Surgeon General. However, rather than addressing 
        the problems he was more aware of than anyone, he 
        continued to downplay and minimize the issues.
          ``We as injured veterans and those family members who 
        depend on military medical facilities deserve nothing 
        less than the resignation of General Kiley.''

    The question becomes, General, what did you know and when 
did you know it? In late spring 2003, the Veterans for America 
had a meeting with you and outlined their concerns about what 
was going on at Walter Reed. Specifically, they talked about 
people in barracks are drinking themselves to death and people 
who are sharing drugs and people not getting the care they 
need.
    February 17, 2005, you sat in on a congressional hearing 
where the following testimony was given: ``Soldiers go months 
without pay, nowhere to live, their medical appointments 
cancelled. The result is massive stress and mental pain, 
causing further harm. It would be very easy to correct the 
situation if the command element supported it. The command 
staff at Walter Reed needs to show their care.''
    This was testimony by Sergeant First Class John Allen, who 
was wounded in Afghanistan, who said ``Walter Reed has a 
dysfuntional system.''
    On December 20, 2006, a board that you co-chair, the DOD 
Mental Health Task Force, once again you heard testimony 
concerning the systemic problems of outpatient care at Walter 
Reed.
    The problems of the bureaucracy have been referenced in 
your testimony today. In fact, the entire panel has referenced 
the problems of bureaucracy. General Kiley, you are a 
professional, not a bureaucrat. My question to you is, do you 
have the authority as the commander of the MEDCOM in the United 
States Army? Do you not have the authority to fix the 
bureaucracy?
    General Kiley. In terms of your question about fixing the 
bureaucracy of med holdover, yes, I do have the authority to 
fix communications and infrastructure. As it relates to the 
member of the MEB process inside Army regulations and 
particularly the PEB process, its adversarial role and the 
resulting sense of despair among soldiers, I individually do 
not have authority to change that, but I am bound to work with 
the rest of the Department of the Army, particularly the 
personnel community, to fix that.
    We recognized some of that in the summer of 2003 and held a 
task force, a summit, with the Army personnel community and the 
Adjutant General to begin to address some of the issues that we 
were seeing in spring 2003 after our ground operations in Iraq 
began.
    I have listened to Mr. Robinson's brief as part of the 
Mental Health Task Force brief in terms of his presentation 
along with members of his organization. I do not remember 
meeting him in 2003, but we were aware of and became aware 
through my own counselors and my own chain of command whom I 
met with, if not weekly, twice a month, to address issues of 
med holdover when I was the hospital commander at Walter Reed.
    Clearly, some of these challenges are complex. They are 
buried in Army regulations. They are buried in DOD 
Instructions. Again, I reference the complexity, the injuries 
we were seeing, and the growing number of them. It was a source 
of frustration for me as the Walter Reed commander that it 
seemed every day we had new issues that we had to address. We 
were anticipating as best we could. But the staff worked hard. 
We paid very close attention to the soldiers' needs. We 
instituted soldier lounges where the soldiers could sit and 
watch games, et cetera.
    I do not think I was passive in command at Walter Reed. But 
obviously, as the commander of MEDCOM we sit here today because 
of my failure to anticipate and correct these things before 
they happen.
    Senator McCaskill. I am just concerned that General 
Weightman was relieved and the Secretary of the Army was 
relieved, and it appears to me that you are in fact the 
commander that was in the position to know the most and be in 
the position to do the most about it. In fact, in your 
testimony I am concerned, General, because on page 8 it is 
almost like you still continue to try to diminish the severity 
of this problem and the fact that it is systemic and that there 
is so much work that needs to be done.
    You say: ``Soldiers and family members in January''--this 
is your testimony today. ``Soldiers and family members in 
January 2007 indicated that less than 3 percent of the 
outpatient soldier population voiced complaints about the 
administrative process.'' It would be hard to walk through 
outpatient at Walter Reed and talk to soldiers and not confront 
a complaint in terms of the bureaucracy and the problems. The 
fact that you want to point out that there were only 3 percent, 
is that not more a reflection--you do not really believe that 
only 3 percent of the outpatients had complaints, do you?
    General Kiley. I think that was General Weightman's 
testimony, Senator, not mine. But what that came from----
    Senator McCaskill. This is your statement that I just read 
you provided to the committee today.
    General Kiley. Yes, ma'am. In the discussions, I was 
referencing the discussions yesterday. What we did in response 
to our concerns about families and the issues with families was 
to begin surveys of soldiers as to what their issues and 
concerns were. We have not gotten back all the surveys. We 
continue to do surveys.
    There is another way to pulse the system to see if we can 
find issues and problems. My understanding as I sit here today 
was that the ratings on the case managers were very good, the 
ratings for the doctors were very good, but we had a whole list 
of issues that soldiers had about the bureaucracy, sometimes 
inpatient, often outpatient.
    Senator McCaskill. On the sergeant that I have been 
visiting with who, as I said, is a double amputee, he indicated 
also problems with the electronics system, and I want to 
briefly bring that up. As he says, on any computer in the world 
he can bring up his enlistment contract, all of his award 
recommendations and commendations, even his counseling 
statements and evaluation that he received during his time in 
the military. This can be sent ahead of a soldier that is 
permanent change of station (PCS)'ing, somebody who is changing 
their station--for people who do not understand--their 
permanent station, so the receiving unit knows the caliber of 
the soldier they are receiving.
    Why cannot that same technology be used to expedite the 
MEB-PEB process? Why is that not a problem that has been 
identified by your command and fixed while you have been in 
charge of this part of the Army?
    General Kiley. I do believe that that is one of the things 
that we want to look at through our iterative analysis of the 
medical board process, is how can we better computerize this 
program and pass it to the PEB. I agree with you. Why we cannot 
do that, I do not know the answer why we do not have that in 
place now.
    Senator McCaskill. Ultimately, the culture of command is 
incredibly important here. It is incredibly important in terms 
of how people feel about complaining and whether they think 
their complaints are going to go anywhere. I must respectfully 
say, General Kiley, I think that belongs at your doorstep.
    Thank you very much, Mr. Chairman.
    Chairman Levin. Thank you, Senator McCaskill.
    Senator Chambliss.
    Senator Chambliss. Thank you very much, Mr. Chairman.
    General Schoomaker, as you wind down your career I want to 
join the sentiments of everybody up here. Thanks for your 
service to our country.
    There is another General Schoomaker who is going to be 
coming to Walter Reed as our new commander there. General Eric 
Schoomaker happens to be somebody that I know very well, having 
served at Eisenhower Medical Center at Fort Gordon. He is a 
good soldier, a good outstanding physician, a good 
administrator, and I have every confidence that he is going to 
be able to address the situation at Walter Reed as we move 
forward.
    Gentlemen, a failure on the battlefield brings disastrous 
results. Here we are seeing a failure off the battlefield that 
brought about disastrous results that none of us are happy 
about, obviously, including you. This is not the first time 
this has happened. In 2003, we had a very similar situation 
that took place in Fort Stewart, Georgia, with our Iraq Walter 
Reed veterans as the Guard and Reserve soldiers in the medical 
holdover unit were waiting months for follow-up treatment and 
the facilities and the living conditions which those men and 
women were put in were horrible.
    At the time, although we were horrified at how our heroes 
were being treated, the Army was very responsive and 
implemented immediate changes at Fort Stewart. In fact, the 
Army staff and the Pentagon assured us, and I quote: ``What we 
learned from this incident is going to help the Army when we 
have other major units returning from Operation Iraqi 
Freedom.''
    Given this response, the Army's recognition of the problem, 
and the commitment from the Army at its highest levels, and 
even the implementation of new policy from then-Acting 
Secretary of the Army Les Brownlee, I have to wonder what the 
Army actually did learn and take away from the situation at 
Fort Stewart. Basically, it concerns me greatly and it should 
concern all of you that we have seen this problem before and 
apparently we did not learn enough from it to stay ahead of the 
issue.
    In relation to the issues that came up in Fort Stewart in 
2003, can you share what were the lessons learned there and how 
and who were they shared with, and who were the take-aways 
communicated to, and what changes were actually implemented? 
Dr. Chu, let us start with you.
    Dr. Chu. Let me start with an issue General Schoomaker has 
already addressed, which is the adequacy of our housing 
facilities for our personnel. I think one of the important 
issues at Fort Stewart was that with the mobilization of 
significant numbers of Reserve personnel, the higher training 
needs for this conflict, we needed more and better housing 
facilities.
    The Department had already embarked on a course of action 
to improve those facilities before the Fort Stewart concerns 
were raised. That was one of the hallmarks of his initial 
decisions as President, the President's decision to direct the 
Department to do so. We have put substantial money into it, but 
I am with General Schoomaker. It is not a problem, 
unfortunately, and I think this is ultimately the source of the 
Building 18 immediate issue, that can be rectified overnight. 
There is a limit to how fast you can do this.
    We have made enormous progress in both family housing and 
barracks housing. We have been spending a billion dollars a 
year or so on barracks housing in the Department during the 
course of this administration. Have we caught up in all areas? 
No, sir. Are we committed to catching up in all these areas? 
Yes, sir. But it is a major challenge to take the Department, 
which had not invested, I regret to say, in earlier decades in 
the housing stock the way it should have, to get to the right 
place.
    Now, in the short run--and one of the earlier questions 
dealt with this. In the short run, it has been complicated by 
the commotion over--Senator Inhofe raised this question--the 
MILCON appropriation for fiscal 2007. I am very hopeful we can 
get that straightened out because that is indicative of how we 
do fall short. As one of the other questions emphasized, when 
we do not get the funding you cannot execute. So it is 
important to keep that funding train, the BRAC funding train, 
on track, if not, as Senator Warner suggested, accelerating 
somewhat.
    I think the major lesson, one of the major lessons that 
came out of Fort Stewart, was this question of the adequacy of 
our billeting for our troops across the board. We did not have 
enough for the expanded operations today. We have put money 
into that. It does take time. It was not all done in 1 year and 
there are still issues to be addressed.
    Senator Chambliss. Anybody else care to comment?
    General Schoomaker. Sir, I will comment because the Fort 
Stewart situation was one of the first things that confronted 
me when I was brought back into the Army. It was one of the 
first challenges I had. I went down there and visited. The 
lessons learned from Fort Stewart were many. There were over 
600 soldiers down there in the Fort Stewart deal. The reality 
is is that was a mobilization issue. Very few of those soldiers 
had deployed and been injured. In fact, I think something like 
14, or less than 20 anyway.
    Nevertheless, we have a responsibility once bringing 
soldiers on Active Duty to correct and to return them 
corrected. So it is a different issue in many respects, yet the 
same issue in terms of the administration--the housing, the 
chain of command, the administration of medicine and the MEB/
PEB process and all the rest of it. What we largely learned was 
to mobilize soldiers and prepare them with their pre-
mobilization training, medical readiness, et cetera, before we 
mobilize them and brought them on Active Duty. That was one of 
the big lessons.
    We obviously learned a lesson in chain of command. We 
learned a lesson in having adequate housing and capacity, et 
cetera. The problem that we are dealing with here on the back 
side of this is an additive problem, and that is many of these 
soldiers that we are now dealing with have very serious war 
wounds, multiple wounds, all of the issues we have heard on TBI 
and PTSD, and all the rest of that. That complicates it 
enormously as this process arbitrates it. So it magnifies way 
over what Fort Stewart was the challenge that faces us here to 
do right by these soldiers.
    Nothing I have said is an excuse. It is that this is by far 
a more complex problem that we are facing here than Fort 
Stewart was. So Fort Stewart did not have all of the answers to 
the dilemma that we face today. No excuse for either one of 
them.
    Senator Chambliss. General Kiley, in your testimony you 
talk about the fact that between 2001 and 2005 more than 
$400,000 in renovations were made to this Building 18. In 2005 
$269,000 in renovations were made. Who made the decision to 
spend that money on Building 18?
    General Kiley. Sir, I believe my predecessor at Walter Reed 
made a decision in 2001 to do some renovation. While I was the 
commander, the numbers that I remember--I was reminded that we 
put $40,000 into the building for new carpets and curtains.
    Then in 2005, I believe General Farmer made the decision to 
do a major renovation at the $260,000.
    Senator Chambliss. During the process of your making the 
decision to spend money on this building, did you go in that 
building?
    General Kiley. No, sir.
    Senator Chambliss. Did you know what you were spending the 
money on at the time?
    General Kiley. Yes, sir. That was not a patient billet in 
my command. It was a standard barracks. The commander came to 
me and said: Look, we could use a little bit of help in 
Building 18; I have some student detachment soldiers over there 
and I would like some money to replace the carpets and the 
curtains. I do not remember the specific conversation, but I 
approved the money.
    In retrospect, would it have been good to go over and take 
a look? Certainly. Certainly, now with what we have seen, I 
erred in not doing that. But I trusted my colonel commander and 
the garrison commander that that is what it needed.
    Senator Chambliss. Who made the decision to convert this 
into a building to house patients?
    General Kiley. Sir, it is my understanding that General 
Farmer made the decision to do that, because of the load of 
soldiers that he was having to care for.
    Senator Chambliss. Is it standard operating procedure to 
make a decision like that without examining the building? Is 
that part of the bureaucracy issue that we are talking about?
    General Kiley. No, sir, I do not believe that is true. I 
honestly do not know whether General Farmer examined that 
building before he made the decision with his chain of command. 
I certainly think that part of our error and certainly my error 
in counseling my commanders, I clearly failed in this regard, 
is in anywhere that we are putting patients, soldier patients, 
despite the fact that we have worked very hard on that from day 
1 at Fort Stewart until a couple of weeks ago when the papers 
revealed our shortfalls, that patient care and patient 
billeting areas should have the highest priority.
    That was part of the problem we found with Building 18, and 
I failed in that regard.
    Senator Chambliss. Thank you, Mr. Chairman.
    Chairman Levin. Senator Clinton is next. There is a vote 
on. We are going to work right through this vote. Senator 
Clinton, when your time is up will you recognize the next 
Senator in order. You will be given that list. I will try to 
get back here in about 10 minutes. If no one is here, could you 
just recess it until one of us returns.
    Senator Clinton. Yes, sir.
    Chairman Levin. Thank you.
    Senator Clinton. Obviously we are here today because we are 
all distressed by the problems that are facing our wounded 
soldiers. I think we all agree that these men and women are the 
best we have and they deserve a lot better from our government 
and our country.
    I have tried to focus in on the needs and treatment of our 
wounded and sick soldiers, and over the last 2 years I was 
disturbed by reports about pay problems that wounded soldiers 
were confronting and had an amendment accepted in the last 
year's DOD authorization bill. My office was recently briefed 
on the result of a study that I commissioned in that amendment, 
an audit that found that 24 percent of wounded soldiers 
requiring inpatient care had underpayments. That is, they were 
not paid on time.
    The Army I know is working to fix the problem, but the 
number is still too high. Now we have learned that wounded 
soldiers are living in substandard conditions, trapped in 
bureaucratic red tape. This is just the latest incident. If all 
we were here to talk about would be the problems in Building 18 
and the other problems that have emerged, not only at Walter 
Reed but other of our facilities, that would be disturbing 
enough. But there is a pattern here that somehow we are just 
not focused on what needs to be done to help these young men 
and women.
    I am deeply concerned that the problems they are 
confronting could be, frankly, overlooked again if we just 
focus on who made what decision to put in new carpeting in 
Building 18 and what else needs to be done. This is a systemic 
problem.
    When I was out at Walter Reed on Friday I had an 
opportunity to visit with a number of our wounded and sick 
soldiers from New York, as well as seeing Building 18 for 
myself. One of the common denominators of the complaints I 
heard remains the disjointed and unfair MEB/PEB process, the 
untrained and overworked PEB liaison officers, the various 
stops along the process, the lack of legal counsel during 
appeals, the prolonged period either to start or complete the 
process.
    We have already heard about the disconnect between the VA 
schedule for rating disabilities that does not adequately 
address the current nature of wounds like TBI and PTSD and 
amputations and hearing loss and diseases. In the audience is 
Steve Robinson. He and I worked together a couple of years ago 
in trying to get a pre- and post-deployment physical exam done 
so that we could actually tell what was the condition of a 
soldier before being deployed and the condition of that soldier 
when he returned. One of the things we could not get through 
was a mental exam assessment before someone was deployed.
    We are now hearing that people who are reporting with TBI 
and PTSD are being told it was a preexisting condition. If the 
proposal that I had made and that others had lobbied before had 
been accepted we might have a baseline to figure out what 
actually happened to these young men and women during their 
deployments.
    The problem that I heard over and over again is a 
perception that Walter Reed was concerned with releasing 
soldiers from Active Duty at a greatly reduced disability 
benefit level, as quickly as possible, a lump sum solution, 
cheaper than a lifetime of financial retirement care.
    I have a number of soldiers whose specific cases I would 
like to present to you and to get your response to. A 
specialist from Grand Island, New York, appealing his PEB 
disability benefit rating of 20 percent, has chronic pain 
conditions and without medical retirement will not qualify for 
lifetime insurance. The pain condition is debilitating. He does 
not believe that is being taken into consideration.
    Here is the dilemma he faces today. He has been offered a 
new treatment, but if he accepts the new medical treatment he 
loses his opportunity to appeal. If he proceeds with his 
appeal, he loses his opportunity for the new medical treatment. 
There is just something wrong with that kind of Hobson's choice 
to present to this young specialist.
    A major from Manhattan. He was injured in Operation 
Enduring Freedom in 2001, but stayed on Active Duty, deferred 
treatment until finally he could not, and now he has been at 
Walter Reed for 26 months. He did not feel he was being well 
taken care of at Walter Reed, so he sought treatment at 
Bethesda, where he was able to appeal the Walter Reed prognosis 
and receive the surgery his injury required.
    He began the MEB process in December 2006, but has not been 
able to meet with his liaison officer because she cancelled his 
first four appointments and now is too busy to meet with him. 
He is trying to get legal assistance. His requests have gone 
unanswered.
    Finally, a staff sergeant from the Bronx, also appealing a 
PEB disability percentage, because he believes that the case 
mis-evaluated his pain and did not give him a high enough 
return. When he met with me, he denied himself his medication 
so that he could meet with me and feel like he was in full 
control of his faculties, and it was totally evident to me that 
he was suffering from pain on an ongoing basis.
    So it is really important that we take on this MEB and PEB 
process. But again, I think we have to do more to try to clean 
up the system now. I know we have to approach the longer term 
problems, but it does strike me as totally unacceptable that, 
according to press reports, there are three lawyers and one 
paralegal to handle a 750-case caseload to deal with these PEB 
appeals.
    General Schoomaker, we have over 4,000 Judge Advocate 
General (JAG) lawyers in the Active, Reserve, and National 
Guard of the Army. Can we please get some help to try to clean 
up this backlog and get people some legal assistance as they 
are trying to go through this process?
    General Schoomaker. We are going to gang-tackle that out 
there. I am not familiar with the numbers you just said.
    General Kiley. I agree with the Senator that we have to get 
this stuff fixed. I agree with the Chief; we are going to take 
that on. This is my reference earlier. There are things or 
actions we can take--more JAG officers, more caseworkers. I do 
think that the first case, the young soldier with the 20 
percent disability, Senator, does not rise to the 30 percent 
which is the medical retirement. Frankly, it is not the fault 
of the doctors or the case managers and it is not the fault of 
the people in the PEB who are just being stingy with the 
dollars. It is more based on what our regulations and our 
policies have in place.
    To me, even if it is a temporary medical retirement until 
the soldier heals up more, I think we should be much more 
aggressive in recognizing that. The VA is very quick to 
recognize the whole man or woman and reimburse at a much higher 
rate. But as we have said earlier, that does not get you the 
medical retirement, it does not get you the care for your 
children and your spouse. There is clearly a financial impact 
over the long haul to the Department and to both Departments in 
terms of that. But I think it is the right thing to do.
    The individual obstacles about getting appointments, et 
cetera, we are taking that on right now, as the Chief has said.
    Senator Clinton. Obviously we need, as General Schoomaker 
often does very memorably say, to gang-tackle this problem and 
let us try to get it on a faster track. Obviously, we have 
systemic problems.
    I just want to end with two additional points because I am 
going to have to recess and go vote. Or maybe, Senator Dole, 
can you go next?
    Senator Dole. Yes.
    Senator Clinton. Let me just conclude by saying, number 
one, I am deeply concerned about the impact that the BRAC 
Commission order had on Walter Reed. It was I believe 
demoralizing. I do not know that we can put an exact frame 
around what did not happen because people were either of the 
opinion that they were going out of business in a few years 
anyway or they were pulled off of caring for patients and 
dealing with the important issues right in front of them 
because they were involved in planning for the eventual end of 
Walter Reed. I really hope--and I told Secretary Gates this--
you got to take a look at this. I do not have an answer for it, 
but I think it has undermined an already fragile system.
    Finally, these independent contractors. It is a problem. 
Our government is outsourcing important services to people who 
we are not accountable for. This idea that yet again 
Halliburton, and it raises its head by being a former 
Halliburton official who got a contract to do in-house 
maintenance at Walter Reed--I tell you, folks, this has to end. 
Somebody has to be responsible, and all this contracting out of 
the important work that we are doing and then we try to turn 
around and find out who in the chain of command is responsible. 
Well, let us start by making it clear that we are just not 
going to turn over important jobs to people that we are not 
directly responsible for.
    So with that, I am going to have to run to vote. But I am 
going to leave it in the good hands of my friend and colleague, 
Senator Dole. I want to commend your husband, Senator Dole. 
Former Senator Dole and Secretary Shalala are going to be 
heading up this commission and I think the President has made a 
very good choice of the two to do that.
    Senator Dole. Thank you very much. I agree with what you 
just said.
    Gentlemen, we know that Walter Reed has a reputation for 
providing world class care for our wounded soldiers. Doctors, 
nurses, and other medical personnel at Walter Reed provide 
extraordinary care to the servicemembers at this facility. It 
is this excellent reputation that makes these recent 
revelations all the more appalling. I have to believe that a 
profound failure of leadership at many levels is responsible 
for these deplorable conditions.
    Everyone from the top down, from the people overseeing 
Walter Reed to the nurses aides, must above all else think 
first of the patient. If that concern is compromised, even the 
best facility in the world can quickly become cold and 
inhospitable, potentially undermining the quality of care.
    This committee has the responsibility to our servicemembers 
and to their loved ones to thoroughly examine what has happened 
at Walter Reed and to ensure that every mistake is corrected 
and every wrong is made right, so that our Nation's heroes are 
always treated with the dignity and care they so richly 
deserve.
    General Schoomaker, let me ask you, how do we go about 
selecting our senior leaders to command at institutions such as 
Walter Reed? Have we been doing something wrong? Are there ways 
in which the selection process can be improved?
    General Schoomaker. I think the ways in which leaders are 
grown and developed is very complex. There is actually training 
and education, et cetera, that goes into all that. But there is 
also statutory board processes that select people for promotion 
under the law. When you get to positions, commander positions, 
we have boards of officers that sit and look at people's 
credentials. Obviously, in the case of medical credentials, the 
Surgeon General is involved in that, and we select people based 
upon not only their specialty, but based on the 
responsibilities, the broader commandership, leadership, and 
demonstrated performance previously.
    It is one of the most important responsibilities we have. 
We call it growing the bench. We selected a new commander at 
Walter Reed who happens to be my brother.
    Senator Dole. Right.
    General Schoomaker. You need to know that I recused myself 
from that process, rightfully so, and allowed the proper people 
to look at who was best out of who was available.
    By the way, everybody was available out there. This was not 
just who is closest and we can grab by the shirt sleeve, but 
taking a look across the whole inventory of people that could 
help solve this problem. In this case, Major General Eric 
Schoomaker ended up being the one that surfaced, which I agree 
was a very good choice.
    So I tell you, I think leader development is one of the 
most important responsibilities we have. You can see what 
happens when we have a failure in these systems and why it is 
so important that we reinforce the chain of command and hold 
people accountable and do the things we have to do. These are 
very, very complex commands we are talking about.
    Senator Dole. General Schoomaker, General Matthew Ridgway 
in his history of the Korean War observed that there is never a 
shortage of physical courage on the battlefield, but that there 
is often an absence of moral courage when and where it is 
needed most. I cannot help but conclude that we confront a 
similar situation today.
    Do you believe that we are observing an instance of leaders 
failing to speak up because they believe they must operate 
within a fixed top-line budget?
    General Schoomaker. No, I do not. I believe that obviously 
that is a factor, but I believe in this case there is just a 
failure in performing their duties and to ask the right 
questions, look in the right places, and to take the right 
kinds of action based on what they saw. I think that is what 
this is.
    I also think it is an extraordinarily complex system that 
they are having to deal with. If you think about what the 
commander at Walter Reed has to deal with, it is not just the 
administration of this very complex process we are talking 
about, but he is running a small city. He is concerned with the 
health and welfare of all the people that are there, the 
scheduling and the patients and all of the things that go on, 
the physical security and maintenance--very, very complex.
    So the financial aspect is an important factor, but there 
is no reason, there was no financial impediment to do what was 
right here. We, as I said upfront, have been spending hundreds 
of millions of dollars correcting inadequate barracks, 
inadequate conditions in all of the rest across the Army, and 
we certainly should have not had them at Walter Reed.
    Senator Dole. Thank you.
    Mr. Chairman, I understand I am going to miss the vote if I 
do not leave immediately, so thank you very much.
    Chairman Levin. Thank you, Senator Dole.
    Senator Ben Nelson. Again, our thanks to you, Senator 
Nelson, for your accommodation.
    Senator Ben Nelson. Thank you. Thank you, Mr. Chairman. I 
want to thank the panelists for being here today as well.
    General Kiley, to be in charge of a hospital, in many cases 
it is the person who has an MBA or a hospital administrator's 
experience or management experience that is used as a base for 
determination of somebody who would be qualified to run a 
hospital. This is not pejorative. It is just an inquiry. Do you 
have an experience like that, an education in hospital 
administration, or any particular qualifications other than 
your rank, which I am not going to challenge?
    General Kiley. I do not have an MBA in hospital 
administration, Senator. My experience in a series of positions 
inside the Army medical department over the last 20 years, 
really longer, both as a practicing physician and as a senior 
executive inside the Fort Bragg Medical Center, and then as a 
hospital commander at Landstuhl from 1994 to 1997 I would say 
or characterize prepared me for further assignments, to include 
command at Walter Reed and the North Atlantic Regional Command.
    We have a system, as the Chief has referenced, of leader 
development inside the Army medical department. It is not just 
doctors that command hospitals. We have had, we have nurses 
commanding, medical service corps, medical specialist corps. We 
have had a nurse, Major General Pollock, commanding at Tripler, 
and Brigadier General Rubenstein commanded Landstuhl as a 
medical service corps officer. We are seeing a nurse command 
Landstuhl.
    I am very comfortable that the system leader develops our 
officers of all corps. Now, dentists do not command hospitals 
because they command dental, and the veterinarians do not 
command because they command veterinarians.
    There is one small point that is not a small point, and I 
think General Schoomaker referenced this, that unlike the 
civilian community, a hospital commander is more than just a 
manager or leader; he is a commander or she is a commander. 
There is part of understanding what command is about, 
accountability for command, executing the mission, completing 
the mission, being held accountable morally, physically, 
ethically for your performance. Not that they do not do that in 
the civilian, but there is real authority vested in commanders 
that I do not know that there is necessarily a counterpart in 
the civilian. That is also part of the career development and 
the leader development inside the Army medical department. We 
certainly have courses--CGSC that we now have, it is called. It 
has changed its name. We have the War College. We have courses 
in medical administration. We do have officers who have gotten 
advanced degrees in hospital administration. We have the Baylor 
program which graduates classes every year.
    Senator Ben Nelson. Do you think that having some specific 
education, specific experience in information technology might 
have led to finding a solution to the problems of the 
bureaucracy and particularly the paperwork? I have heard of 22 
forms that had to be filled out with 8 different commands, to 
the point where a staff sergeant, after moving to outpatient 
status, had appointments for 2 weeks and nothing. ``I thought, 
should they not contact me? I did not understand the paperwork. 
I would start calling phone numbers, asking if I had 
appointments. I finally ran across someone who said: I am your 
case manager; where have you been?''
    That is a combination of a lack of coordination of the care 
command and the garrison command, as well as the paperwork. 
Would information technology help in that area?
    General Kiley. Yes, sir, it would. We have evolved an 
electronic medical record inside not only the Army medical 
department, but the entire MHS, that we call ALTA. It is not 
complete yet. There are parts and pieces of it, as they say, 
that still need to be developed. It is a very big and complex, 
privacy protected program that is worldwide. That is part of 
the solution.
    Moving the MEB and PEB process to a totally paperless 
process would improve it. But if we still have 22 forms that 
have to be filled out electronically, that is still 22 forms 
that need to be filled out.
    Senator Ben Nelson. Or fill out one and transfer it to 20 
different locations.
    General Kiley. Yes, sir, but it is about 20 different forms 
with potentially 20 different pieces of information on it. It 
is very cumbersome, and we want to challenge the complexity of 
that.
    Senator Ben Nelson. Secretary Chu, I have the American 
Legion coming in today, the VFW coming in today, the Nebraska 
Veterans Home Administrators coming in today, and the VFW 
coming in tomorrow. What should I tell them?
    Dr. Chu. I think you should tell them that we are committed 
to correcting the shortcomings here, we are committed to 
looking at the fundamentals of the system, and that we are and 
we will get on top of the issues that have been raised.
    Senator Ben Nelson. Can I tell them that we are going to 
work toward seamless care and seamless transfer from Active 
Duty status to the veterans care, so that we do not have people 
stranded somewhere in between or trying to choose which one 
works better for them?
    Dr. Chu. Absolutely. We have made, I think as you are 
aware, significant progress on that score in the last several 
years. We have a system now which alerts the VA, particularly 
when someone is going to go on the temporary disability 
retirement list, that this patient is coming so they can begin 
the reception process and so that there is not a seam in the 
process.
    We have sent several million records electronically to the 
VA in the last several years so that they have that evidentiary 
base. A much stronger relationship I would argue, sir, between 
the two agencies now than there was 5 or 6 years ago.
    Senator Ben Nelson. As much as we commend, and I think we 
should commend, the inpatient care, the acute care facilities, 
and the care that the soldiers get is outstanding and second to 
none, and the care that is provided by the caregivers, whether 
it is the physicians or the nurses or the other personnel and 
staff, is outstanding. But it does break down, as we have 
talked, about outpatients. It is not just the outpatients that 
have been there on the campus or across the street from Walter 
Reed. People get stranded when they are sent home.
    I met with, a little over a year ago, a soldier, a wounded 
soldier in Nebraska who was sent home with floating ribs and 
the kind of care that was going to require somebody who had--a 
bone surgeon, it was going to have to have something in the 
orthopedics. The follow-on care was so inadequate that when I 
met with that patient and her parents that they had not been 
able to get calls back, they had not been able to get referred 
to a physician in Nebraska in the middle part of the State, 200 
miles from Offutt with the hospital and care that might be 
available there.
    I just picked up the phone and called the nurse at Walter 
Reed who was assigned to this patient. This nurse was 
apparently very overworked and asked me why I was butting in. I 
got to thinking, if a United States Senator has trouble trying 
to cut through the bureaucracy, why would you not expect the 
average family might have a very serious problem cutting 
through that follow-on care, that aftercare, when somebody is 
sent home to convalesce, as you said, General Kiley, the 
healing process.
    Well, this healing process I think was interrupted by the 
lack of follow-on care. Fortunately, by the end of that day we 
were able to get an orthopedic physician assigned to that 
patient, that hero, that wounded soldier, who was otherwise 
unable to get it done.
    We are going to have to do a great deal more to make sure 
that the follow-on care, the aftercare, because there is a 
stranding that can go on once they are that far away from 
Walter Reed or from wherever the facility is.
    So I guess, Dr. Chu, can I tell them that we are going to 
do a better job for follow-on care and follow-up care and to 
make sure that the aftercare that they get is first rate just 
like the acute care that they get at the hospital?
    Dr. Chu. Yes, sir. If I could reiterate, that is one of the 
reasons we created this military severely injured center, as a 
backstop to the service programs. We recognize that people may 
not get satisfaction at the first level. We need another level 
of intervention. So to that individual now or in the future who 
has those issues, if he or she is not satisfied with what was 
done, that telephone number is there 24 hours a day with a 
masters degree level person who is trained to intervene in the 
bureaucracy, figure out what is the issue, and get it resolved 
and provide a warm handoff to another person for the resolution 
of that problem.
    So I invite those who feel that--and I think that is part 
of the issue here. There are going to be individuals who are 
not satisfied with the first level response. If they are not 
satisfied, that backstop is there and that safeguard is there 
to try to make sure we do not have these situations.
    Senator Ben Nelson. That might help avoiding the situation 
that I had with the near-Nurse Ratchett situation. Thank you.
    Dr. Winkenwerder. Senator, if I might also say, that just 
should not be the experience that someone should have. I happen 
to believe----
    Senator Ben Nelson. I did not think I should have been 
treated that way, but I was not the patient.
    Dr. Winkenwerder. Absolutely. Not you or the soldier. It 
just should not happen.
    I think that from where I look at this across the entire 
system, people need to understand, we take care of across the 
entire system 110,000 patient visits a day. This is a very 
large system. This is not a large number of people that we are 
talking about who have these issues and concerns. We ought to 
be able to have case managers who could follow these 
individuals and ratios so that we ensure that everybody gets 
touched and helped when they need to.
    I would just add one other thing that we have done that I 
think is making a difference. It is the 4- to 6-month post-
deployment health reassessment process that started 2 years 
ago. Everybody, not just when they come back, but 4 to 6 months 
down the line--and this is when many problems do occur, not 
necessarily for everybody--but we reach out, and it is a 
requirement. Every single person is supposed to have that, that 
touch and evaluation, not just a questionnaire; personal, 
professional evaluation: How are you doing? How is your family 
doing? What do you need?
    So that hopefully is another step to reach out to people.
    Senator Ben Nelson. We sure know more than we knew before.
    Thank you.
    Chairman Levin. Thank you, Senator Nelson.
    Senator Webb.
    Senator Webb. Thank you, Mr. Chairman.
    I believe that, gentlemen, the opinions of this committee 
have been pretty forcefully stated today. I am going to resist 
the temptation to pile on in a lot of anecdotal ways here. I 
would like to thank the chairman, first of all, for committing 
to further hearings, particularly with the Veterans Committee. 
I am also on that committee. I think it is probably the best 
way to address some of these overlapping issues.
    Dr. Chu, always good to see you. I have been privileged to 
work with Dr. Chu for more than 20 years, 4 years inside the 
Pentagon on a daily basis. We were sort of fellow data dinks 
and I know how hard it is to scrub some of these numbers.
    I approach this issue from two different perspectives, one 
as a lifetime recipient of military medicine. I grew up in the 
military. I was very fortunate to be the recipient of a great 
deal of compassionate care while I was on Active Duty, after I 
was wounded, when I was recuperating, and I have been able to 
use the system since then because I was medically retired from 
the Marine Corps following that experience.
    I also have worked on these issues as a committee counsel 
on the Veterans Committee when we were looking at a number of 
these issues nearly 30 years ago, some of them. Particularly, 
one comment, Mr. Chairman, with respect to the questions about 
the military evaluation of PTSD. I served as counsel for a good 
percentage of those hearings when we were attempting to fully 
understand PTSD back in the late 70s. One of the challenges 
with PTSD is that it does not always manifest itself when you 
are on Active Duty. It is a very difficult thing, I think, for 
military medicine to get its arms around.
    What we were seeing when we were looking at the data--and 
we went back to all war eras when we were looking at PTSD--is 
that in many cases it will not manifest itself until typically 
8 to 10 years after someone goes through the experience, and 
then again more than 20 years after someone goes through the 
experience. So this is an area that in my view should be a 
principal focus of the VA with correlation with DOD.
    With respect to BRAC, just having listened to some of these 
hearings, one of the things that I have observed over my 
lifetime is the continuing consolidation of medical facilities. 
It is difficult to recruit physicians. It is difficult to keep 
them on Active Duty. When I was on Active Duty, we had a full-
up hospital in Quantico. I was treated there. We had medical 
facilities down here at 23rd and Constitution Avenue that I 
used when I was in the Marine Corps. They are gone.
    So when we talk about eliminating yet another facility, 
even though I take the point with respect to the consolidation 
of research information and the ability to have the National 
Institutes of Health (NIH) across the street and all the rest 
of that, I am very concerned whenever we start eliminating 
military medical facilities, given not only the people on 
Active Duty, but also the retiree population that frequently is 
served by military medicine.
    But I also look at this and cannot help but look at this 
issue with the perspective of someone who spent a good bit of 
time in command and also civilian responsibilities. Uniquely in 
the military, there are the responsibilities and the 
obligations of command. One of those responsibilities is to 
show up and to supervise any facility that is under one's 
jurisdiction. When I would visit ships when I was Secretary of 
the Navy, the first thing I would do would be to go down to the 
engineering spaces down in the boiler rooms, and one of the 
first questions I would ask them was: When is the last time the 
commanding officer visited you down here in the boiler rooms, 
where the 1,200-pound steam boilers were going? That was a 
pretty good indicator, I think, of command, of command 
responsibility and the attention that command was paying.
    To borrow another metaphor here, General, this is sort of 
the boiler room. This is the boiler room of Walter Reed. People 
needed to be showing up and talking to the troops and asking 
them how they were doing.
    What I have been seeing from the veterans side and also 
from the military side on these issues is that we seem to be at 
a clear breakdown at the point of transition, with DOD on the 
one side in a number of these problems, how you process these 
people after they have been given undoubtedly some of the 
finest medical care in the world, how we process them, evaluate 
them, either return them to duty or get them into the veterans 
network.
    Also on the VA side, we have a 400,000-case backlog in the 
VA in terms of evaluating people's claims. These transitional 
programs go beyond medical. They go to disability evaluation. 
Dr. Chu, I want to ask you a question about this in a minute. 
They also go to such areas as how we are rewarding service, 
which is one of the reasons that I introduced a good GI Bill, a 
World War II type GI Bill, for these people who have served 
since September 11, which seems to be resisted in some cases 
because potentially of the cost. Well, how do you evaluate the 
price of service and how do you evaluate the value of service?
    What I am seeing here in many cases is an indication of 
where leadership is putting its priorities, civilian and 
military. We know we have to put priority on the battlefield. 
But we need a greater expression from this administration and 
from military leaders about these kinds of priorities, the 
sorts of things that we are focusing on.
    I have a question--and again, Dr. Chu, you and I love data. 
This is a March 20, 2006, GAO report on the military disability 
system. It has been around for a year. Its title was ``Improved 
Oversight Needed to Ensure Consistent and Timely Outcomes for 
Reserve and Active Duty Servicemembers,'' and it goes through 
the evaluations of individuals and how their disability claims 
were processed.
    One of the things that jumps out at me--I am not going to 
ask you to answer this in detail today, but it is just a real 
point of curiosity. It is on page 50 of this report, where it 
gives the statistics for disability evaluations from 2001 
through 2005. On the face of it, it is an Active Duty versus 
Reserve component evaluation. But here is the thing that jumps 
out at me, and it goes along the line of questioning here about 
perhaps pushing these people out of the system, or maybe it is 
just the inability to collect the right kind of data.
    What it shows here is that on the Active Duty side there 
were in 2001 6,378 total people evaluated, in 2002 6,632 people 
evaluated. By 2005, with the war going on, there were only 
6,465 people evaluated. That just seems implausible to me when 
you consider the casualty flow from these operations from 
woundeds and also from people who were injured but not wounded.
    I would greatly appreciate a clarification of this data 
before we can jump into trying to figure out where solutions 
might be needed.
    Dr. Chu. Delighted to.
    Senator Webb. Good. Thank you very much.
    Thank you, Mr. Chairman.
    Chairman Levin. Thank you, Senator Webb. You are looking 
for that for the record?
    Senator Webb. Yes, I would appreciate a response for the 
record. We can provide you with a follow-up letter with the 
data on it.
    [The information referred to follows:]

    The data on page 50 of the Government Accountability Office report 
is incorrect. The Department asked the Army to verify their data, and 
the Army provided corrected data for disability dispositions, as shown 
below. These revised data show an increase in the number of soldiers in 
the Disability Evaluation System (DES), especially for the years 2004 
and 2005. In 2006, there were 7,665 Active component soldiers in the 
DES, which is a significant drop from 2005, but is still significantly 
higher than in 2001. For the Reserve component, the increase was 
significant across the last 5 years, from 567 in 2001 to a high of 
4,213 in 2004, and with 2,784 in 2006.

                      UPDATED NUMBERS FROM THE ARMY
                              March 5, 2007
------------------------------------------------------------------------
                                                            Physical
                                                        Disability Case
             Case Count by Calendar Year                   Processing
                                                          System Total
------------------------------------------------------------------------
 Active component:
  2001...............................................              6,557
  2002...............................................              6,907
  2003...............................................              6,094
  2004...............................................              8,277
  2005...............................................              9,297
  2006...............................................              7,665
------------------------------------------------------------------------
 Reserve component:
  2001...............................................                567
  2002...............................................                773
  2003...............................................              1,624
  2004...............................................              4,213
  2005...............................................              3,221
  2006...............................................              2,784
------------------------------------------------------------------------


    Chairman Levin. That would be great.
    Senator Webb. Thank you, Mr. Chairman.
    Chairman Levin. Thank you so much.
    Senator Kennedy.
    Senator Kennedy. Thank you, Mr. Chairman. I think all of us 
are grateful to you for having these hearings and, as others 
mentioned, enormously troubled by all of this situation.
    Let me just mention--I know you have heard these stories 
before, but just in my own State of Massachusetts we have story 
after story of the soldiers who are wounded: Bilad, Iraq, 
November 2003, changing a tire on an Army helicopter, accident 
resulted in the loss of both arms; working with the USO, our 
office facilitated the soldier's family's travel to Washington, 
DC, so they could visit at Walter Reed. Then the family 
contacted us because it appears that the soldier was falling 
through the cracks. He received adequate care at Walter Reed, 
then experienced difficulty receiving care at a VA facility 
because the discharge paperwork was delayed. Ultimately, 
because of administrative problems he needed assistance in 
receiving his annuity pay, as well as receiving care at the 
Brockton VA hospital.
    We have instance after instance of that type of thing, 
which we must avoid.
    But let me come back to the central issue, and it is not 
unrelated to what Senator Webb has mentioned. A month ago the 
DOD reorganized the way it releases the casualty figures from 
Iraq and Afghanistan. On January 29, the Department's Web page 
listed a total of more than 47,000 non-mortal casualties. The 
next day, on the same Web page the category of non-mortal 
casualties had been replaced by one titled ``Total Medical Air 
Transported,`` and the figure was slightly more than 31,000.
    This new figure excludes more than 16,000 wounded or 
injured servicemen and women whose conditions were deemed not 
serious enough for evacuation. On the Department's press 
resources Web site, only those who are wounded in action are 
mentioned, about 23,000 troops. So we have these figures. These 
differences are both confusing and raise questions that we hope 
that you can answer. They have implications in both the short- 
and long-term about care of our troops, about allocations of 
resources, about what the needs are when you have these kinds 
of disparities.
    Dr. Winkenwerder, why has the DOD suddenly felt the need to 
cut in half the number of soldiers who needed the care?
    Dr. Winkenwerder. Senator, thank you for that question. 
There was confusion. I think we within the Department created 
that confusion unnecessarily. Let me assure you and others that 
there is no intent other than to accurately and properly inform 
everybody of what casualty figures are and what they are not, 
just to be absolutely candid about this.
    What had arisen was the term--it gets to the term 
``casualty.'' The individuals that were being moved from the 
theater for the last 3 or 4 years for whatever reason--and 
early on there were quite a number of people because there was 
not medical care there--that might have been moved for a 
routine exam, a female exam, whatever, these were not 
casualties. These were just people moved for routine care. That 
is called medical air transports.
    People had taken that information, I think because we had 
expressed it improperly, and had concluded that these were war 
injuries or war wounds, and they were not. So it was just an 
effort to clarify that. We should not have misled people in the 
way that we did in the first place. So that is what it is, that 
is what it was. The figures are what they are, and it would be 
crazy, absolutely insane, to try and imply that the figures are 
any different than what they are. That is it, that is the 
answer.
    Senator Kennedy. Thank you, but how--what were your--did 
you have the estimates of what you thought were going to be the 
casualties? Did you make the estimates now of what you thought 
were going to be the casualties, say for March of this year? 
Did you make those estimates a year ago or a number of months 
ago, so that you would know whether there is going to be the 
allocations of personnel and the allocations of resources and 
the training of different personnel and trying to anticipate 
that? Are these, the numbers that we have now, the same as 
those? Are they different? How are they different?
    Dr. Winkenwerder. The casualty estimates, going back to 
even the beginning of the conflict, are generated by, and any 
projections of those and therefore what sort of medical 
resources in theater do we need, are made by the Joint Staff. 
They are really military estimates. We review them and assist 
it with ensuring that the right level of medical care was in 
theater.
    As things have progressed, obviously, over the last 3, now 
4 years, we observe and track, and I know General Kiley and the 
other surgeons general and the other service leaders are 
tracking the casualty flow to ensure that all the resources not 
only are there in theater, but when people get back. That is 
how it is done, and so there is a constant look at it.
    Senator Kennedy. Dr. Chu, did the career professionals in 
DOD estimate the number of military personnel who would need 
health care services as a result of service in Iraq and 
Afghanistan?
    Dr. Chu. The Department has conducted a thoroughgoing 
analysis of what the size of its capacity needs to be for all 
our contingencies, including the ongoing challenges in Iraq and 
Afghanistan. Based on that, we have sized the present and 
future medical establishment.
    I also want to note the Department has transformed--this is 
an extraordinary achievement by the medical community--how we 
deal with war casualties. Our prior model, as you are aware, 
was to try to take forward the care apparatus. That is bulky, 
it does not necessarily get the best clinical care for the 
complex wounds we are seeing today. The transformation in these 
two conflicts, Afghanistan and Iraq, is that the role of the 
forward medical community is to stabilize the patient, to act 
as a safeguard against any surge in casualties, but that our 
objective is to bring the casualties back to the United States, 
where we can concentrate the best clinical talent on their 
recovery, their recuperation.
    That is the great achievement in the last several years. It 
is an enormous tribute to the skill of the medical personnel in 
theater, to the skill of medical personnel who are manning this 
in-transit system. As you have seen in the press reports, 
people are accurately reporting that they have gone from the 
battlefield to Walter Reed or Bethesda, often in 36, 48 hours, 
and they are the better for it.
    It allows us, among other benefits besides the sheer 
medical benefit of the transformation, to bring the family to 
the bedside in a way that the previous model did not. Really 
quite an extraordinary change in how we do business.
    Senator Kennedy. Secretary, no one is complaining about 
that. We are full of admiration for that service. It is heroic 
efforts, every single day, the people. That is not our issue 
that we are talking about here. We are talking about an 
entirely different situation, what is happening to these 
individuals over their experience of their lives.
    I mentioned--I will give you another. Here is soldier 
number two, a paraplegic, served two tours in Iraq and 
Afghanistan, due to injuries sustained in combat ended up at 
Walter Reed, transferred to West Roxbury VA facility, did not 
have specific problems with the care, but once transferred to 
the VA facility the Army, specifically Walter Reed, lost track 
of him, resulting in lack of pay for the soldier and his 
family.
    Our office was contacted to help out in October. We talked 
to Walter Reed. The paperwork was incomplete, leaving him in a 
troubling grey area where he is not on Active Duty, not 
officially discharged. This is the situation that is repeated, 
where people are being left out and effectively dropped.
    Another patient received psychiatric treatment at Walter 
Reed, had been at Walter Reed for 21 months. He came to our 
office, he was getting transferred to a VA hospital. Once he 
got transferred to the facility, his family was told that he 
was being discharged because he was technically still Active 
Duty and his discharge documents were waiting on signatures. 
Due to the fact that he was no longer at Walter Reed, yet not a 
veteran, he was unable to receive any kind of benefits.
    This is instance after instance. I am not going to take the 
time, but that is the great gap that we are seeing, and that is 
both in treatment and in care and attention and focus. As was 
mentioned, I think, earlier during the course of the hearing, 
getting an advocate, the advocate that is going to speak and 
follow for the individuals, is something which is enormously 
valuable and very helpful in the health care system in any 
event, and is something that we certainly ought to consider 
with regards to the veterans.
    I thank the chair.
    Chairman Levin. Thank you, Senator Kennedy.
    Senator Sessions.
    Senator Sessions. Thank you, Mr. Chairman.
    As is so often the case, I had another hearing, but I have 
benefited from what we have heard today. I believe Secretary 
Gates has an awesome responsibility and he has ultimate 
responsibility for everything in DOD. I think he has shown 
courage and leadership and he has insisted on strict 
accountability, and I am sure that some might feel that that 
power may not have been wielded perfectly, but I believe he 
wielded it effectively and I think it has helped us begin to 
emphasize the need to revaluate what is going on in the health 
care of our soldiers.
    The care that they receive I agree with Senator Lieberman 
should be commensurate with the risks we have asked them to 
undertake for us. We have asked them to give everything they 
have to execute our policies. Therefore we should do everything 
we can to make sure that their health and safety are taken care 
of, particularly if they are injured while serving their 
country. I think we all understand that, but obviously we have 
not met the high standards that we would like to meet.
    One article I believe in the Christian Science Monitor of 
recent days noted that a Colonel Garibaldi had warned that, 
``Patient care services are at a risk of mission failure,'' due 
to a privatization effort that had left the hospital short-
staffed. General Kiley, could you give us your insight into 
that troubling comment?
    General Kiley. Yes, sir. That is part of the A-76 study 
that actually started when I was in command at Walter Reed, 
following the law and the requirements of the Army to identify 
capabilities on the installation. In this case, it was the 
garrison operations, the personnel actions, the Director of 
Public Works.
    Senator Sessions. Explain the garrisons for those who are 
listening.
    General Kiley. A garrison is the command that is 
responsible for essentially running the town or city. So every 
one of our installations has a commanding officer accountable 
to the senior mission commander and to General Wilson, except 
for Walter Reed because it is a separate installation to date.
    Senator Sessions. Are those uniformed personnel?
    General Kiley. Yes, sir.
    General Schoomaker. City manager is what it is.
    General Kiley. Yes, sir, city manager.
    In this case, the MEDCOM had Walter Reed, Fort Dietrich, 
and Fort Sam Houston and had undergone an A-76 at Fort Sam 
Houston and was directed to undergo an A-76 analysis, which 
would require the government employees to compete against the 
contractor. They began that process. In the process of appeals 
and re-appeals, Colonel Garibaldi realized that he was at risk 
to dip below a functional capability to manage the city, not 
necessarily for clinical----
    Senator Sessions. It is one thing to have an A-76 study 
about privatization for cutting the grass at a military base. 
It is another thing when you are dealing with entrusting the 
health care of our soldiers. Is that correct?
    General Kiley. The health care was not part of that A-76. 
It was just the installation support, to include maintenance.
    Senator Sessions. But that is why that is relevant to 
maintenance at the facility.
    General Kiley. Yes, sir, and particularly to Building 18. 
That same capability was at risk and that was part of Colonel 
Garibaldi's challenge.
    He sent that memorandum up through General Weightman, to my 
resource manager with a series of requests. We analyzed that 
and concurred that he needed support and resources and provided 
those to him. His challenge was that because of the nature of 
the pending shift to the contractor, there were people that 
were not interested in coming to work for a couple of months 
and that made him struggle a little bit in completing the 
mission because of the lack of personnel to complete the 
mission.
    Senator Sessions. I think it indicates that we have had 
some knowledge of our danger earlier. I do believe that perhaps 
all of us in Congress could have done a better job of 
maintaining oversight. I just must say that. We have had 
oversight over prison treatments. We have had half a dozen 
hearings on Guantanamo and how we are treating the terrorists. 
Perhaps we should have had some hearings on how to treat our 
own soldiers, or maybe a lot more hearings on it.
    Tell me about this deal of this situation in which a 
soldier who has been severely injured, they need a good bit of 
reconstructive surgery, and then they are eligible to go back 
home, or perhaps when do they go back and receive care where 
their families may be, and when do they stay here, and are we 
confident we are making the right decisions about that?
    General Kiley. Yes, sir. We have two populations. We have 
the Active Duty population med hold. We have Reserve and 
National Guard in the med holdover. I believe it was in 2004 we 
began a program called the Community-Based Health Care 
Organization (CBHCO), where we recognized--and some of this 
came out of our experiences at Fort Stewart--that we had 
soldiers who had injuries, combat injuries, and were going to 
require long-term, not low level, but not high risk health 
care, physical therapy, occupational therapy, care they could 
receive in their communities where they lived. They simply 
asked the question: Why can I not go home and see a doctor or a 
therapist in my hometown, and then I will remain on Active Duty 
while I do that, under the control of a CBHCO command and 
control?
    So we established that. We have been running that for a 
couple of years. We presently have about 1,300 soldiers around 
the Nation at home getting their health care. At some point as 
they heal up, they either become fit to be released from Active 
Duty, or if they need an MEB/PEB we begin to do that. We have 
done that for the last couple years.
    Senator Sessions. How would you evaluate the success of 
that program?
    General Kiley. In general, I think that program has been 
very successful.
    Senator Sessions. Now, is that the problem we are dealing 
with?
    General Kiley. No, sir.
    Senator Sessions. What is the difference in that?
    General Kiley. The difference is that many of the soldiers 
that are at Walter Reed--and by the way, Walter Reed has almost 
by an order of magnitude got a larger number of soldiers in 
outpatient status around Walter Reed than most of the rest of 
my medical facilities, although I have sent the teams to them.
    These soldiers have very complex, very complex multi-system 
injuries--we heard a soldier last week--with PTSD, and TBI, and 
orthopedic injuries, sometimes amputations, and the need to 
develop prosthesis, sometimes multiple prosthesis, sometimes 
requirements for sequential surgeries over time.
    Senator Sessions. I am aware of that.
    General Kiley. We and often the soldiers would like to stay 
at Walter Reed and get their care done and then reach a final 
decision, maximum therapeutic care, and make a decision about 
return to duty. Some of them would like to come back to duty 
even with amputations and prosthesis. Some are ready to be 
medically boarded and discharged.
    So we make a decision almost on a case-by-case basis, or we 
should be, that says, you should stay here, I want to stay 
here. If we have soldiers that would like to go, for example, 
from Walter Reed to Brook Army Medical Center because they are 
from Texas or from San Antonio or Fort Lewis, we will make 
arrangements to transfer them there.
    Senator Sessions. My time has expired. I would note that 
there is an article, op-ed I guess, in the New York Times by 
retired General Paul Eaton that said ``Soldiers have long 
joked''--I guess, Dr. Winkenwerder, I will ask you this--``long 
joked, `If you are really sick or injured, Army medical care is 
okay. But if you are hurting only a little, especially if it is 
not visible, you are in big trouble.' ''
    General Eaton goes on in a critical piece here, he does go 
on to say, ``The American soldier still receives the best 
trauma care in the world, especially at Walter Reed. The 
problem there has been with deplorable outpatient care 
management. The system, the military health system, is 
seriously undermanned and underfinanced for the number of 
casualties coming home.''
    Let me ask you to comment on those remarks.
    Dr. Winkenwerder. I do not know how familiar General Eaton 
is with things that have been done in the last 4, 5, or 6 
years, the advances, not just in battlefield care, which he 
alludes to and does not have a concern about. Just based on the 
evaluations that we do, from the clinical quality and the 
satisfaction across the system, would not support his 
conclusion about that.
    Senator Sessions. Is that on the question of money or the 
question of----
    Dr. Winkenwerder. On the question of whether people get and 
are satisfied with their care as outpatients or for everyday 
kinds of care. In fact, the survey work--and again, our goal is 
to have no bias. That is why we benchmark to the private 
sector, and that is where I spent my career, so I have some 
sense of this--is that the satisfaction is very good with 
everyday routine care. The issues that we have been talking 
about now I think are for the special population of people who 
have the--it is outpatient care, but it is the long-term 
rehabilitation population, not someone who is coming in for 
cold or flu or for a sprained ankle.
    That may have been the case--and General Schoomaker or 
others can comment--historically within the Army, but I think 
there have been dramatic improvements in satisfaction, and we 
have very good data that can show that. Are we satisfied? No, 
we are never satisfied. We can always be better, and I think 
that is the culture, that is the idea that we need to embrace: 
Never satisfied, always get better, always compete to get 
better.
    General Schoomaker. Sir, if I could add something. I do not 
mean--this is not meant to be flippant, but I said earlier this 
is not about comparing to other things. This is about what is 
right and what should be expected and what the standard should 
be for these soldiers. If you look at the Gallup Poll in 2005 
and 2006, health maintenance organizations in this country were 
at the bottom of everything on the list, and I would not 
measure military medicine against civilian medicine in any form 
or fashion. Our soldiers and their families deserve far better 
commitment than the standard that is out there in the civilian 
thing.
    I personally object to the business attitude about all of 
this. This is a bigger commitment than that. So I am not 
lecturing you, but I want to go back to this business about 
what the right price for things are. You cannot put a price on 
what these young men and women are doing and the responsibility 
we have for them for the rest of their lives.
    I was just looking at the figures. Just of the Army, 31,581 
soldiers were evacuated out of the area of responsibility 
(AOR), just Army, since October 7, 2001, and those figures are 
good as of March 3 of this year. So it is very new information. 
Seventy-two percent of those evacuated are outpatients. That is 
22,738.
    This is what our difficulty is here. The 8,843 that are 
inpatients are getting the finest care in the world. But we 
have to bring this standard to the people in the outpatient 
business. We cannot compare it to business and to civilian kind 
of stuff and all these people because it is not respected out 
there on the civilian side, according to the Gallup Poll. I do 
not know because I do not go out there.
    I will tell you, just of the 31,581 people that have been 
evacuated out of the AOR--these are the people who have been 
evacuated now, not the ones who have been returned to duty--
4,000 of them are battle-injured, and 8,843 are non-battle 
injuries. Over twice the non-battle injuries than battle 
injuries, and 18,633 are disease. So 59 percent of all those 
evacuated were disease, 28 percent non-battle injury; 13 
percent were battle injuries.
    I guess what I have been trying to say throughout this 
testimony here is this is another layer on top of a system that 
is already dealing with a baseline of families and soldiers and 
all the rest of it here. Much more complex. So again, I am 
sorry to sound pedantic here, but I do feel passionately about 
this Nation's responsibility, not only to resource our 
soldiers, sailors, airmen, marines, and everybody else that is 
serving this country when they are well and how we put them 
into battle, but we damn sure ought to be doing better than we 
are doing on those that have been injured or diseased or hurt 
while we are doing it.
    So I hope our baseline is against what should be and could 
be, not about some kind of what is happening out there in small 
town America.
    Senator Sessions. Thank you, General Schoomaker, for your 
magnificent service to your country. I have to tell you, I 
understand your brother has many of the qualities of integrity 
and commitment that you do and I am confident that he will make 
progress for us.
    General Schoomaker. Thank you, sir.
    Chairman Levin. Thank you, Senator Sessions.
    Senator Akaka.
    Senator Akaka. Thank you very much, Mr. Chairman.
    Let me welcome Secretary Chu, Dr. Winkenwerder, General 
Schoomaker, and General Kiley to the Senate committee this 
morning and tell you, General Schoomaker, you were right on 
target in what you just said about our commitment, and the 
commitment is with you as well as us here in the Senate to give 
the best to our troops as they continue to serve us.
    We are here to look at the problems with patient treatment 
at Walter Reed and our effort here is to find out what it is 
all about, what we are dealing with, and to try to find 
solutions to do that. For that reason, I really am grateful for 
your responses today.
    One of the things that the chairman mentioned--and I want 
to thank the chairman for this hearing--was that the Veterans 
Affairs Committee and the Armed Services Committee should work 
together on this and to meet together in a joint hearing as 
well. We have talked about it and I do look forward to that 
happening, Mr. Chairman, and all for the effort of trying to 
find solutions to the problems that we are facing. We can do no 
less than the best that we can.
    One of the concerns that I have had, and I have mentioned 
this before, has been about BRAC and what impact that BRAC has 
had on all of this. We all know that in 2005 the BRAC 
Commission did name Walter Reed as a facility that would be 
closed by 2010, in a 10-year period. I just would like to have 
a comment from Dr. Chu and Dr. Winkenwerder about what they 
feel about that, the decision that was made by the BRAC 
Commission, and whether that has had an effect on what is 
happening now?
    Dr. Chu. Let me speak to the decision and allow General 
Schoomaker and General Kiley to speak to any effects at Walter 
Reed as a campus. It is a decision the Department supports. We 
think it will further advance the cause of military medicine 
because we bring these two great institutions together on a 
single campus with the revamped state-of-the-art facilities 
they ought to have to meet the standard General Schoomaker just 
outlined.
    Both buildings, both institutions, need their physical 
plant refurbished. Walter Reed is the more urgent, the current 
Walter Reed building is the more urgent of the two, but 
eventually Bethesda needs the same thing. The Bethesda location 
that was selected by the commission we think has great 
advantages because it is also the campus for the Uniformed 
Services University of Health Sciences and, as you appreciate, 
right across Wisconsin Avenue is NIH.
    So we have charged the President of the Uniformed Services 
University with improving the partnership with NIH as a prelude 
to what we hope will really be a truly extraordinary national 
asset.
    I want to emphasize one of the important additional 
elements in the BRAC decision and that is the call to increase 
our capacity at Fort Belvoir. If you look at where our people 
live in this region, they are mostly south, west, however you 
want to call it, of the Potomac River. So therefore it is very 
important that we have a better primary care capacity at the 
principal inpatient location in the region, that is Fort 
Belvoir. So a very important piece of this is Fort Belvoir and 
what it will give in terms of primary care capacity.
    Dr. Winkenwerder, would you like to add something?
    Dr. Winkenwerder. I just agree with everything you have 
said. I would also just add to that that our message coming 
certainly from my office is we have a critical mission. It 
continues right until the day of that transition. We have 
continued to invest in the Walter Reed campus. There is a new 
amputee center that a decision was made about in 2005, $10 
million. It is going up. It will be completed later this year. 
If there are more issues or more needs, we continue to invest.
    We cannot underfund, and we will not underfund, and have 
not underfunded what is going on today and that has to 
continue. That will be what takes place. Maybe from the other, 
day-to-day aspect, I do not know if, General Kiley, you would 
want to comment from your vantage point.
    General Kiley. Just two quick comments. I made a comment 
earlier. After the Washington Post article was released, I was 
asked the question, did BRAC cause this. My answer was no from 
the basis of my position as the MEDCOM commander, in that I was 
not making any funding decisions nor was I restricting any 
funding to Walter Reed because of the BRAC. The intent was to 
maintain Walter Reed as robustly as we could and with all the 
resources that they needed.
    Subsequent to that, in my discussions with General 
Weightman, it is clear that, even though I went out probably a 
couple months ago with the Navy Surgeon General to reassure the 
professional staff at Walter Reed that the new National 
Military Medical Center at Bethesda would carry on all the 
great traditions at Walter Reed, there is clearly still a 
psychological impact on the organization. I do not believe it 
impacts on the health care of the soldiers, but it has some 
second and third order effects downrange in terms of recruiting 
and retention that I am not real sure what that impact is.
    So from a financial perspective, from an operational, 
OPTEMPO perspective, it did not impact and should not have 
impacted. But culturally and emotionally, I am not sure how 
much it impacted on Walter Reed.
    Then of course, the analysis of the soldiers and the 
soldier flow is still something that we need to take a look at.
    Senator Akaka. Thank you for that. I have worried about 
that and I am grateful for your responses.
    One of the problems that we think has affected what has 
happened has been the budget for treatment. You just mentioned, 
General Kiley, that this did not happen as far as Walter Reed 
is concerned. But the Boston Globe reported yesterday that the 
Pentagon is concerned that the cost of health care could erode 
our military readiness and that is very important to us.
    Dr. Winkenwerder, you are quoted in the article as saying 
``Without relief, spending for health care will divert critical 
funds needed for warfighters, their readiness, and their 
critical equipment.'' The focus on the article is on the impact 
of health care on military readiness and therefore it is very 
critical that we deal with that. I am concerned about whether 
or not budgetary constraints are forcing our military to take 
tough measures to address rising health care costs and whether 
these measures are a contributor to the systemic problems as we 
are finding at Walter Reed.
    Dr. Winkenwerder. Thank you, Senator. That is an excellent 
question and I am glad to address it. The issue is that we do 
have a growing cost challenge for health care broadly. But I 
would like to put into perspective where most of those dollars 
go. Over 60 percent of our entire budget goes for retiree 
health care, not for today's Active Duty and their families. It 
is that retiree portion within which we have experienced the 
greatest cost growth.
    So I do not believe we have had any issues to date that 
have affected necessary investments in the direct provision of 
health care at Walter Reed or other institutions or anything 
that we are doing today. My concern was as I look forward and 
look out that there has to be pressure, growing pressure, with 
these costs and it has created and will create more pressure in 
the future for the entire DOD. So there is a challenge out 
there that we have to address and recognize and deal with.
    I would invite Dr. Chu or General Schoomaker to comment as 
well.
    General Schoomaker. I am a retiree and I am about to be 
released from Active Duty and to be one again. I just remind 
you that the retirees we are talking about fought World War II, 
they fought Korea, they fought Vietnam, they fought the global 
war on terror, and they have earned this. We are about to have 
in my view, as has already been alluded to, a growing 
population from the global war on terror and the long war as we 
go of many very seriously injured young men and women that are 
going to become older men and women with these very serious 
injuries and all the complicating factors. I think that if it 
is not a problem today, it will be a problem, and that what we 
ought to be doing is anticipating it.
    It is no surprise to anybody here because I have been 
saying it a long time: This Nation spends too little on 
defense, and part of defense, a big part of defense, are the 
people that volunteer to man our formations. So I have heard it 
back on some other committees what I have said before: We ought 
to be spending 5 percent at least of gross domestic product 
(GDP) on defense. We ought to be taking care of people, who are 
our most valuable asset. We ought to be putting the very best 
equipment on these people when we ask them to go in harm's way, 
and we ought to take care of them after they perform their 
service. That is where I stand and I am at odds with lots of 
people that think they are managing some kind of checkbook and 
that some how our priorities ought to be in other areas. I just 
disagree with them.
    Senator Akaka. Thank you, General Schoomaker. You are right 
on target.
    Thank you, Mr. Chairman. My time has expired.
    Chairman Levin. Thank you, Senator Akaka.
    Senator Thune.
    Senator Thune. Thank you, Mr. Chairman.
    I appreciate that last comment. I also agree. In World War 
II we were spending a third of our GDP on military. Korea and 
Vietnam, it dropped down in the 10, 15 percent range, and then 
Cold War, post-Cold War period, continued to drop, and it is 
about 3.8 percent of our GDP today. We are at war, we are in a 
war.
    I think that these are all symptoms of a bigger problem. 
That is that we are not putting enough into making sure that 
when we fight wars we are able to fight and win, but second 
that when we have people coming home from those fights that we 
are taking the appropriate care of them.
    I have been to Walter Reed Hospital on five different 
occasions visiting with soldiers. I have been to Landstuhl in 
Germany, and I think in every case when I have been there and I 
have visited with people who have been treated there, 
particularly in the inpatient setting, there is a high level of 
satisfaction with the quality of care. At least that has been 
my observation in visiting, interacting with soldiers who have 
been injured.
    It does seem that this is a function more of a very 
different type of war and one where we are having a lot more 
injuries. Fortunately, people are living because of the body 
armor, but it creates a very different strain on the military 
health care system.
    But I guess I have a question with regard to outpatients. 
Perhaps, General Kiley, you can answer this. There have been, I 
am told, nearly 4,000 outpatients that are currently in the 
military's medical holding or medical holdover companies which 
oversee the wounded. What is the average length of time a 
wounded soldier spends in a medical hold or holdover status and 
are we keeping soldiers in that status longer than is 
necessary?
    General Kiley. Sir, I would have to take the--I do not know 
the answer to the average stay across the entire MEDCOM. I can 
report that back to the committee. I think the answer to ``are 
we keeping them too long'' clearly identifies one of the 
challenges we have, because we have soldiers that want to get 
on with the process of going through the MEB and the PEB, 
working their way through that bureaucracy, and we have other 
soldiers who are concerned that all of their concerns will not 
be diagnosed and properly cared for. So we have this tension 
between how long is too long.
    [The information referred to follows:]

    The average length of stay in medical holdover for Reserve 
component soldiers is 172 days when they remain at a Military Treatment 
Facility. The average length of stay in Community-Based Health Care 
Organizations (CBHCO) is 291 days. The average length of stay for 
Active component soldiers in medical hold status at Army hospitals is 
176 days. The average time in medical hold begins when the treating 
physician initiates the Medical Evaluation Board and ends with final 
disposition by the U.S. Army Physical Disability Agency.
    It is important to note that the medical hold (Active component 
soldiers) does not include time spent healing after injury or illness. 
Most Active component soldiers remain assigned to and working within 
their units during this phase. Duty limitations for medical hold 
soldiers are specified in temporary profiles issued by the treating 
health care provider. Medical holdover and CBHCO averages stay includes 
healing or rehabilitation time.

    General Kiley. I hear occasionally allegations or concerns 
that soldiers, they are rushing us out the door, they are 
rushing us out the door. So we continually give guidance to the 
commanders all the way down to the CBCHOs and to the hospital 
commanders who oversee the medical board piece of this that, 
you have to take the time to examine all the issues that 
soldiers have and properly take care of them.
    Where we are at risk and where we are going to redouble our 
efforts so as not to delay the processing of soldiers is in 
that area where we are down to one or two conditions, as an 
example, and we have one or two more consultations and then we 
can begin to type up the summaries and do the 22 pages of 
paperwork and there are delays. A clinic appointment is 
cancelled or it takes another couple of weeks to get a test. 
Those are case-by-case, but they start to mount when you have 
4,000 individuals in med hold and med holdover.
    We need to go back and take a look at that, and I think 
part of that has to do with again the complexity of the 
conditions, requiring multiple consultations instead of a 
single one. Part of it has to do with making sure that we have 
the ancillary support staffs that we need, properly 
proportioned to the numbers of soldiers, so that we can in 
exactly the right timing work them through this very 
bureaucratic process.
    Senator Thune. Secretary Chu, in the National Defense 
Authorization Bill last year there was some report language 
that directed the Department to look at--in fact, the language 
says, ``The conferees continue to learn of instances in which 
returning members of the Armed Forces have been delayed in 
receiving needed health, mental health, and rehabilitative 
services both in military hospitals and in medical holdover 
status. The conferees believe that a wounded, injured, or ill 
soldier, airman, or marine deserves the highest priority for 
care. Should sufficient resources in the military hospital 
system not be available, civilian resources must be made 
available without delay.''
    There was a requirement in here that there be a tracking of 
these wounded soldiers as they come back and that you prepare a 
report regarding that. I am curious to know what the status of 
that report is.
    But second, is this a capacity problem and do we need, 
particularly in this outpatient setting, where we have a lot of 
these injuries, to be referring more to a civilian resource if 
that is necessary? That was the last observation of the 
conference committee last year in the National Defense 
Authorization Bill. What is the status of the report?
    Dr. Chu. The report should be to you within the next couple 
of months. We have begun working on the issues that the 
conference report language raised.
    On the capacity issue, broadly I think the answer is no, 
there is not a capacity issue. That is not to say that we 
should not advantage ourselves of the best care in the country 
for the particular conditions the person might have. So I do 
not want to rule out the use of the civil sector. Indeed, you 
see an example of our partnership with the non-DOD sector in 
using the VA's four major polytrauma centers for TBI. We 
recognize this is not going to be something that every facility 
can offer.
    It does raise, and I think General Kiley has touched on 
this already, a tension for our people. They often do want to 
go home and that was the purpose of the Army's CBHCO effort. We 
must recognize sometimes that there will not be quite the same 
level of care in some communities for the tertiary type 
situations as there might be at a major medical center, and 
that is a choice the individual has to make.
    But we are committed to devoting the resources necessary to 
get these people well. I do think a place that we may yet put 
additional resources--and this is an evidentiary matter, 
although the Army has already put a good deal of resources in 
this effort--is in the staffing for case management. It may be 
that, as several members have noted, it is the importance of 
the advocate for the patient that will bring the bureaucratic 
process together in a way that is more effective, especially 
for someone who is trying to understand where is he or she 
going with his life, what is the future going to look like 
here.
    But the bottom line, I would argue, is I do not think we 
have an important capacity issue per se.
    Senator Thune. I want to commend you for acting quickly and 
decisively with respect to the Building 18 issue. I do think 
that these men and women who serve our country are heroes and 
they deserve the best of care, whether that is in the inpatient 
or outpatient setting.
    The other thing we are going to be dealing with at the VA, 
if you look at the statistics from Vietnam or Korea, there were 
three injured soldiers per one dying soldier. World War II it 
was two injured per one dying. In this current conflict it is 
16 injured for 1 dying, which I think points to down the road 
as these soldiers get on with life they are going to have 
ongoing medical needs that are going to put additional strains 
and stresses on the VA, and I think that is something that we 
have to be prepared to deal with as well, and it is a cost of 
war.
    But these people who serve our country are heroes and they 
deserve the very best of care, and I appreciate the fact that 
you responded quickly and are trying to shore up some of the 
shortcomings that we have in the system today, and particularly 
with regard to the outpatient setting. So thank you for your 
testimony and I am sure this will not be the last time that we 
discuss this issue, but clearly this committee wants to act 
quickly as well and make sure that we are doing everything we 
can to see that you are resourced to deal with these problems 
and challenges. Thank you.
    Thank you, Mr. Chairman.
    Chairman Levin. Thank you, Senator Thune.
    Senator Graham.
    Senator Graham. Thank you, Mr. Chairman.
    Chairman Levin. Excuse me for interrupting you, Senator 
Graham. But if you are the last Senator to have an opportunity 
this round, we will not be able to go to a second round, given 
the hour, and I just want to announce that. But the record will 
be kept open for questions.
    Senator Graham. I am sure they will want to stay and hear 
my questions, but I do appreciate your letting everyone know 
that. If I could go I would, but I have to actually ask them.
    General Kiley, should you resign?
    General Kiley. Sir, that is a difficult question to answer. 
I certainly serve at the pleasure of the senior leadership of 
the Department and would respect their decisions. I am 
accountable for what happened at Walter Reed, as I am 
accountable for Landstuhl and accountable for Brook and the 
Center for the Intrepid, for the quality of the doctors and 
nurses that go to the combat zone.
    If I could step away from myself, I think at this time, 
with us still at war, we have had some changes in the 
leadership already in the MEDCOM. I still think I have the 
right skill sets and the right experience to fix these 
problems. But as I said, I stand ready for decisions.
    Senator Graham. It seems to me that Building 18 is one part 
of the problem, obviously, and the system problems are large 
and complicated. Mr. Chairman, we need a whole hearing about 
retiree health care in the DOD and what we can do to get a grip 
on it. Because you are going back into retirement, General 
Schoomaker; do you believe that you were promised as part of 
your contract lifetime health care in retirement free, without 
any shared responsibility?
    General Schoomaker. No, because it is not free.
    Senator Graham. Well, it is not. There are copayments, and 
we have to figure out what is fair to the retirees.
    General Schoomaker. Sir, I do believe that there is an 
expectation that that was very much a part of the compensation 
for service, because as you know we are not compensated in 
fiscal terms.
    Senator Graham. Do you have a problem with a retiree having 
to make a copay for TRICARE services or a premium payment?
    General Schoomaker. No, I do not, because we do now.
    Senator Graham. That is right, and we need to look at that 
system over time and see what is fair. I want to work with 
everyone on this panel to do it.
    But about the building itself, could you provide us, 
General Kiley, the names of the first sergeants--and I do not 
speak Army, so I do not know what organizational--I know one 
thing, that people in the Army complain a lot less than they do 
in the Air Force. I cannot imagine people in the Air Force not 
complaining about this building, and apparently no one 
complained. Is that true? No one that lived in that building 
ever complained to anybody?
    General Kiley. Sir, I think Specialist Duncan yesterday in 
his testimony clearly stated he not only complained to his 
leadership at Building 18, he made his concerns known to 
Sergeant Lester, who is the NCO in charge.
    But sir, that whole thing, if I may, is still under an 
official investigation, and I can certainly provide for the 
record the names of the individuals.
    Senator Graham. I do not want you to provide--I would like 
with the chairman to work on a list of people who are 
responsible for that building at every level of command for as 
long a period of time it was in a state of disrepair, so that 
eventually at an appropriate time we could talk with them. I 
would like to know how a building could be in that state of 
disrepair that long and it not percolate up.
    How long do you think the building was in a state of 
disrepair that would be unacceptable? Do we know the time 
period in question?
    General Kiley. Sir, as I understand it the building 
underwent a $260,000 renovation, to include paint and repairs 
of exactly the kinds of things that were addressed in the 
article. That happened in 2005. I cannot tell you at what point 
Room 205 started having mold behind the wallpaper. I think it 
is an old building. I think it has had a series of continuing 
repair jobs. I think there is a humidity issue in this 
building, I am told.
    But I think it has had renovations. People have attempted 
to pay attention to it. Clearly what changed the calculus was 
that we were putting patients in there, and there is no excuse 
to have soldiers in moldy rooms like that. But I think our 
sense of urgency was not heightened at that point and we should 
have been more aggressive.
    Senator Graham. Right. I guess what I am trying to find out 
is, when we start assessing who is responsible I would like to 
know who was closest to the problem, and we can go up to the 
President if we want to, but I do believe in the military that 
command responsibility is a shared obligation, and if I am a 
commander I do expect my subordinate commanders to be out there 
doing their job and I want to look at the whole, how did 
Building 18 get to become Building 18. I think it would be 
helpful for us to know that.
    General Kiley. Yes, sir.
    General Schoomaker. Sir, let me, if I could add to it. I 
agree with that track. I think that is exactly the right way to 
go. But just for clarity sake, every room in Building 18--and I 
know you have been through it--was not moldy.
    Senator Graham. No, I have not been through it, and that is 
what I need to learn.
    General Schoomaker. There is a leak, the roof leaks on the 
east side of that building on the fourth floor. There is a 
humidity issue there. It has been through several renovations. 
There are many rooms--and I talked to soldiers over there--they 
are perfectly happy with the rooms, they are dry, they are 
clean. They have their TVs in there. They are doing some stuff. 
But it is not the standard for the whole building that we 
should expect to have soldiers in.
    Senator Graham. The only reason I mention each room by room 
is that what we have in this war is a capacity problem. We are 
looking at every building we can get our hands on and we are 
throwing as much duct tape as we can, and what you see in the 
health care area you see in other areas of military. We are 
asking a lot. Nobody anticipated this war lasting this long, 
causing this many casualties, and we are playing catch-up.
    General Schoomaker. Sir, there is another issue here, and 
this is what we are investigating, going down through the chain 
of command. But we had empty rooms in Building 14 on the campus 
over there, which is a state-of-the-art one-plus-one, standard 
wonderful place. We had Building 18 that was not full. Only 
two-thirds of the rooms or something like that were being 
utilized. There were rooms that were open there and some of the 
rooms that were in the worst shape, obviously, were not being 
occupied.
    Senator Graham. What we need to take from this whole 
exercise is that our military is under stress at every stage. 
Abu Ghraib was about people not being trained to do a job and 
being asked to do a job they were not trained about, a prison 
that had 200 or 300 people in it that wound up with 6,000. We 
have to get ahead of some of these problems.
    So what I want to learn from this is how did each room go 
bad and for how long and why no one caught it. But look at the 
bigger picture: What do you need? Is this a management problem 
or is this a resource problem? Is Building 18 a result of bad 
management or just we are having to take every resource, no 
matter how delapidated, and put it into play?
    General Schoomaker. Sir, my quick look at it, it is a 
leadership problem, it was a management problem, and it was 
also a resource problem in that the A-76 thing that went on for 
6 years went from 300 maintainers to 60 maintainers on the 
installation and therefore ended up with some of these issues.
    So it is all of the above and it is not acceptable, and we 
are going to hold everyone accountable for it.
    Senator Graham. Including us here in Congress. I will say 
that. You do not have to.
    But now let us talk about very quickly what happens to a 
person who is injured in Iraq, and you are taken out of the 
line because your injuries are so substantial that you have to 
come back. Dr. Chu, the first thing that happens to that 
injured soldier is a determination as to whether or not they 
can ever go back to Active Duty; is that correct?
    Dr. Chu. Yes, sir, that is the first bureaucratic step in 
that regard. But of course, our first priority is getting the 
soldier well.
    Senator Graham. No, I understand that. I am talking about 
now we are past the health care.
    Dr. Chu. Once it is decided that the individual may not--
and I underscore the word, ``may not''--meet retention 
standards because of physical issues, then the so-called 
medical board is held, MEB. A narrative summary is dictated 
that describes the case, describes the situation.
    Senator Graham. How long does that normally take?
    Dr. Chu. It can take a long time.
    Senator Graham. I know my time is up, Mr. Chairman. I am 
just trying to walk through this very quickly.
    Dr. Chu. Our standard is 30 days. It is not a standard 
Walter Reed was meeting, although that is understandable given 
the complexity of the conditions.
    It then passes to the PEB, which decides on disposition of 
the case. First there is an informal board, essentially based 
upon the documents, and if the soldier is agreeable to the 
finding of that informal board that is the end of the process. 
If, however, the soldier wishes to continue, there is a formal 
board. The soldier can be represented at that board. Again, if 
the soldier is not comfortable with the conclusion the soldier 
may appeal, so there is appellate review.
    Our standard is 40 days for that whole board process. The 
Army on average meets that standard, although not typical at 
Walter Reed, I should admit. The majority of the Army's cases 
stay within the 40-day limit, although the distribution does 
spill outside that limit.
    I should emphasize that the cases that go to the PEB, if I 
remember the Army's numbers correctly, about 20 percent or so 
the soldier is returned to duty. So this is not a black and 
white situation.
    Senator Graham. And the 80 percent do not?
    Dr. Chu. And 80 percent do not.
    Senator Graham. They have to go to the VA and start all 
over again, basically, do they not?
    Dr. Chu. No. We have changed that process. If we anticipate 
that you are going to be on the temporary disability retirement 
list, we notify the VA right away that Smith is coming and we 
start opening a case file at the VA, so that when the 
individual arrives under the VA's aegis the VA is better 
prepared to deal with him or her. So for the most seriously 
injured this is handled differently from a more routine 
situation in that regard.
    As General Schoomaker just said earlier this morning or 
today, we have all sorts of cases in this physical evaluation 
system peace or war.
    Senator Graham. Thank you.
    Chairman Levin. Thank you, Senator Graham.
    Senator Graham has suggested that we get the names of the 
people directly in charge of the maintenance and repair at 
Building 18 and that we would then talk directly to those 
people. We do not need them to be stated publicly here, but for 
the record if you will get us their names, Senator Graham's 
staff, our committee staff, will work together to interview 
those people to get the kind of picture which Senator Graham 
has talked about.
    If you also for the record--there will be other questions--
tell us what the role of privatization either has been or will 
be in this process. There is some privatizing going on. Is that 
going to create even more uncertainty, confusion, and possible 
gaps? The record will be kept open until tomorrow afternoon for 
additional questions for all of you.
    [The information referred to follows:]

    Walter Reed began an A-76 competition for Base Operations in 2000, 
which reached initial decision in September 2004. The final decision 
report was submitted to Congress on June 5, 2006. Proposed 
congressional actions called into question whether Congress would allow 
fiscal year 2007 funds to be used for performance of this contract. 
These proposed congressional actions caused the medical command to 
delay the contract award and start of the 90-day transition to full 
contractor performance until November 2006. iAP Worldwide Services 
(iAP) began full performance of the contract on February 4, 2007.
    In 2004, a Residential Communities Initiative to privatize family 
housing took effect. A total utility privatization effort began prior 
to the Base Realignment and Closure (BRAC) 2005 announcement, but this 
effort was stopped following the BRAC recommendations.
    An Enhanced Use Lease (EUL) privatization contract was planned in 
May 2004 for Building 40, which had been empty for over 4 years at that 
point. The EUL on Building 40 did not have any personnel impact, 
because the building was empty.The effective date of BRAC was estimated 
to be over 6 years from the time it was announced in 2005.
    The Department of the Army provided to the committee the names of 
individuals who filled key leadership positions at Walter Reed Army 
Medical Center with responsibility for oversight of maintenance and 
repair at Building 18:


Brigade Commander
  COL Ron Hamilton.............................        July 2006-present
  COL Rosaline Cadarelli.......................                2004-2006
  COL Dorene Hurt..............................                2002-2004
------------------------------------------------------------------------
Brigade Command Sergeant Major
  CSM Monshi Ramdass...........................     July 2006-March 2007
  CSM George Sosa..............................                2004-2006
  CSM Santiago.................................                2002-2004
------------------------------------------------------------------------
Med Hold Company Commander
  CPT Aaron Braxton II.........................                2006-2007
  MAJ Carzell Middleton........................                2004-2006
  CPT Matthew Bowles...........................                2002-2004
------------------------------------------------------------------------
MED Hold First Sergeant
  1SG Donald Walker............................                2005-2007
  SFC Warren-Clark.............................                2004-2005
  1SG Andrew Patterson.........................                2002-2004
------------------------------------------------------------------------
Med Holdover Company Commander
  CPT Arthur Jenkins...........................                2007-2007
  CPT Sheri Swandal............................                2006-2007
  MAJ Carzell Middleton........................                2004-2006
  CPT Matthew Bowles...........................                2002-2004
------------------------------------------------------------------------
Med Holdover First Sergeant
  1SG Angello Gordon...........................                2007-2007
  1SG John Zelch...............................                2006-2007
  SFC Carol Warren-Clark.......................                2004-2005
  1SG Andrew Patterson.........................                2002-2004
------------------------------------------------------------------------
Student Company Commander (occupied Bldg #18 in
 02-04)
  CPT Tonia Ashton.............................                2002-2004
------------------------------------------------------------------------
Garrison Commanders
  COL Bruce Haselden...........................        July 2007-present
  COL Peter Garibaldi..........................                2005-2007
  COL Jeffrey Davies...........................                2003-2005
  COL Randy Treiber............................                2001-2003
    Chairman Levin. We thank you again for your testimony and 
we will stand adjourned.
    [Questions for the record with answers supplied follow:]
             Questions Submitted by Senator Daniel K. Akaka
                            command pressure
    1. Senator Akaka. General Schoomaker, a report in the Army Times 
states that some of the Walter Reed patients thought they were being 
punished with morning inspections and being made to clean their rooms 
as retribution for the Washington Post article. Moreover, patients were 
told that they could only talk to media after getting permission from 
the chain of command, if they were going to be interviewed on 
government property. They were further told that they could go down the 
street to a coffee shop, if they did not want to seek permission to 
speak with the media first. From the outside world, this would seem 
like the Walter Reed leadership is applying pressure on the patients to 
prevent them from talking to the media.
    These are very serious allegations. It's my understanding that in 
General Kiley's testimony before the House National Security 
Subcommittee on Monday, March 5, he stated that you had discussed the 
allegations from the Army Times article with the brigade commander, 
Colonel Hamilton, and that his sense was that the troops were not being 
pressured to keep quiet. Is that correct?
    General Schoomaker. Lieutenant General Kiley and Major General Eric 
Schoomaker both discussed the allegations in the Army Times with 
Colonel Hamilton. An investigation of the allegations has not been 
completed. Colonel Hamilton did hold a formation during which he 
reemphasized his open-door policy and encouraged soldiers to bring 
their problems and concerns to the chain of command so the command 
could address those issues. The chain of command exists to help 
soldiers with problems such as those uncovered by the Washington Post, 
and commanders should be available and approachable so soldiers can 
bring problems to the command's attention without fear of retribution 
or reprisal. Additionally, the Army has established the Wounded Soldier 
and Family Hotline, to connect callers directly with staff in the Army 
Operations Center. These issues will be briefed weekly to the Army 
leadership.

    2. Senator Akaka. General Schoomaker, I cannot help but notice that 
there is a significant disparity between the allegations made in the 
Army Times and the results of General Kiley's discussion with Colonel 
Hamilton. Did you or any of your staff discuss these allegations with 
the troops themselves in order to understand what is causing these 
perceptions by the patients at Walter Reed?
    General Schoomaker. The Army leadership has frequent personal 
contact with soldiers, patients, families, and others expressing 
concern about medical care and leadership concerns, among other issues. 
My staff reviews those complaints, forwards them to the appropriate 
Army command for investigation, and provides a response to the soldier/
patient. However, these specific allegations were not raised in my 
discussions. I am confident that the Commander at Walter Reed Army 
Medical Center will conduct a thorough review of the allegations and is 
very sensitive to the perception created by the article. If additional 
information comes out that substantiates the allegations in the 
articles we will take appropriate action.

    3. Senator Akaka. General Schoomaker, has it been your policy for 
you or your staff to discuss complaints of this nature from patients 
directly with the patients?
    General Schoomaker. Yes. The Army leadership has frequent personal 
contact with soldiers, patients, families, and others expressing 
concern about medical care and leadership concerns, among other issues. 
My staff reviews those complaints, forwards them to the appropriate 
Army command for investigation, and provides a response to the soldier/
patient.

                          contractor oversight
    4. Senator Akaka. General Schoomaker, how did the Walter Reed 
command ensure that renovations conducted on Building 18 since 2001 
were conducted correctly? What oversight of the contractor was 
conducted?
    General Schoomaker. The current contractor took over responsibility 
of performing maintenance on Building 18 on February 4, 2007. All 
previous renovations to Building 18 were the responsibility of the 
Government. Currently all work performed by the contractor is inspected 
in accordance with the Quality Assurance Surveillance Plan by the 
Continuing Government Organization before it is accepted.

    5. Senator Akaka. General Schoomaker, how was the contractor 
selected to perform the work, and what type of contract was awarded?
    General Schoomaker. The contractor was selected based on a public/
private competition in accordance with Office of Management and Budget 
Circular A-76. As the private sector contractor chosen to compete 
against the government bid, the private sector contractor was selected 
based on a competitive formal source selection process conducted in 
accordance with the Federal Acquisition Regulation, Part 15, Negotiated 
Procurements. Part 15 procedures are designed to foster an impartial 
and comprehensive evaluation of offerers' proposals, leading to 
selection of the proposal representing the best value to the 
government. The resulting contract was a 1-year cost-plus award fee 
contract, with four 1-year option periods.

    6. Senator Akaka. General Schoomaker, did the contractor have a 
record of performance on government contracts? If so, how had they 
previously performed?
    General Schoomaker. The Government performed an extensive check of 
past performance prior to award. The evaluation process included 
checking references provided by the contractor, checking Department of 
Defense (DODI-wide performance databases, and performing three on-site 
evaluations at the following DOD facilities where the contractor was 
performing the work: Forts Gordon and Polk, and Jacksonville Naval Air 
Station. All findings were positive. The contractor had extensive 
facility operations experience at several locations where the 
government contract administrative staff gave the contractor overall 
excellent ratings.
               determining service connected disabilities
    7. Senator Akaka. General Schoomaker, as chairman of the Veterans' 
Affairs Committee, and as chairman of the Armed Services Committee's 
Subcommittee on Readiness and Management Support, I find myself looking 
at the issue of determining disability for wounded or injured 
servicemembers from two different perspectives.
    Please explain why it seems that DOD uses a different standard for 
determining service connected disabilities than the VA. After all, we 
are talking about one servicemember with one set of medical problems.
    General Schoomaker. The DOD is required to use the statutory 
standards found in chapter 61, U.S.C. Specifically, title 10, U.S.C. 
1201 indicates servicemembers can be compensated for impairments 
incurred or aggravated while entitled to basic pay. This has been 
interpreted by past Comptrollers General opinions to be the ``date or 
onset of a disease or occurrence of the injury.'' The VA is bound by 
title 38, U.S.C. 105 and definitions found at title 38, U.S.C. 101. The 
VA defines ``service-connected'' as any injury or disease incurred or 
aggravated during active military service determined to have been in 
line of duty.
    There appears to be little difference in how the VA and DOD define 
eligibility for disability compensation. However, the Services can 
compensate for non-service incurred or aggravated impairments when the 
servicemember has over 8 years of Active Duty (10 U.S.C. 1207a), while 
the VA cannot, and the VA has statutory presumptions regarding when 
certain diseases are presumed service-connected where the Services do 
not. There might also be some disparities as the result of different 
views of the evidence by individual reviewers.

    8. Senator Akaka. General Schoomaker, to follow-up, I understand 
that there is a big difference between the percentage of retired 
disability that separating Operation Iraqi Freedom and Operation 
Enduring Freedom servicemembers have received from DOD versus what they 
later received from the VA. Please explain how this can happen. Also, 
please provide statistics on the numbers of percentages of retired 
disabilities awarded by DOD versus the VA. Please break out the 
statistics to show Active, Guard, and Reserve Forces separately.
    General Schoomaker. The VA rates every service-incurred condition, 
whereas the Army rates only those conditions that make a soldier unfit 
for further duty. Although there may be specific conditions the VA 
rates higher than the Army, the Army does not have visibility on VA 
ratings. The Veterans Disability Benefit Commission results should 
provide that information.
    Fewer than 15 percent of Army soldiers are separated or retired 
through the Army's disability system with combat-related injuries. The 
vast majority of soldiers wounded in action are returned to duty--a 
testament to our great medical care. From the beginning of October 2001 
to 1 April 2007, the Army placed 18.48 percent on disability 
retirement; Active component 17.97 percent; U.S. Army Reserve 18.97 
percent; and National Guard 20.80 percent.
                            budget concerns
    9. Senator Akaka. Secretary Chu, Dr. Winkenwerder, and General 
Schoomaker, at the hearing on Tuesday, March 6, I raised a question 
regarding an article in the Boston Globe. Specifically, the Boston 
Globe reported on Monday, March 5, that the Pentagon is concerned that 
the cost of health care could erode our military readiness. Dr. 
Winkenwerder is quoted in the article as saying, ``Without relief, 
spending for health care will . . . divert critical funds needed for 
warfighters, their readiness, and for critical equipment.'' I raised my 
concerned about whether or not budgetary constraints are forcing our 
military to take tough measures to address rising health care costs, 
and whether these measures are a contributor to the systemic problems 
we are finding at Walter Reed. I was assured by you all that it was 
not.
    I note that several times during the hearing, you all stated your 
belief that budgetary issues were not the cause, or part of the cause, 
for the problems at Walter Reed. However, at the same time, General 
Schoomaker repeated his statement that the Army has been historically 
underfunded. We heard during the hearing that the problems at Walter 
Reed are systemic and have been occurring throughout the military 
medical system for quite some time.
    How can you be sure that the military medical community is not 
feeling pressure to keep costs down, potentially contributing to the 
problems at Walter Reed?
    Dr. Chu and Dr. Winkenwerder. We do not believe available resources 
were the cause for the facility issues at Walter Reed. In the Defense 
Health Program, the Military Health System leadership (including the 
medical department senior leaders) collaboratively determines the 
programmed budgets. As with any appropriation, emerging requirements 
during a fiscal year can exceed available funding. However, since 
fiscal year 2001, we have been able to restore enough funds during our 
midyear review budget adjustments to meet, and in some years exceed, 
projected annual requirements in the areas of facility sustainment, 
restoration, and modernization. The ultimate uses of those funds are at 
the discretion of the individual Services' medical departments.
    General Schoomaker. The U.S. Army Medical Command (MEDCOM), like 
the entire Military Health System, is under pressure to keep costs down 
but budgetary constraints were not the root cause of all the problems 
that have surfaced at Walter Reed Army Medical Center. The Assistant 
Secretary of Defense for Health Affairs (ASD(HA)) has funded our 
immediate requirements as we have identified them. Historically, MEDCOM 
begins the fiscal year with sufficient resources as identified in our 
President's budget request. Any additional military health service 
unprogrammed requirements or higher execution of programmed needs 
compete for funding at mid-year. Routinely, by year's end, the AD(HA) 
funds all reasonable requirements to support the global war on 
terrorism and other high priority requirements.

    10. Senator Akaka. Secretary Chu, Dr. Winkenwerder, and General 
Schoomaker, what budgetary guidance have you given the Army medical 
community? Have they been given everything they have requested in each 
year's Army budget dating back to fiscal year 2001?
    Dr. Chu and Dr. Winkenwerder. The medical community (including 
Army) begins the budget process by making adjustments to the previous 
year's Defense Health Program President's Budget. This base line amount 
is then adjusted for programmatic changes, such as new or discontinued 
missions, planned military to civilian conversions, savings assumptions 
associated with cost reduction initiatives, changes in managed care 
support contracts, and other similar items. This revised amount is then 
inflated at standard DOD rates to establish the next year's budget 
proposal.
    As with all Federal agencies, proposals can exceed funding 
availability within the top line budget guidance provided for the 
Defense Health Program by DOD leadership. When this occurs, the 
Military Health System leadership (including medical department senior 
leaders) collaboratively decides what areas of the budget risk may be 
taken without harming patient care.
    Actual budgets, of course, are determined by Congress. In 
execution, the mid-year budget review reallocates funds to areas of 
need. Since fiscal year 2001, we have used this review to ensure we 
meet or exceed projected requirements for medical facilities 
sustainment and modernization.
    General Schoomaker. The Army received adequate Defense Health Care 
Program funding by year's end to accomplish our core missions. However, 
we start a typical fiscal year with an inadequate budget and compete 
for additional resources from the TRICARE Management Activity 
throughout the year. This resource uncertainty precludes a stable 
business environment and creates inefficiencies.

    11. Senator Akaka. Secretary Chu, Dr. Winkenwerder, and General 
Schoomaker, if these problems at Walter Reed Army Medical Center were 
not a result of lack of funding, then what do you believe is the root 
cause? Is it due to a lack of judgment?
    Dr. Chu and Dr. Winkenwerder. The DOD Review Group and the other 
reviews by the Army will assist the Department in understanding the 
root causes of the issues at Walter Reed. It would be premature to 
speculate before their reports are rendered.
    I would respectfully point out, however, that while there are many 
factors involved, it would not be fair to conclude that the A-76 
competition had a destabilizing effect on Walter Reed. Although the 
Army should have proceeded with its public-private competition in a 
more timely manner, Army data does not show a precipitous drop in the 
number of employees providing base operating support during the 
competition. In fact, I understand the number of employees remained 
relatively constant during the competition and up through May 2006 when 
congressional actions delayed the formal award of the contract and the 
transition to contract performance. In the final analysis, competitive 
sourcing allowed the Army to reach a sound management decision for the 
efficient and effective performance of maintenance at Walter Reed. 
Under the Army's supervision, the contractor will be required to meet 
the same quality standards, at a minimum, as would have been applied to 
the in-house team. The contract will save resources--estimated at more 
than $32 million over 5 years, which is $17 million more than would be 
realized if the work were retained in-house that can be applied to 
other Service needs.
    General Schoomaker. I want to emphasize that the quality of medical 
care provided to our soldiers at Walter Reed is absolutely superb. 
There are problems with billeting and administrative processes for 
medical hold and medical holdover soldiers and we are fixing those 
problems. Several factors contributed to the infrastructure problems at 
Walter Reed Army Medical Center. First, a prolonged A-76 competition 
had the effect of attriting the garrison workforce that maintained the 
infrastructure. The BRAC decision resulted in infrastructure and 
capital improvement projects being down-scoped or cancelled, along with 
enhanced use lease projects for Building 18 and the old Walter Reed 
Army Institute of Research Building to be placed in abeyance. In 
general, the aged infrastructure at Walter Reed requires intensive 
maintenance. The war resulted in a significant increase in medical 
hold/holdover outpatients, stretching the ability to serve and support 
this population.

    [Whereupon, at 1:36 p.m., the committee adjourned.]

                                 
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