[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]



                         [H.A.S.C. No. 111-60]

                                HEARING

                                   ON

                   NATIONAL DEFENSE AUTHORIZATION ACT

                          FOR FISCAL YEAR 2010

                                  AND

              OVERSIGHT OF PREVIOUSLY AUTHORIZED PROGRAMS

                               BEFORE THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                MILITARY PERSONNEL SUBCOMMITTEE HEARING

                                   ON

           BUDGET REQUEST ON DEFENSE HEALTH PROGRAM OVERVIEW

                               __________

                              HEARING HELD

                              MAY 15, 2009

                                     

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]





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                    MILITARY PERSONNEL SUBCOMMITTEE

                 SUSAN A. DAVIS, California, Chairwoman
VIC SNYDER, Arkansas                 JOE WILSON, South Carolina
LORETTA SANCHEZ, California          WALTER B. JONES, North Carolina
MADELEINE Z. BORDALLO, Guam          JOHN KLINE, Minnesota
PATRICK J. MURPHY, Pennsylvania      THOMAS J. ROONEY, Florida
HANK JOHNSON, Georgia                MARY FALLIN, Oklahoma
CAROL SHEA-PORTER, New Hampshire     JOHN C. FLEMING, Louisiana
DAVID LOEBSACK, Iowa
NIKI TSONGAS, Massachusetts
                David Kildee, Professional Staff Member
               Jeanette James, Professional Staff Member
                     Rosellen Kim, Staff Assistant









                            C O N T E N T S

                              ----------                              

                     CHRONOLOGICAL LIST OF HEARINGS
                                  2009

                                                                   Page

Hearing:

Friday, May 15, 2009, Fiscal Year 2010 National Defense 
  Authorization Act--Budget Request on Defense Health Program 
  Overview.......................................................     1

Appendix:

Friday, May 15, 2009.............................................    31
                              ----------                              

                          FRIDAY, MAY 15, 2009
FISCAL YEAR 2010 NATIONAL DEFENSE AUTHORIZATION ACT--BUDGET REQUEST ON 
                    DEFENSE HEALTH PROGRAM OVERVIEW
              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Davis, Hon. Susan A., a Representative from California, 
  Chairwoman, Military Personnel Subcommittee....................     1
Wilson, Hon. Joe, a Representative from South Carolina, Ranking 
  Member, Military Personnel Subcommittee........................     2

                               WITNESSES

Middleton, Allen W., Acting Principal Deputy Assistant Secretary 
  of Defense for Health Affairs, Department of Defense; Lt. Gen. 
  Eric B. Schoomaker, USA, Commanding General, U.S. Army Medical 
  Command, The Surgeon General, U.S. Army; Vice Adm. Adam M. 
  Robinson, USN, Surgeon General, U.S. Navy; Lt. Gen. James G. 
  Roudebush, USAF, Surgeon General, U.S. Air Force; and Charles 
  Campbell, Chief Information Officer, Military Health System, 
  Office of the Assistant Secretary of Defense for Health 
  Affairs, Department of Defense, beginning on...................     4

                                APPENDIX

Prepared Statements:

    Davis, Hon. Susan A..........................................    35
    Middleton, Allen W...........................................    38
    Robinson, Vice Adm. Adam M...................................    81
    Roudebush, Lt. Gen. James G..................................    94
    Schoomaker, Lt. Gen. Eric B..................................    57
    Wilson, Hon. Joe.............................................    37

Documents Submitted for the Record:

    [There were no Documents submitted.]

Witness Responses to Questions Asked During the Hearing:

    Ms. Shea-Porter..............................................   113
    Mr. Wilson...................................................   113

Questions Submitted by Members Post Hearing:

    Ms. Shea-Porter..............................................   117
 
FISCAL YEAR 2010 NATIONAL DEFENSE AUTHORIZATION ACT--BUDGET REQUEST ON 
                    DEFENSE HEALTH PROGRAM OVERVIEW

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
                           Military Personnel Subcommittee,
                              Washington, DC, Friday, May 15, 2009.
    The subcommittee met, pursuant to call, at 9:00 a.m., in 
room 2118, Rayburn House Office Building, Hon. Susan A. Davis 
(chairwoman of the subcommittee) presiding.

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

    Mrs. Davis. Good morning. Today's hearing is on the 
Department of Defense's fiscal year 2010 budget for the Defense 
Health Program.
    For the first time in three years, the Department of 
Defense (DOD) has not proposed massive TRICARE fee increases as 
part of their budget request. The increases proposed in 
previous years would have provided large savings for the 
Department, but most of the savings would have been the result 
of raising fees so high that large numbers of beneficiaries 
would choose to leave the system. We are encouraged that the 
Department has not chosen to pursue that course of action this 
year.
    The Secretary of Defense has said that his intent was to 
fully fund military health care in the fiscal year 2010 budget 
and then engage Congress in a dialogue about what comes next. 
We will obviously have to wait to start that conversation until 
the President's appointees are in place, but we look forward to 
the discussion this committee has been trying to have with the 
Department for years. Our beneficiaries deserve no less.
    We must now closely examine the budget proposal to see if 
it is, indeed, fully funded. I should mention that we have only 
had the budget justification materials for about the last 36 
hours and are still awaiting answers from the Department on 
various issues. It would be helpful if our witnesses could 
offer any insights they may possess on how certain amounts were 
chosen and how various decisions were made.
    During our annual reviews of the Defense Health Program 
(DHP) budget, we always ask questions about how the proposed 
budget will support our deployed service members and their 
families. In light of recent events, we will undoubtedly focus 
additional attention on how this proposed budget will improve 
mental health services, as well as any unfunded mental health 
requirements the services may have.
    For our witness panel, we have the Acting Principal Deputy 
Assistant Secretary of Defense for Health Affairs, Mr. Allen 
Middleton, representing the Office of the Secretary of Defense. 
Until recently, Mr. Middleton was the Acting Deputy Assistant 
Secretary of Defense for Health Budget and Financial Planning.
    So we know, sir, that you will be able to answer our budget 
questions in great detail.
    We also have all the service surgeon generals: Lieutenant 
General James Roudebush, from the Air Force; Vice Admiral Adam 
Robinson, from the Navy; and Lieutenant General Eric 
Schoomaker, from the Army.
    General Roudebush, I understand that you will be retiring 
in August, and we really appreciate all of your service. We 
want to thank you for the quiet determination with which you 
have led the Air Force Medical Service and the unwavering 
commitment that you have displayed for our men and women in 
uniform. Thank you very much, sir.
    General Roudebush. Thank you, ma'am.
    Mrs. Davis. You will be missed, and we wish you well in 
your future endeavors.
    And now I will turn to Mr. Wilson for his opening comments.
    [The prepared statement of Mrs. Davis can be found in the 
Appendix on page 35.]

   STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM SOUTH 
   CAROLINA, RANKING MEMBER, MILITARY PERSONNEL SUBCOMMITTEE

    Mr. Wilson. Thank you, Chairwoman Davis.
    Today, the subcommittee meets to hear testimony on the 
Defense Health Program, DHP, for fiscal year 2010. Although we 
routinely have an annual hearing on the DHP, I want to 
emphasize that there is nothing routine about the Military 
Health System and the extraordinary care it provides to our 
service members around the globe and their families.
    This subcommittee remains committed to ensuring that the 
remarkable men and women who are entrusted with the lives of 
our troops have the resources to continue their work for future 
generations of our most deserving military beneficiaries. I 
would like to express my deep appreciation to all of the 
Military Health System (MHS) leadership and personnel who are 
responsible for delivering the highest-quality health care 
during these most challenging times.
    To begin, I want to commend the Department of Defense for 
sending us, for the first time in four years, a fully funded 
budget for the Defense Health Program. I applaud Secretary 
Robert Gates for hearing what Congress and our military 
beneficiaries have said repeatedly: Increasing TRICARE fees is 
not the solution for containing the rising costs of military 
health care.
    With that, I am anxious to hear from our witnesses today 
how the Department plans to develop a comprehensive approach to 
providing world-class health care to our beneficiaries while, 
at the same time, controlling costs. I look forward to working 
with the leadership of the Military Health System toward that 
end. I would also like to hear your commitment that all of the 
stakeholders in the military health care will be involved in 
the process.
    I am interested in hearing from the witnesses how the DHP 
supports the critical mental health services needed by our 
service members and their families, particularly the National 
Guard and Reserve members, who rely primarily on TRICARE 
Standard.
    I would like to hear from our military surgeon generals 
whether the DHP will fully support their responsibility to 
maintain medical readiness, provide health care to eligible 
beneficiaries, provide battlefield medicine to our brave men 
and women in Iraq and Afghanistan in the Global War on 
Terrorism, and care for those brave men and women through the 
long recovery process when they become injured and wounded.
    And, as we conclude, I want to join with Chairwoman Davis 
and commend General Roudebush on his service.
    And thank you very much, and we wish you well and a long, 
healthy, and happy retirement.
    General Roudebush. Thank you, sir.
    Mr. Wilson. With that, I would like to welcome our 
witnesses and thank them for participating in the hearing 
today. I look forward to your testimony.
    [The prepared statement of Mr. Wilson can be found in the 
Appendix on page 37.]
    Mrs. Davis. Thank you, Mr. Wilson.
    I also wanted to introduce Mr. Charles Campbell, chief 
information officer for the Military Health System, Office of 
the Assistant Secretary of Defense for Health Affairs, the 
Department of Defense.
    Thank you very much, sir, for being here.
    And I will start with some questions, and hopefully, you 
know, we might end up with a real dialogue today because, as 
you know, Members went back to their districts, and so we have 
fewer Members today.
    Mr. Middleton, Mr. Campbell, back in March, we, along with 
the Subcommittee on Terrorism and Unconventional Threats and 
Capabilities, held a joint hearing on the Department of 
Defense's health information technology systems. And at that 
hearing, we heard from the services about the difficulties they 
had faced with Armed Forces Health Longitudinal Technology 
Application (AHLTA). We were encouraged to hear from Health 
Affairs that you agree that there are serious problems and even 
more encouraged when you presented what appeared to be an 
ambitious and comprehensive plan to overhaul the system to 
address all of the issues raised by the services and provide 
the best health information technology (IT) system possible for 
the Department's beneficiaries.
    At that hearing--I am starting to ask you questions before 
you make your presentation, but maybe I will do that and you 
can start trying to incorporate them, if you will? Okay?
    Or maybe not. Let's go ahead. Let's just start the hearing 
with your presentations, and then we will get to our questions. 
I am so eager to ask that question. But it is important to hear 
from you first.
    If you want to address the IT question, you can, but we 
will come back to it and come back to a number of other 
questions. As I mentioned, mental health is certainly on our 
minds, and we know that there are a number of issues that you 
really want to share with us, as well.
    So let's begin with Mr. Middleton. Thank you.

   STATEMENTS OF ALLEN W. MIDDLETON, ACTING PRINCIPAL DEPUTY 
 ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS, DEPARTMENT 
   OF DEFENSE; LT. GEN. ERIC B. SCHOOMAKER, USA, COMMANDING 
 GENERAL, U.S. ARMY MEDICAL COMMAND, THE SURGEON GENERAL, U.S. 
 ARMY; VICE ADM. ADAM M. ROBINSON, USN, SURGEON GENERAL, U.S. 
NAVY; LT. GEN. JAMES G. ROUDEBUSH, USAF, SURGEON GENERAL, U.S. 
  AIR FORCE; AND CHARLES CAMPBELL, CHIEF INFORMATION OFFICER, 
 MILITARY HEALTH SYSTEM, OFFICE OF THE ASSISTANT SECRETARY OF 
       DEFENSE FOR HEALTH AFFAIRS, DEPARTMENT OF DEFENSE

                STATEMENT OF ALLEN W. MIDDLETON

    Mr. Middleton. Thank you, Madam Chairman, members of the 
committee. Thank you for this opportunity to discuss the 
priorities of the Military Health System and its budget for 
fiscal year 2010. We are pleased to be here.
    The men and women of America's Armed Forces are our 
country's greatest strategic asset. And apart from defending 
the Nation, the Department has no higher priority than to 
provide the highest quality and support to our forces and, of 
course, their families.
    As Secretary Gates has said, at the heart of the All-
Volunteer Force is the contract between the United States of 
America and the men and women who serve, a contract that is 
legal, social, and sacred. When young Americans step forward on 
their own free will to serve, he said, they do so with the 
expectation that they and their families will be properly taken 
care of.
    Indeed, the Military Health System has one overarching 
mission: to provide optimal health services systems in support 
of our Nation's military mission anytime and anywhere. Today, 
the Military Health System serves 9.4 million beneficiaries: 
active duty, their family members, our retired military members 
and their families.
    In addition to force health protection and family support, 
the MHS provides humanitarian assistance at home and around the 
world and supports world-class education, training, and 
research.
    Our strategic plan, developed in concert with the surgeon 
generals and the joint staff, supports all of these three 
component missions. It also recognizes the outcomes the 
American people expect from their investment in military 
medicine. In addition to a fit, healthy, and protected force, 
our goals include the lowest possible rate of death, injury, 
and disease during military operations; superior follow-up care 
that includes transition to the Department of Veteran Affairs; 
healthy and resilient individuals, family and communities; and 
the high-quality, cost-effective care our Nation expects.
    We appreciate deeply the support that Congress, especially 
this committee, has provided to us to help deliver the very 
best health care for our forces and their families, and in 
particular for our wounded, ill, and injured. I believe we have 
made significant progress toward each of these goals.
    And I have provided this information in considerable detail 
in my submitted written statement to you. For now, let me 
briefly summarize the uniform medical budget request for 2010.
    The Department's total request for health care in fiscal 
year 2010 is $47.4 billion, including the Defense Health 
Program; the wounded, ill, and injured for rehabilitation; 
military personnel; military construction; and contributions to 
the Medicare-Eligible Retiree Health Care Fund.
    The largest portion of our budget, almost $28 billion, is 
requested by the Defense Health Program for operations and 
maintenance, procurement, research and development, test and 
evaluation. $0.3 billion is requested for equipment and systems 
procurement; $0.6 billion is requested for military-relevant 
medical research; and $0.4 billion to improve survivability and 
quality-of-life issues.
    For military personnel, the budget request is $7.7 billion 
to support more than 84,000 military personnel who provide the 
mental health care services to our deployed forces around the 
world, including aeromedical evacuation, shipboard and undersea 
medicine, and global humanitarian assistance and response.
    Funding for military construction is at $1 billion in 
fiscal year 2010 for 23 construction projects, including phase 
one of the replacement at Guam and for an ambulatory care 
center at Lackland Air Force Base, Texas.
    In the Medicare-Eligible Retiree Health Care Fund, the fund 
which supports the TRICARE for Life program, our estimated 
normal cost contribution this year is just under $11 billion.
    For our wounded, ill, and injured members, the 2010 DHP 
budget includes $1.7 billion for enhanced care as well as 
research efforts to mitigate the effects of psychological 
health and traumatic brain injury.
    All of the requirements of both the service medical 
departments and the TRICARE management activity were funded by 
the Secretary, and we do not anticipate any additional 
requirements at this time.
    You will be interested to know that this budget does not 
include any benefit reform savings, as you mentioned, with 
beneficiary enrollment fee or co-pay increases, and they remain 
the same.
    The military treatment facility (MTF) efficiency wedge 
previously assumed has also been fully restored to the 
services' medical departments. And the previously programmed 
military-to-civilian conversions are being restored in 
accordance with the fiscal year 2008 National Defense 
Authorization Act, and that restores just under 5,500 billets 
in 2010.
    Madam Chairman, the Military Health System is dedicated to 
doing the very best we can for the men and women who give 
everything they have for each one of us. We can never fully 
repay them for the sacrifices they make for our country and for 
our future, but we can and will continue to do everything we 
can to heal their wounds and to honor their courage and 
commitment to the country that we all love.
    Thank you again for this opportunity with you, and we do 
look forward to your questions.
    [The prepared statement of Mr. Middleton can be found in 
the Appendix on page 38.]
    Mrs. Davis. Thank you very much.
    General Schoomaker.

            STATEMENT OF LT. GEN. ERIC B. SCHOOMAKER

    General Schoomaker. Madam Chairwoman, Representative 
Wilson, and other distinguished members of the Military 
Personnel Subcommittee, thank you for the opportunity to 
discuss Army Medicine and the Defense Health Program today.
    In recognition, again, that 2009 is our year of the non-
commissioned officer (NCO) in the Army, I am joined today by my 
senior enlisted medic and my battle buddy, Command Sergeant 
Major Althea Dixon. And she is my constant reminder that our 
NCO corps really is what makes Army and Army Medicine strong.
    What distinguishes military and Army Medicine from U.S. 
health care as a whole is our commitment to improving and 
sustaining the health of the force as a strategic imperative. 
On the Army strategy map that was a part of the packet that you 
all received, we used a Kaplan and Norton-developed Harvard 
Business School balanced score card approach to both leadership 
and management of Army Medicine.
    We have included two of our six strategic goals, or ends, 
that highlight the improved health and protection of our 
personnel, be they warriors or families or beneficiaries or 
civilians. The health of the force, and by extension that of 
our families and all of our beneficiaries, is a national asset. 
It is heightened by our reliance on an All-Volunteer Force. I 
will say that again: Our reliance on an All-Volunteer Force 
especially has pushed us toward an increased focus upon keeping 
the force healthy and able to be mission-focused from the 
beginning.
    In order to make the assertion that we are a system of 
health, as opposed to a health care system, delivering health 
care alone, that we are a system of health, we have taken 
several key actions.
    First, we stay focused at a corporate level on optimizing 
health through evidence-based practices, which raise our 
markers of future care, or proxies I call them, of current and 
future health, like vaccination rates or compliance with the 
United States Preventive Services Task Force guidelines for 
screening, and our Healthcare Effectiveness Data and 
Information Set, or HEDIS, measures. These are population 
health improvement and evidence-based practices which are being 
uniformly applied across U.S. medicine but especially within 
the Military Health System.
    A second issue or approach is by resourcing our commands to 
effect these population health outcomes and permit the 
generation of revenue, which encourages these and other best 
practices aimed at raising the health of the beneficiary 
population. This is different than much of American medicine, 
where preventative measures in optimizing health is not well-
reimbursed and resourced. We have shifted our revenue stream 
increasingly toward optimization of health.
    Third, we have moved toward maintaining strong links to 
like agencies and organizations which foster and reduce risky 
behaviors that enhance evidence-based practices and promote 
healthy lifestyles, the Department of Veterans Affairs (VA) 
being among them.
    We establish programs and partnerships which protect the 
health of the population through shared health surveillance, 
through the prevention of epidemic disease, enhanced food and 
water safety, enhanced resilience of the force, and the like.
    Army Medicine is currently reviewing options for developing 
a public health command within the Army, where we have a single 
focus of public health within the Army from all of those who 
contribute to that, whether they be veterinarians, public 
health officers, nurse community health workers, or the like. I 
think it would be beneficial to the Army and our soldiers to 
create a single point of expertise and responsibility for 
public health.
    These and other examples demonstrate that Army and military 
medicine--I am joined by my colleagues--are increasingly a 
system for health in every regard raised, from increasing HEDIS 
measures, to a health-focus performance-based budgeting 
process, to the development of the Army comprehensive soldier 
fitness initiative where we build resilience and the physical, 
emotional, intellectual, spiritual fitness in response--and it 
is illustrated by our response to H1N1 flu this year and our 
stance against future bio threats.
    It is one significant aspect of how military medicine is 
different from civilian medical organizations and why we cannot 
be compared entirely to civilian medicine. I strongly believe 
that we must focus on building and maintaining health and 
resilience and in conducting science-based, evidence-based 
practices focusing on optimal clinical outcomes when bad things 
happen to good people and they fall off this balance beam of 
health. That happens in combat; it happens with serious disease 
and injury.
    I believe--and you all posed this question--I believe that 
this approach will ultimately lead to the best results both for 
the Army and the military community, and it will deliver the 
most cost-effective system of health and health care. Focus on 
evidence-based practices, on health and on outcomes.
    Another striking difference between military and civilian 
medicine is our Wounded Warrior mission. It is an inherent--
there are inherent, operationally driven inefficiencies 
involved in the delivery of care to this complex population of 
warriors in transition.
    On a per capita basis, the care of wounded, ill, and 
injured soldiers, or what we call Warriors in Transition, 
consume upwards to six times as much health care resources as a 
healthy population. Now, you see this when you go to our 
military hospitals in our Warrior Transition Units (WTU), where 
we have placed some of the talented officer and NCO leaders and 
where nurses and physicians and occupational therapists, 
physical therapists, behavioral health providers and many 
others combine their expertise in an intense effort to recover 
and rehabilitate and transition and reintegrate these great 
warriors and care for their families.
    The intensity of care delivered to these almost now 10,000 
warriors is not comparable in any other civilian setting. These 
Warriors in Transition deserve every bit of the care and 
attention, as mentioned earlier by my colleague, from Health 
Affairs. But I raise this as another example of the uniqueness 
of Army and military medicine. It is not replicated in the 
civilian setting, and it probably never will be because of 
expertise and cost inefficiencies in running such a program.
    Finally, let me just comment--as you asked, ma'am, and you, 
sir--about our efforts to prevent, mitigate, identify, manage, 
and treat behavioral health consequences of service in uniform 
and those arising from frequent deployments, long family and 
community separations, and exposure to the rigors of combat.
    Army leaders at all levels recognize that combat and 
repeated deployments are difficult for soldiers and they stress 
our families. We are making bold, sustained efforts to improve 
the resilience of the entire Army and its family, to reduce the 
stigma associated of seeking mental health care, and to provide 
multidisciplinary care which addresses specific behavioral and 
health needs promptly and expertly.
    We are resolved to prevent adverse social outcomes 
associated with military service and combat, such as driving 
while intoxicated and family violence and other such 
misconduct.
    Suicides are unacceptable losses of our soldiers. Realizing 
that the loss of even one soldier to suicide is one too many, 
we are looking closely at factors involved. And rather than 
post-traumatic stress disorder, as one might expect, we 
continue to see that fractured relationships and work-related 
stresses are the major factors in soldier suicides. We have 
numerous coordinated and integrated initiatives in place to 
help soldiers and their families. I am eager to discuss these 
and any other issues in this realm that you wish to address.
    In closing, I want to thank again the committee for their 
terrific support of the Defense Health Program and of Army 
Medicine.
    As I close, I would like to salute our non-commissioned 
officers for their professionalism and competence and 
leadership.
    And, ma'am and sir, I am pleased that you recognized my 
colleague, our colleague, Jim Roudebush, as he gets ready to 
depart a long and distinguished service in Air Force Medicine. 
He embodies, really, a scholarly wisdom, unflappability, and 
experience. And he has really taught us what being a wingman 
is.
    And what we are very pleased with is, as he leaves service, 
he leaves a son in an Army uniform in a Stryker Brigade in Fort 
Lewis, Washington. And so I will close by saying, ``Army strong 
and air power.''
    [The prepared statement of General Schoomaker can be found 
in the Appendix on page 57.]
    Mrs. Davis. Thank you very much.
    Admiral Robinson.

            STATEMENT OF VICE ADM. ADAM M. ROBINSON

    Admiral Robinson. Good morning. Chairwoman Davis, 
Congressman Wilson, distinguished members of the committee, 
thank you for the opportunity to be here this morning.
    Navy Medicine continues on course because our focus has 
been and will always be providing the best health care for our 
sailors, Marines, and their family members while supporting our 
Nation's overseas contingency operations.
    As Admiral Mullen pointed out earlier this week, the Navy 
is doing a lot more than most people know about. Navy Medicine 
is meeting the mental and physical needs of our service members 
abroad and preparing healthy and fit sailors and Marines to 
protect our Nation and deploy.
    We are continuously making the necessary changes and 
improvements to meet the requirements of the biggest consumer 
of our operational support efforts, the Marine Corps. 
Currently, we are realigning medical capabilities to support 
operational forces in emerging theaters of operation. Navy 
Medicine's combat medical support has proven exceptionally 
successful, and we will sustain and improve those efforts in 
the future.
    The Navy's humanitarian and civil assistance missions are 
increasing, and this year, our efforts will include missions in 
the U.S. Southern and Pacific Command areas of operation.
    As previously announced, our plans included deploying the 
USS Dubuque (LPD 8) later this year as part of the Pacific 
Partnership 2009. However, an outbreak of H1N1 influenza among 
the ship's crew has altered those plans. We are actively 
engaged in finding alternative ways to deliver medical care to 
these nations and ensuring the medical care provided positively 
impacts the perception of the United States and our allies by 
other nations.
    I would like to take this opportunity to point out that, 
although the operational portion of our humanitarian missions 
are funded by the Navy's Fleet Forces Command, Navy Medicine is 
not afforded any credit for the work performed during these 
critical missions. In fiscal year 2008, Navy Medicine deployed 
medical providers in support of worldwide missions. These 
providers had almost 130 outpatient and over 1,100 inpatient 
encounters worldwide. We are also taxed in our direct-care 
reimbursement funding as part of the Health Affairs pay-for-
performance calculations.
    I also remain concerned about how the increases in private-
sector care costs will be addressed, as the care we provide in 
our medical treatment facilities must be preserved in order to 
meet our dual mission of operational support and beneficiary 
health care. Growing resource constraints for Navy Medicine are 
real, as is the increasing pressure to operate more efficiently 
without compromising health care quality and workload goals. We 
continue to make improvements to meet the needs of sailors and 
Marines who have been injured and have significantly expanded 
services so wounded warriors have access to timely, high-
quality medical care.
    Navy Medicine's concept of care is patient- and family-
focused. We never lose our perspective in caring for our 
beneficiaries. Everyone is a unique human being in need of 
individualized, compassionate, and professionally superior 
health care.
    As of May 2009, 171 medical case managers were assigned to 
45 medical treatment facilities and ambulatory care clinics, 
caring for approximately 1,500 Operation Enduring Freedom/
Operation Iraqi Freedom casualties. The medical case care 
managers collaborate with Navy Safe Harbor and Marine Corps 
Wounded Warrior Regiment and new programs, such as Families 
Overcoming Under Stress, FOCUS, in working directly with our 
beneficiaries, our wounded warriors, their families and 
caregivers, and the multidisciplinary medical team to 
coordinate the complex services needed for improved health 
outcomes.
    The Bureau of Medicine and Surgery (BUMED) Wounded Warrior 
Regiment Medical Review team and the Returning Warrior 
Workshops support Marines and Navy sailors, reservists, and 
their families by focusing on key issues faced by personnel 
during their transition from deployment to home.
    Navy and Marine Corps liaisons at medical treatment 
facilities aggressively ensure that orders and other 
administrative details, such as extending reservists, are 
completed. In addition, we recently hired 25 psychological 
outreach coordinators to identify and meet the mental health 
needs of our reservists.
    Navy Medicine has also partnered with Navy and Marine Corps 
communities to identify specific populations at risk for 
traumatic brain injury in frontline units, such as SEALs (Sea, 
Air, Land) and Navy Explosive Ordnance Disposal Units.
    Navy Medicine's innovative deployment health centers, 
currently in 17 high fleet and Marine Corps concentration 
areas, supports the deployment health assessment process and 
serve as easily accessible and nonstigmatizing portals of entry 
for our forward mental health care. Since their establishment 
in 2007, the centers have accomplished over 150,000 health care 
encounters, with about 23 percent for psychological health 
issues. This further demonstrates our expanded efforts where 
primary care providers are addressing the mental health needs 
of our sailors and Marines, as we continue to expand our 
operational stress and resiliency programs from boot camp 
through war college.
    Navy Medicine's partnership with the Department of Veterans 
Affairs' medical facilities continues to be mutually 
beneficial. This coordinated care for our warriors who transfer 
to or are receiving care from a VA facility ensures their needs 
are met and their family concerns are addressed.
    Working closely with the Chief of Navy Personnel, medical 
recruiting continues to be one of our top priorities. And we 
thank Congress for their generous support of our medical 
special pay and bonus authority.
    In spite of the successes in medical and dental corps 
recruitment into our scholarship programs, meeting our direct 
accession mission still remains a challenge. I anticipate 
increased demand for Medical Service Corps personnel, our most 
diverse corps with 31 specialties. This is especially true 
among Medical Services Corps specialties linked to mental, 
behavioral, and rehabilitative health and operational support, 
such as clinical psychologists, social workers, occupational 
therapists, physician assistants, and physical therapists.
    Consistent with increased operational demand signals, as 
well as to compensate for prior shortfalls in recruiting, the 
overall recruiting call for the Uniformed Medical Service Corps 
officers have nearly doubled since fiscal year 2007. For the 
first time in over five years, Navy Nurse Corps officers gained 
in 2008 outpaced losses. Despite the growing national nursing 
shortage and the resistance of the civilian nursing community 
to recession, the recruitment and retention of Navy nurses 
continues to improve.
    Chairwoman Davis, Congressman Wilson, I would like to take 
this opportunity to offer my deep condolences to the Springle 
family and the families of the other victims of this week's 
tragic events at Camp Liberty in Iraq. Commander Springle was a 
Navy social worker serving with the Army's 55th Medical Company 
as an individual augmentee.
    I would also like to extend my congratulations to Jim 
Roudebush on being a wonderful shipmate, wingman, a wonderful 
partner in this military health establishment that we have 
here, and someone that was always dependable, both as a 
professional and as a friend.
    Thank you again for providing me the opportunity to 
testify, and I look forward to answering your questions.
    [The prepared statement of Admiral Robinson can be found in 
the Appendix on page 81.]
    Mrs. Davis. Thank you, Admiral.
    And, General Roudebush, if you would continue. And 
obviously you have been a tremendous mentor and colleague to 
many that you served with. And we thank you again.

            STATEMENT OF LT. GEN. JAMES G. ROUDEBUSH

    General Roudebush. Madam Chairwoman, Congressman Wilson, 
thank you for the very kind thoughts you have expressed, and 
certainly those of my colleagues. I will tell you, it is a 
privilege to serve, but as I move to the next chapter, each of 
us who serves may stop wearing the uniform but we never take it 
off and we continue to serve. And I look forward to that. Thank 
you, ma'am.
    It is a pleasure to be here today to talk to you about the 
Air Force Medical Service. Air Force Medicine contributes 
significantly to our joint capability as part of a joint team 
in the joint war-fight, serving those men and women in harm's 
way and serving our Nation with combat casualty care, wartime 
surgery, and aeromedical evacuation.
    On the ground, at both the Air Force Theater Hospital in 
Balad, Iraq, and the SSG Heath N. Craig Joint Theater Hospital 
in Bagram, in Afghanistan, we are leading numerous combat 
casualty care initiatives that will positively impact combat 
and peacetime medicine for years to come.
    Air Force surgeons have laid the foundation for a state-of-
the-art intervascular operating room at Balad, the only DOD 
facility of its kind. Their innovative technology and surgical 
techniques have greatly advanced the care of our joint war-
fighters and coalition casualties. And in conjunction with our 
Army and Navy brothers and sisters, they have literally 
rewritten the book on the use of blood in trauma resuscitation.
    To bring our wounded warriors safely and rapidly home, our 
Critical Care Air Transport Teams, our CCATTs, provide a unique 
intensive care unit (ICU) care in the air within DOD's joint en 
route medical care system. We continue to improve the outcomes 
of the care of our CCATT wounded warriors by incorporating 
lessons learned in clinical practice guidelines and modernizing 
equipment to support that mission.
    This Air Force-unique expertise also pays huge dividends 
back home. When Hurricane Katrina and Rita struck in 2005, Air 
Force active-duty Guard and Reserve medical personnel were in 
place conducting lifesaving operations. Similarly, hundreds of 
members of this total force team were in place September 1st, 
2008, when Hurricane Gustav struck the Louisiana coast and when 
Hurricane Ike battered Galveston, Texas, less than two weeks 
later. During Hurricane Gustav, Air Mobility Command 
coordinated the movement of more than 8,000 evacuees, including 
600 patients. Air crews transported post-surgical and intensive 
care patients from Texas area hospitals to Dallas. I am 
extremely proud of this incredible team effort.
    The success of our Air Force mission directly correlates 
with our ability to build and maintain a healthy and fit force 
at home station and in theater. Always working to improve care, 
our Family Health Initiative establishes an Air Force medical 
home. This medical home optimizes health care practice within 
our family health care faculties and clinics, positioning a 
primary care team to better accommodate the enrolled population 
and streamline the processes for care and disease management. 
The result is better access, better care, and better health.
    The psychological health of our airmen is also critically 
important. To mitigate their risk for combat stress symptoms 
and possible mental health problems, our program known as 
Landing Gear takes a proactive approach with education and 
symptom recognition, both pre- and post-deployment. We educate 
our airmen that recognizing risk factors in themselves and 
others, along with a willingness to seek help, is the key to 
effectively functioning across the deployment cycle and 
reuniting and reintegrating with their families. Likewise, we 
screen very carefully for traumatic brain injury at home and at 
our forward-deployed locations.
    To respond to airmen's needs, we have over 600 active-duty 
and 200 civilian and contract mental health providers. This 
mental health workforce has been sufficient to meet the demand 
signal that we have experienced to date. That said, we do have 
challenges with respect to active-duty psychologist and 
psychiatrist recruiting and retention. And we are pursuing 
special pays and other initiatives to try to bring us closer to 
100 percent staffing in these two critically important 
specialties.
    For your awareness, over time we are seeing an increasing 
number of airmen with post-traumatic stress disorder (PTSD). 
One thousand seven hundred fifty-eight airmen have been 
diagnosed with PTSD within 12 months of return from deployment 
from 2002 to 2008. As a result of our efforts at early post-
traumatic stress identification and treatment, the vast 
majority of these airmen continue to serve with the benefit of 
treatment and support.
    Understanding that suicide prevention, as well, lies within 
and is integrated into the broader construct of psychological 
health and fitness, our suicide prevention program, a 
community-based program, provides the foundation for our 
efforts. Rapid recognition, active engagement at all levels, 
and reducing any stigma associated with seeking help are 
hallmarks of our program. One suicide is too many, and we are 
working hard to prevent the next.
    Sustaining the Air Force Medical Service requires the very 
best in education and training for our professionals. In 
today's military, that means providing high-quality programs 
within our system, as well as strategically partnering with 
academia, private-sector medicine, and the VA to ensure that 
our students, residents, and fellows have the best training 
opportunities possible.
    While the Air Force continues to attract many of the finest 
health professionals in the world, we still have significant 
challenges in recruiting and retention. We are working closely 
with our personnel and recruiting communities, using accession 
and retention bonus plans to ensure full and effective staffing 
with the right specialty mix to perform our mission.
    At the center of our strategy is the Health Profession 
Scholarship Program (HPSP). HPSP is our most successful 
recruiting tool, but we are also seeing positive trends in 
retention from our other financial assistance programs and pay 
plans. Thank you for your unwavering support in helping us both 
establish and fund those programs.
    In summary, Air Force medicine is making a difference in 
the lives of airmen, soldiers, sailors, Marines, family 
members, coalition partners, and our Nation's citizens. We are 
earning their trust every day.
    As we look forward to the way ahead, I see a great future 
for the Air Force Medical Service, built on a solid foundation 
of topnotch people, outstanding training programs, and strong 
partnerships. It is indeed an exciting, challenging, and 
rewarding time to be in Air Force and military medicine. I 
couldn't be more proud of this great team.
    We join our sister services in thanking you for your 
enduring support, and I look forward to your questions.
    [The prepared statement of General Roudebush can be found 
in the Appendix on page 94.]
    Mrs. Davis. Thank you, General.
    As I started to ask you earlier about the health IT system, 
this is obviously something that is of great concern. Going 
back to March, along with the Subcommittee on Terrorism and 
Unconventional Threats and Capabilities, this committee held a 
joint hearing on the Department of Defense's health information 
technology systems. And we heard from the services about the 
difficulties that they were really having with the AHLTA 
system.
    We were encouraged to hear from Health Affairs that you 
agree that there are serious problems, and even more encouraged 
when you presented what appeared to be an ambitious and 
comprehensive plan to overhaul the system to address all the 
issues raised by the services and provide the best health IT 
system possible for the Department's beneficiaries.
    And at that particular hearing, Dr. Casscells and you also, 
Mr. Campbell, assured us that you were committed to moving 
forward with your proposed solution but that you could not 
discuss cost details because both the fiscal year 2009 
supplemental request and the fiscal year 2010 budget were still 
in progress.
    But now that we have received the 2010 budget justification 
materials, we can't seem to find any mention of any of the 
promises that you made during the March hearing. And a review 
of the fiscal year 2009 supplemental request did not turn up 
any mention of that plan either. So, as you can imagine, we are 
trying to understand that.
    And sometimes this kind of conflict is not really 
unprecedented. During preparation of last year's National 
Defense Authorization Act, Mr. Campbell, you and Dr. Casscells 
both assured us, during a Member briefing, that you were aware 
of the problems with AHLTA and would provide us with a plan to 
fix the problems.
    And following that meeting, Health Affairs provided us with 
a roadmap for the way ahead. But, again, none of the elements 
of that roadmap ever found their way into either the 2008 
supplemental request or fiscal year 2009 budget request at that 
earlier period. And so, we have some concern that things are 
not moving forward.
    Could you please share with us what is going on? What is 
happening in the decision-making around the issue? And when 
will we see some fulfillment of the commitments that were made 
to the committee back in March?
    Mr. Campbell. Yes, ma'am. Thank you for the question.
    Going back to the 2007 discussion that we had, as you 
mentioned, it wasn't in the budget for that year. What we did, 
though, is, within the budget that we had, we focused our 
efforts to meet the requirements of the theater health 
information systems that were----
    Mrs. Davis. If you could get a little closer to the mike. 
Thank you.
    Mr. Campbell. Sorry, ma'am.
    So we focused that year, in 2008, and part of also 2009, we 
continued to focus our efforts on the theater health systems. 
And within our budget at that time--we didn't ask for 
additional dollars, but within our budget at that time we 
implemented that services-oriented architecture approach that 
we had talked about for doing the larger-scale system and have 
made some great improvements in that, in setting up that 
application or that system that allows us to more quickly 
develop capabilities for the users and to allow us to more 
seamlessly share that information across DOD and across the VA. 
So that was implemented over last year, in 2008, and we are 
still working that in 2009 within our current budget.
    You are absolutely right in that, when we were here in 
March, we had a very comprehensive plan. We still have that 
comprehensive plan. It wasn't complete at that time. I think we 
mentioned that at the end of March was when the blueprint was 
going to be finished. The blueprint was finished and turned in. 
And we are in discussions right now on how we are going to 
implement that within the current budget.
    So we are doing things to improve the systems now with our 
current baseline. For example, one of the key components that 
the services and others have mentioned to us is maintaining the 
stability of the system. A key to that stability is our one 
central data repository that we have where all of the 
information is stored. If, for some reason, that goes down and 
is not working, then everyone goes into a failover mode.
    So we have focused some efforts recently, within the last 
two months, on stabilizing the central data repository so that 
we can keep it up and running. And we have made some good 
improvements on that.
    Mrs. Davis. Mr. Campbell, could you identify the dollars 
that you have available to you to do this work?
    Mr. Campbell. Within our current budget?
    Mrs. Davis. Yes.
    Mr. Campbell. Yes, ma'am. Within our current--I think it is 
the 2009 budget, I think for the total electronic health record 
system in our current budget, I believe it is around $500 
million, in our current budget for 2009, for all parts, all 
components of the electronic health records system. That 
includes the infrastructure piece, that includes the central 
data repository, the old legacy system, Composite Health Care 
System (CHCS).
    A lot of that money is used to sustain our current efforts, 
but it also has some dollars in there for development and for 
procuring new equipment.
    Mrs. Davis. What would you anticipate then--where are the 
shortfalls going to be? Are there any, in terms of being able 
to do all the work that you really feel that you need to do to 
speed up this effort?
    Mr. Campbell. And, ma'am, we are going through that right 
now. We are analyzing that now to determine where all of the 
shortfalls are, what other parts of the electronic health 
records system we can postpone fixing until we fix these main 
issues. So we are still in the deliberations of that right now, 
ma'am.
    Mrs. Davis. So there are some areas that won't be 
addressed?
    Mr. Campbell. The focus will be to fix the stability, the 
performance, and the usability of AHLTA.
    Mrs. Davis. Is there a sense of how important this is?
    Mr. Campbell. Absolutely, ma'am. Absolutely. This is key. 
We understand--and, you know, we have had many different forums 
where we have talked to the users, whether it is through the 
Web halls, through town hall meetings. I have gone out to many 
facilities and directly talked with the providers there. We 
absolutely understand how important this is to fix this and 
make it right.
    What we are doing with this not only is, though, important 
for just DOD, the stabilizing, making this work, building this 
new architecture we know is extremely important to support and 
enable what President Obama mentioned was the, you know, 
virtual electronic record with VA. And so this does support and 
enable that. So we understand how important this is, ma'am.
    Mrs. Davis. For people who are watching and for families 
out there, I think we talk about the system itself, but how 
does this really affect the men and women who serve and their 
families? Why is it important to them?
    Mr. Campbell. From my perspective, ma'am, it is important 
for the users, the providers who use the system, who treat the 
patients, to have all of that information available wherever 
they are at and all of the information that they need to 
provide that care. It is absolutely important that they have 
that information and it is always available and the data is 
always available and the system is always available.
    So we understand how important it is to the individuals. 
And not only that, from the longitudinal health record 
perspective, we understand how important it is to capture all 
of that information electronically so that, when a service 
member does retire or separate and goes to the VA, they get all 
the benefits that they have earned and deserve.
    Mrs. Davis. I wonder if the surgeon generals would like to 
respond. Is that a satisfying answer to you? And what 
information could you share with us, as well?
    General Schoomaker. Well, ma'am, I will take a stab.
    I mean, I completely concur with what Mr. Campbell just 
talked about, as far as the central role of electronic health 
record. I mean, quite honestly, we are in an era----
    Mrs. Davis. I think I am referring more to the issue we 
have around the budget and whether or not we are going to be 
able to do the work that is required and in a timely fashion.
    General Schoomaker. Well, I can't speak to that as much. I 
mean, I can tell you that, since the hearing earlier, the joint 
hearing that was held around the information system, certainly 
Health Affairs has redoubled their efforts to bring the 
services inside the building of a comprehensive strategy, 
rather than to piecemeal a plan that just Band-Aids over 
problems. I am getting feedback from our representatives on 
that group that we are doing some very serious, truly building 
the comprehensive strategy.
    Mrs. Davis. That is good. Would you say that that wasn't 
the case before?
    General Schoomaker. No, ma'am, I wouldn't. That is what we 
said at the time.
    Mrs. Davis. Okay. Thank you. Good to hear that.
    Admiral.
    Admiral Robinson. I am always careful when I get into the 
IT world because it is not something that I know a lot about 
from a technical point of view.
    From a patient- and family-centered care point of view, the 
question you asked is, how is this important to the men and 
women, our beneficiaries? And the essence of care centers 
around the availability of relevant information that can be 
easily attainable at any time of the day and night in any place 
in the world.
    So the impact of the casualty care system that we have 
encountered in Iraq, Afghanistan, with the CCATTS, with the 
Army, Navy, Air Force coming together, part of that has been 
based upon having good information. We have to have the same 
type of electronic medical records system in this country.
    And I would also say, it is a patient issue, but it is also 
a provider issue. Our providers, in all services, want to have, 
must have, a capable system that is user-friendly and that will 
allow them to make the encounter with their patients the most 
meaningful and with the best quality of care. So this hits a 
number of issues, but, at the essence, it is the patient and 
the care issue and the quality issue that this becomes 
extraordinarily important.
    There comes a point when trying to get it done isn't good 
enough; you have to get it done. And I am speaking now as a 
surgeon and as a physician, not as an administrator. You just 
have to--sometimes you have to get it done, and you have to get 
it done right.
    I think that we are at the point now where Health Affairs--
and Chuck and Mr. Campbell and all of the folks--are, in fact, 
doing the best that they can. But we really have to solve this 
because this becomes a quality and a care issue that is not 
going to go away, and we will have to get this solved.
    Mrs. Davis. Thank you.
    General.
    General Roudebush. Ma'am, I would certainly echo the 
thoughts provided. Information that is accurate, timely, and 
available is absolutely essential to the standard of care that 
we provide at home and deployed. It is absolutely critical to 
providing that level of care that is both expected and 
deserved. So I think everything that we need, in terms of 
delivering that care, needs to be present. Information is a 
central piece of that.
    I would agree that the emphasis is appropriately provided. 
I think we are all in agreement that this is a central and 
critical issue. We are also in agreement that we have great 
work to do, much work to do, and that there is much yet to do.
    I would offer one additional perspective. It is very 
important to the patient, no doubt about that. It is very 
important to the provider to be able to deliver that kind of 
care. But I would also suggest that it is an important 
retention issue for our providers, because it is a source of 
great frustration and very time-consuming as our medical 
professionals attempt to have balance in their lives, as well, 
between a satisfying and engaged practice of medicine at all 
locations--personal growth, professional growth, and time with 
their families. Having an information system that is an ally 
and an asset in delivering that care, finding that balance is 
important.
    And AHLTA, frankly, has not been a positive factor in this 
discussion. It needs to be. And I believe the leadership has 
the appropriate focus. We will work to assure that we have the 
right plans and strategy in place. But we need to see that 
progress; this is a ``show me'' discussion.
    Mrs. Davis. Uh-huh.
    General Schoomaker. Ma'am, at the risk of being gaveled 
down, I just have to pile on the one aspect. I mean, you held 
me to a discussion only about whether this can be done with the 
funding available, but I just have to add my thoughts to what 
my colleagues have said about how critical this is.
    We tend to think of an electronic health record as an 
electronic way to manage our checkbook. But we have gone way 
beyond that. We are now in the realm of knowledge management, 
so that your checkbook is now embedded with an electronic 
universe where you are literally seeing the evolution of 
knowledge about how to use your money, how to invest it, where 
to place it, in real time.
    And it is a very simple analogy, but one of the things that 
I would respond to you earlier in your question about how we 
are going to contain health care costs is by exploiting this 
knowledge of the network that we are developing.
    I will give you two real quick examples. Earlier last year, 
the Food and Drug Administration (FDA) released a warning about 
a drug that was in common use. And they were getting anecdotal 
response that this was a potentially dangerous drug and it had 
side effects, but had no idea how big the denominator of use 
was. We were able to go in, through our electronic health 
record and the fact that we have catalogued all of those 
pharmaceutical uses and prescriptions, as well as any side 
effects and symptoms that are out there, and almost immediately 
respond that, ``Wait a minute, in our universe of users of this 
drug, we are not seeing problems, and it is probably far safer 
than you think it is.''
    H1N1 is another good example. We are able to monitor 
syndromes of illness, in real time, in people who show up at 
our hospitals and clinics, so that we can literally identify 
people who might be carriers of H1N1 and then surge to respond 
to that.
    I mean, that is a knowledge network. And so it is organic 
to how we now give care. In fact, I monitor the use of AHLTA 
and the electronic health record not as an information measure 
of performance but as a clinical measure of performance. Does 
that make sense?
    Mrs. Davis. Yeah. Absolutely.
    And I think one of the issues that we have heard from men 
and women who are serving is even their location in the war 
theater and some of the problems that they are experiencing, 
how close they were to explosions that were occurring and 
whether or not those were deemed to be sufficient enough to 
have created a traumatic brain injury (TBI) or whatever that 
may be. And I think all of that kind of information is 
certainly critical.
    Thank you. I appreciate that, and we may come back to it. I 
certainly want to let Mr. Wilson weigh in here.
    Mr. Wilson. Thank you, Madam Chairwoman.
    Thank you all for being here today.
    Mr. Middleton, the National Defense Authorization Act for 
Fiscal Year 2008 required the Department of Defense to 
establish a joint pathology center (JPC). Can you tell us what 
the status is of the creation of that center?
    Mr. Middleton. Yes, sir, I can. We have an extensive 
working group that is looking at the mission that is described 
by the National Defense Authorization Act. As you know, that 
requires a certain management of the military referrals for 
pathology to oversee the tissue repository that remained from 
Armed Forces Institute of Pathology (AFIP). Will not be doing 
civilian consults, as you know, as well. So it is under way.
    The placement of it in the organization is still being 
discussed. The Defense Health Board has looked at this, which 
is an independent advisory board that convenes at the behest of 
the Secretary of Defense, has looked at the JPC to figure out 
and make recommendations about the joint pathology center, its 
organizational location, et cetera.
    So I think we are well on our way to implement what was 
described by law, for us build the JPC and, in concert with 
that, close down AFIP, which was described in the 2005 Base 
Realignment and Closure (BRAC).
    Mr. Wilson. And there would be an opening date goal?
    Mr. Middleton. Yes, sir.
    Mr. Wilson. And when would that be?
    Mr. Middleton. I will take that for the record and get back 
to you, sir.
    [The information referred to can be found in the Appendix 
on page 113.]
    Mr. Wilson. Good. Thank you very much.
    And for our surgeon generals, I want to thank you all for 
your service. I am very, very grateful, as the son of a 
veteran; General Schoomaker and I were speaking a few minutes 
ago about my dad serving in the Army Air Corps. I am very 
grateful I served 31 years in the Army Guard and Reserves. I am 
particularly grateful that I have four sons currently serving 
in the military. And, with that background, I am so 
appreciative.
    To me, I want more Americans to know and understand that 
American military medicine is the best ever. You are leading 
the world in prosthetics, promoting the ability for people to 
have replacements of arms, legs, hands. It is extraordinary 
what you are doing.
    And I had the privilege of visiting with Major David 
Rozelle at Walter Reed, and I have visited Bethesda, I have 
visited Balad. I am grateful for the Wounded Warrior Programs 
that I have seen at Moncrief Army Hospital at Fort Jackson, at 
Beaufort Naval Hospital.
    It is just so impressive what you are doing. And for the 
general population, it is going to be so helpful. And I want, 
particularly, persons who are in the military, their families, 
and then prospective members and their families to know that 
military medicine is the best in the world.
    Additionally, with trauma care, particularly with 
improvised explosive devices, with brain injury, head injury. 
When I served in the State Senate 20 years ago, I worked on 
head injury issues, and now, thanks to military medicine, it is 
better than ever. I want to thank you.
    And in regard to mental health issues, I really want family 
members to know that the military is uniquely situated to help 
people with mental health issues. General, you mentioned your 
battle buddy right back there. That is the way the military 
feels, and that is that each person who serves in the military, 
it is like a giant family. You care about each other. And you 
also have a finite population; you have a somewhat controlled 
population.
    And so people should know that the ability for mental 
health care, I think, is better in the military than any other 
segment of our population. And I am the former president of the 
Mental Health Association. I have worked on this issue for 40 
years. And so I know the extraordinary abilities and efforts 
that are being made for our personnel.
    A concern I do have is screening prior to recruiting 
persons. And then, we know the stresses of normal life--and 
that is, it can be financial, it can be the breakup of a 
family, it can be a divorce, child custody, it can be drugs and 
alcohol. But what is being done for prescreening, and then what 
is being done for our service members who have not just post-
traumatic stress disorder but the normal stresses that 
Americans and world society face?
    General Roudebush. Sir, we, the military, live in the 
broader population of the United States. As men and women raise 
their right hands, swear to support and defend, we are drawing 
from communities across the Nation. We have individuals who 
come to us in good health. They are appropriately screened in 
terms of their physical and mental health history. But each one 
arrives as an individual, with their own set of coping skills, 
their own history, if you will. And, as a military, our job is 
to assure that they are provided the support that they need in 
order to both serve and operate in some very demanding 
environments, but to also have the help and support that they 
might require at some point, if, in fact, circumstances 
dictate.
    I believe our screening is appropriate. I believe our 
screening is bringing us individuals of good physical and 
mental ability. I think it is incumbent on us that we continue 
to have very strong continuing screening and surveillance to 
assess and detect circumstance as they occur during an 
individual's period of service and to have the capabilities to 
intervene appropriately as we move through.
    So I believe that our pre-screening and our pre-assessment 
brings us good individuals willing and able to do our Nation's 
work. And our job is to ensure that we continue to support them 
in that endeavor and to have the right capabilities to assist 
them if such assistance should be required.
    Ms. Shea-Porter. The first one has to do with the report 
that the defense contractors have been receiving medical care 
and not reimbursing the Federal Government. It has been costing 
taxpayers about $1 million a month for that. And indeed, when 
the Inspector General (IG) took a look at the report, you 
didn't even have any standards set up or any way for military 
medical personnel to keep track of how many people they were 
treating. And so my question to you is, why did that happen? 
Why did the taxpayers have to pay, in addition to all of the 
other money they pay contractors, a million dollars a month for 
the medical care? And what are you doing about it, please.
    Mr. Middleton. Thank you.
    The issue of how that happened, I think, had to do with 
exigencies of a war situation and moving many contractors in 
where we hadn't seen that before; providing emergency care for 
those that are injured in the line of their duties during the 
period of their time; and our lack of those kinds of business 
operations systems in the deployed setting.
    In our civilian setting, we have collections, and we have 
registration. We have scheduling. We have all of the revenue 
cycle issues that you would see in a normal health care 
setting. We didn't have all of those initiatives, those things, 
in a deployed setting.
    Ms. Shea-Porter. Well, can I interrupt right now and ask, 
why not? Because when they drew up the contracts, they are 
pretty detailed contracts for pretty much everything, and the 
contractors manage to get in coverage for many, many things. 
And so if we were putting that much attention to contracts in 
general and knowing that they would be requiring medical care, 
I don't understand the answer, if I understood you correctly, 
that we were too busy, too rushed, too many people coming in. 
Because they managed to take care of their part of the business 
contract, and I think that we should have taken care of the 
taxpayers' part of the business contract.
    Mr. Middleton. I would certainly agree with you, ma'am. And 
as a result of that Government Accountability Office (GAO) 
report, we have taken a look, with the Services, to take a look 
at what we can do in that deployed setting in order to capture 
that information that we need in order to make those claims for 
health care dollars.
    So we didn't ignore that GAO report. We are certainly going 
to take action on that GAO report. In fact, there is a working 
group that I am familiar with that is actually looking at that 
right now in fact to figure out how we can go about doing that 
process.
    Ms. Shea-Porter. Will we be reimbursed?
    Mr. Middleton. I don't know the answer to that question, 
ma'am. I don't know the contractual arrangements of that for 
that particular answer, but I will certainly take that back as 
part of the work group to find out.
    [The information referred to can be found in the Appendix 
on page 113.]
    Ms. Shea-Porter. Thank you.
    And then the second part is I wanted to ask you a question 
about dwell time. I was an original cosponsor of requiring more 
dwell time for our troops. And as a former military spouse, I 
think this is absolutely essential for these family members to 
have this. My husband never went into combat, but it was during 
the Vietnam era, and we certainly saw a lot of the fallout, if 
you will.
    And so my question is, how much time do you think our 
military men and women need as a minimum for dwell time? And 
are there any plans to create more dwell time for them?
    Mr. Middleton. Ma'am, I don't think that is a question that 
I would have the answer to personally. That is not something 
that is in the cognizance that I have and the responsibilities 
that I have been given. Not to defer to the surgeons, but they 
may have better insight on that from the service perspective.
    Ms. Shea-Porter. I am happy to do that. I was going to work 
my way right now. Thank you.
    General Schoomaker. Well, ma'am, the Army does focus on 
dwell time. It has been a major frustration to Army leadership 
and soldiers and families that the demand on soldiers, prior to 
the growth of the Army, has really demanded deployments with 
sometimes dwell times, that is time back at station with 
family, that did not equal to or exceed the amount of time 
spent deployed. That was especially true during the surge when 
we went to 15-month deployments.
    I was asked by another committee last year about what I 
felt on the medical side and, especially from the standpoint of 
behavioral health, what the optimal deployment length was, and 
at that time, based upon the results of the--and this is a 
medical response, not an operational response. I mean, the 
operational--the length of a deployment is much driven by and 
dictated by the operational requirement.
    Below a certain point in the Army, for troops on the 
ground, one could make the argument that it is dangerous; that 
one needs to have sufficient time to have continuity of command 
and to learn and to operate effectively and in theater. But 
based upon the results of the Mental Health Advisory Teams that 
we have put into Iraq and Afghanistan now, the sixth one is on 
the ground now in Afghanistan and has just finished in Iraq, I 
responded by saying that I think there are three factors.
    One is the length of the deployment. We know that after 
nine months or so, deployment length for soldiers is quite 
onerous. Above 12 months and into 15 months, we saw very 
clearly that problems began to almost grow exponentially.
    I thought the second factor is dwell time. And at that 
time, I gave the kind of seat-of-the-pants answer that the best 
advice I could get from those who have experienced that is 18 
months minimum.
    I think the current Mental Health Advisory Team, which is 
just coming back from Iraq and Afghanistan, will give us some 
of our best data. And I have not seen that data yet, and I am 
anticipating it coming out, and it will help give us an idea of 
optimal dwell time is.
    And then the last thing I said was the number of 
deployments, frequency of deployments.
    So I think it is a function of length of deployments, dwell 
time between deployments, and the frequency. All three are 
determinants. The Army's aspiration is to have soldiers dwell, 
you know, at minimum 24 months between deployments, so you are 
one out and two back. And for the Reserves, to be on a more 
generous cycle of four to five years of dwell between 
deployments.
    Does that answer your question?
    Ms. Shea-Porter. Thank you. Yes, and I know you have had 
concerns about this issue, and I appreciate it.
    Admiral Robinson. I think that General Schoomaker summed up 
my view on this very much in his three answers, and I think 
that the dwell time is absolutely incredible.
    I think that the thought on dwell time has been what my 
mental health experts have said is a way to not only reset the 
individual but also reset the family. So it is not just a 
soldier, sailor, airman, or an active person's reset; it is 
also a family's reset. And it has to occur over a length of 
time where the reset can actually occur. That was my only 
addition.
    Ms. Shea-Porter. Thank you.
    General Roudebush. Yes, ma'am.
    And from an Air Force perspective, of course, this is a 
line discussion which by extension we certainly reflect from a 
medical perspective our support of the line activities.
    General Schwartz has made it very clear that the Air Force 
is all in, so the driver is the demand signal: What is required 
to support the mission, wherever we find it in the world?
    Now, having said that, we also understand that for a 
repetitive aerobic deployment cycle, that dwell time is 
critically important. So as we look at the operational 
requirements, which at times may require an extended deployment 
to work effectively in some of the environments, building 
relationships, working extended programs with individuals where 
that relationship is paramount, can drive some of those 
operational requirements, and that exists medically as well. 
But our line leadership has been very forward leaning about 
matching the pipeline to the demand signal.
    And if we need to make a difference in terms of building 
more of an asset, could be low-density, high-demand asset, in 
order to increase the opportunity for individuals to deploy, 
but then come back home, retrain, reblue, reintegrate with 
family before the next deployment experience, that is a key 
parameter of what we do. Our banding efforts in doing that I 
think have gone a long way.
    But I share my colleagues' concerns that, that dwell time 
is critically important for an All-Volunteer Force, the 
majority of whom have families and want to continue to serve 
and do so effectively.
    Ms. Shea-Porter. Thank you very much.
    Mrs. Davis. Thank you. And I am going to follow up, and I 
understand you have another question, and we will come back in 
a second.
    As we have spoken about this, we know how important it is. 
And getting back perhaps even to the IT system, how much 
tracking is done of the number of deployments that people have 
had and that our service members have had and their dwell 
times? And how is that communicated to the military leadership, 
the commander on base and some of the subordinates there? 
Because I am just wondering whether there is an appreciation of 
what that service member has gone through and how that factors 
into any other relationships or any other concerns that are 
made. Is that information readily available, and how is it 
used?
    General Roudebush. Ma'am, I can speak to that from the Air 
Force.
    Our Air Force Personnel Center and our Air Expeditionary 
Center, which oversees both deployment and operational 
engagement, follow that very closely. Particularly if in fact 
an individual may deploy, come back to home station, and then 
be transferred to another home station; do they enter into a 
new environment where that deployment is not recognized? No. 
That is tracked through.
    Now, from a medical perspective, we also track closely on 
cohorts of individuals perhaps at increased risk, our explosive 
ordnance personnel, our terminal attack controlling personnel, 
among others, security forces, because their exposure and their 
experience puts them at higher risk of post-traumatic stress, 
TBI, those sorts of outcomes. So we track them as well to 
assure that we are monitoring and supporting them over an 
extended period of time and not simply during a singular 
deployment.
    Admiral Robinson. From the Navy's perspective, Navy 
Personnel Command has this wrapped up very tightly. It has been 
an interesting evolution because, in this particular conflict, 
or conflicts, or wars, there have been individual augmentees. 
So there has been--and on the Navy side, there are 14,000 
individuals, and there are comparable numbers on the Air Force. 
The Army and Marine Corps side have the same, but they also 
have units. So for the services that have had the individual 
augmentees, it has become a challenge at the very beginning to 
make sure that we did keep up with them and make sure that we 
did know who was coming in and out of certain theaters and 
where they had been. And when they got transferred--and this is 
very important--or even when they came back to their home 
station, often there would be people there or whole groups of 
folks that wouldn't understand where that individual had been.
    So this has been taken up from Chief of Naval Operations 
(CNO) and Chief of Naval Personnel, and these are tracked. We 
are right on top of where the individuals are, where they have 
been. We absolutely wrap them up and keep a close contact with 
who is gone. And in some instances, we even, in some types of 
positions and jobs, we even have policies in place that you 
don't repeat a deployment or you don't repeat the same 
deployment for that individual. You have to get new people in. 
It depends on what the situation is. But they are very well 
tracked, and the Navy Personnel (PERS) and Chief of Naval 
Personnel has this information. It is readily available to all 
of us who need it.
    General Schoomaker. And, ma'am, for the Army it is exactly 
the same thing. The personnel community tracks this down to the 
day, and it is reported to the very highest level. I know that 
all senior leaders of the Army, the Chief and Secretary and 
Vice Chief level, track this extraordinarily closely.
    Rather than just repeat everything that my colleagues have 
said, because it is identical in the Army, let me just comment 
about when in dwell. Another thing that has become very evident 
to us is that when back home, if you return from combat and 
then almost immediately go out to train, it is equivalent to 
being deployed again, although not to a combat zone. So there 
is a lot of focus being placed upon reintegration and reset.
    In fact, I think the chief's ambition is that we have an 
almost inviable six-month period once a soldier returns where 
they can reintegrate and reestablish with family, that we can 
do the necessary screening for the emerging symptoms that they 
may experience from post-traumatic stress and the like, and 
that we can institute that human dimension reset that we have 
talked about.
    And I think what we are learning, and your questions are 
very well poised to address, is what is the human dimension 
inside of these almost institutional and industrial processes 
of iteratively preparing a soldier to go to war, deploying that 
soldier, and then bringing them back and reset. You can reset 
the equipment. You can reset their tactics, techniques and 
procedures, but the human dimension sometimes is on a different 
time scale.
    Mrs. Davis. I think one of the concerns that I have heard 
is, it partly relates to readiness, but the fact that a smaller 
percentage of men and women are able to actually return to 
theater after multiple deployments, or that we are relying I 
think on a smaller proportion of people who are serving. Is 
that a correct assessment?
    General Schoomaker. Ma'am, I don't think that is an 
entirely accurate depiction of that.
    I mean, some of the most frequently deploying units are, 
for example, Special Operations units, which have deployed 
maybe 10 times or more. And deployment experience alone--I 
mean, in suicide, for example, suicide is not necessarily 
predicted by more frequent deployments. In fact, a third of 
Army suicides are in soldiers who have not deployed at all. And 
as one deploys more, what we are finding is that the suicide 
rate drops.
    Now, that might be a reflection of the fact that once--that 
if you have difficulty with deployment, that you are unlikely 
to remain longer after that first deployment. And so that we 
enrich for a population of families and soldiers who can endure 
multiple deployments.
    Mrs. Davis. Are we pulling people from theater when we do 
see after several deployments that in fact this is not 
something that is going to move forward with a good outcome for 
them? I mean, is that something--do we have numbers that are 
being assessed once returning to theater that it is not a good 
idea for them to be there?
    General Schoomaker. Well, we certainly in theater very 
aggressively address in-theater behavioral and mental health. 
We have, again, one of the major efforts of Mental Health 
Advisory Teams that have been going in for the last six years 
was to exactly assess that: What was the level of mental health 
support? And was it available to a very disbursed force, both 
in Afghanistan and Iraq? As you saw the other day in the 
tragedy, I mean, this was a Combat Stress Control Team that was 
out there with soldiers and Marines and others and sailors that 
was conducting health care on the battlefield, literally.
    Mrs. Davis. Mr. Wilson.
    Mr. Wilson. Another perspective on deployment, I know our 
office has helped expedite in my local community with the 
National Guard one of the most prominent certified public 
accountants (CPAs) in our community who wanted to be 
transferred from one National Guard unit to the other to be 
deployed.
    And then, Admiral, I am very grateful that, at Fort 
Jackson, South Carolina, the augmentees you mentioned, the 
sailors, the naval personnel are being trained there to be sand 
sailors. And it has been very inspiring to me to go out and 
visit these sand sailors as they are on their way to Iraq and 
Afghanistan. And when I visit with them in Kabul or Baghdad, 
they are so grateful for their opportunity to serve.
    And I am also very pleased, I can now also mention my Air 
Force connection, I am very proud to have a nephew who has 
recently returned to theater, and it is his second deployment. 
And these are volunteers. They want to serve. They want to 
protect our country. So thank you very much.
    General Roudebush. Madam Chairman, if I might. If I could 
put one other perspective on your scope.
    We have significant numbers of people who do not in the 
traditional sense deploy. Our airlifters, who are moving people 
and things critically important to our effort as well as 
providing air medical evacuation around the world, do not 
deploy. But they are gone from home for extended periods of 
time, launching every 90 seconds around the clock, 24/7, 365. 
They, too, need to be very carefully supported and attended to 
because of their critical piece of the mission.
    We have unmanned aerial vehicle (UAV) operators at Creech 
in Nevada who don't deploy but have not had leave, have not had 
time away, have been basically focused on providing that 
unblinking eye above our Marines and soldiers in important 
parts of the world who have a particular kind of stress that 
applies to their life and their world as well.
    So it is broad spectrum of people who serve who may not 
traditionally deploy but are pulling their boots on every day 
to serve combatant commanders and our Nation in a variety of 
ways that we can't lose sight of either.
    Mrs. Davis. Thank you.
    Just one quick follow-up, and then I want to go to Ms. 
Shea-Porter.
    I know we have done a far better job in trying to educate 
our military leadership in the field at all levels in which 
they are accountable for their troops to be more aware, to be 
able to help share information, to create an atmosphere where 
people are comfortable. But I am wondering if there are some 
ways in which we can do an even better job there in trying to 
help them in how they help their troops deal with the death of 
comrades, best practices or trying to at least--everyone is not 
going to respond to the same way to these tragedies, but 
perhaps helping them understand better the way that the next 
few days weigh out really for them makes a difference in the 
way people are going to be able to handle.
    How much time are we really spending in trying to help 
educate, to consult, to counsel them in that way? It is a busy 
theater. There is not a lot of time to do that. And I am just 
wondering how critical it is and whether we just need to think 
more about how we do that.
    General Schoomaker. I will tell you about three initiatives 
the Army has undertaken in the very least. One was about a year 
ago, the senior leadership of the Army initiated really an 
unprecedented chain teaching effort, right from the very top of 
the Army, the Chief of Staff and the Secretary right down to 
the last soldier, to impress upon them the importance of 
reducing stigma and recognizing that the human cost of 
deployment and exposure to combat for all humans was 
experiencing some degree of behavioral and health challenge and 
emotional challenge.
    We are working in the comprehensive soldier fitness arena 
to make that experience not a lifelong disability, but actually 
to exploit post-traumatic growth, because as many more people 
return from this experience having been enriched in the sense 
of having seen a meaningful aspect of their life in uniform 
that they didn't experience before. That goes back for many 
wars and many militaries. So that was the first.
    The second is a more recent effort to intervene and prevent 
suicide, in which we have had a mandatory standdown as an Army, 
with small unit teaching by facilitators using, in a very good 
interactive video, called ``Beyond the Front,'' in which you 
role play several different roles. One is a young soldier who 
is deployed and is experiencing many challenges to include the 
breakup of a relationship back home, a loss of a buddy in 
combat, financial issues, and the like. And you work through 
this interactive video.
    The other is, back in home station, a senior NCO who has 
got a fellow NCO who is literally falling apart in front of his 
eyes with family problems, alcohol use, and the like. And you 
are asked in this interactive fashion to make decisions what 
you are going to do and then go down those branches and 
sequels, and then go back and restudy it.
    Those are just several very important efforts that we have 
undertaken to educate and train.
    The last is the Battlemind Training. The Army has developed 
a series of sort of branded tools called Battlemind Training 
that prepares soldiers and families to be deployed, and then 
are used even in redeployment that sensitize the entire force 
to, again, the emergence of symptoms and problems that are 
associated with service and deployment. And these have been 
integrated into all enlisted and officer training throughout 
the life cycle of every soldier so that they are exposed, 
again, to your point being made, that, are we making efforts to 
educate and train? Absolutely.
    Mrs. Davis. Thank you, General. And I guess the next 
question is, how are we evaluating that? And are we going to be 
able to--I am interested and I don't know.
    General Schoomaker. Battlemind has actually been validated. 
And the Mental Health Advisory Teams have seen in subsequent 
years that stigma, for example, has been reduced when they go 
out and survey the force.
    Mrs. Davis. Thank you.
    Ms. Shea-Porter.
    Ms. Shea-Porter. Thank you.
    I really appreciate your sensitivity, all of you, to the 
needs of the military. I want to talk about their families. And 
I know you share those concerns. But I had a chance to mention 
to Secretary Gates the other day to please consider this, and I 
wanted to bring it up to you also.
    I know and I have heard some stories about children whose 
parents are both deployed in theater. And I worry about the 
impact on the children. I do know that the mission has to come 
first, and that if you need personnel, you need personnel. 
However, I would like to ask how much consideration you give to 
those couples who have children who are seeing repeated 
deployments.
    And the stress on the children is pretty awful and the 
stories that the parents tell are heartbreaking. And so, can 
you give me an idea of how many, first of all, parents are 
there who are both deployed in theater, so that I can see the 
extent of the problem? And what is being done for the children 
and the families to try to minimize the impact? Are you trying 
to rotate so they are not both in theater, et cetera?
    General Roudebush. Ma'am, I can speak from the Air Force 
perspective. That circumstance is, fortunately, relatively 
rare. Our Air Force Personnel Center and the Air Expeditionary 
Forces (AEF) center do work to avoid simultaneous deployments.
    But I would also add that the family has the opportunity to 
weigh in on that both in terms of providing plans that are 
appropriate for their family to assure that the youngster, if 
in fact the circumstances might dictate a simultaneous 
deployment, to place those children in the most appropriate 
place, whether it is with a close relative, whoever might be 
the most appropriate.
    Ms. Shea-Porter. The problem with that is that with 
repeated deployments it is more and more difficult for those. 
And plans fall apart. People who have the best intentions 
suddenly have circumstances change. And so I appreciate the 
fact that there are plans, but we both know that life gets in 
the way of plans.
    General Roudebush. I don't diminish the importance of that 
at all and understand that certainly can occur. But to the 
extent fully possible, our Personnel Center, our AEF center, 
including the individual's commander, those individuals' 
commanders have a voice in that decision. So we do find that to 
be relatively rare in the Air Force.
    General Schoomaker. Ma'am, for the Army, I would have to 
take it for the record as to what the actual numbers of both 
parents being deployed are, and we will get that back to you.
    [The information referred to can be found in the Appendix 
beginning on page 113.]
    General Schoomaker. But I think we have a number of single-
parent families that for whom the parent is deployed, and so 
some of the concerns I think that you have expressed with both 
parents being gone extends to those families as well.
    I can tell you that there are several initiatives ongoing 
within the Army and the military community in general about 
this. Our current Secretary of the VA, Secretary Shinseki's 
wife, Patty Shinseki, is very active in the Military Child 
Education Coalition, which is doing outreach into the education 
community to find support for children and to be sensitive to 
the needs of military children, especially those for deployed 
parents.
    There are pilots ongoing in the Pacific Northwest around 
Fort Lewis, Washington, and Tripler Army Medical Center in 
Hawaii for that right now, and they are undertaking a number of 
studies and outreach programs and educational for that.
    Our chaplains are playing a very role, too, with outreach 
to the ministerial community to extend services and be 
sensitive to it and be monitoring and helping our children in 
those kinds of situations. So I think there is great 
sensitivity about what you are addressing, ma'am, and we are 
looking very actively at that.
    Ms. Shea-Porter. Is there any particular place they can go 
when a family feels strained to the breaking point? And what is 
the procedure? How would a mother, for example, say, I thought 
I had a good plan, but then my husband got deployed, and we 
left the kids with grandma, but she got sick, and then we 
passed the children off to so and so? Do you have some kind of 
caseworker or person assigned to follow, and I am sure that the 
number of families aren't that great, but to work particularly 
with those families? Or do you think that would be helpful?
    General Schoomaker. Ma'am, that happens. All of those 
assets are available, and starting with the chain of command 
for the soldier. The NCO and officer chain of command is 
immediately engaged in situations like that, because the health 
and well-being of that family is extraordinarily important to 
that command.
    Ms. Shea-Porter. But do they have criteria or directions, 
say, if they do take it to the chain of command, and the chain 
of command may or may not consider that as critical as the 
family member does, what is the next step?
    General Schoomaker. The chaplains getting involved. The 
health care community gets involved in a sense validating or 
documenting the state of the family. And commanders are very 
sensitive to this, in my experience, and will bring a deployed 
soldier home or divert them from an assignment that they may be 
undergoing until that family situation stabilizes.
    Ms. Shea-Porter. I just want to make it very clear for the 
families that they know where to go and what path to take.
    So thank you.
    Mrs. Davis. Thank you, Ms. Shea-Porter.
    And I know that some of those questions come out of the 
trip that we took to Afghanistan over Mother's Day and spoke to 
a number of, happened to be, mothers who were experiencing some 
of these difficulties with double-deployed households. And it 
wasn't easy, and we tried to support them and try and lead them 
to some of the services that might be available to them. It is 
tough.
    I want to thank you all very much for being here. I know we 
have some deadlines that we have to meet today. And we 
appreciate it.
    One of the issues that you brought up earlier and we didn't 
address in any great detail was really developing the men and 
women in the health care professions that would be needed over 
the next number of years. And we also didn't talk about the 
private sector and what we can do to encourage more 
professionals to come in and be supportive, either through 
other contracts or what communities services, and so that would 
be an issue that we will ask you about in written questions and 
look forward to some responses in that as well.
    Again, I want to thank you very much.
    Thank you, Mr. Wilson and Ms. Shea-Porter.
    And the meeting is adjourned. Thank you.
    [Whereupon, at 10:38 a.m., the subcommittee was adjourned.]
?

      
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                            A P P E N D I X

                              May 15, 2009

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              PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                              May 15, 2009

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    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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              WITNESS RESPONSES TO QUESTIONS ASKED DURING

                              THE HEARING

                              May 15, 2009

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              RESPONSE TO QUESTION SUBMITTED BY MR. WILSON

    Mr. Middleton. Based on the recommendations of the Joint Pathology 
Center Work Group (JPCWG), the Defense Health Board, and the Senior 
Military Medical Advisory Committee, the Assistant Secretary of Defense 
for Health Affairs selected the Joint Task Force National Capital 
Region Medical's (JTF CapMed's) proposal to establish the federal joint 
pathology center. JTF CapMed, with input from the JPCWG, developed a 
concept of operations and an implementation plan for the center. 
Initial operating capability is targeted for July 2010 and full 
operating capability is planned by mid-September 2011. [See page 18.]
                                 ______
                                 
          RESPONSES TO QUESTIONS SUBMITTED BY MS. SHEA-PORTER
    Mr. Middleton. Billing and collecting for medical care provided to 
contractors by deployed medical units in Southwest Asia is being 
pursued. The January 7, 2007 Office of the Secretary of Defense, 
Comptroller (OUSD(C)) memorandum established medical billing rates and 
requested the Military Departments to establish policies for 
eligibility, billing, and collections for deployed medical or non-fixed 
medical facilities. A working group, chaired by OUSD(C), is determining 
roles and responsibilities and developing specific policy for 
implementing and overseeing a billing process in Southwest Asia. This 
will include a process to bill for healthcare provided in prior years 
to contractors. [See page 21.]
    General Schoomaker. According to information provided by the 
Defense Manpower Data Center, since 11 September 2001 the Army has 
simultaneously deployed over 2800 dual-military couples with 
dependents. The Army implements the Department of Defense (DoD) policy 
as it relates to dual-military couples with dependents or single 
parents deployed into combat zones or imminent danger areas. DoD 
personnel assignment and deployment policies exist to enhance the 
capability of the Military Services to meet National Security 
objectives. Each member similarly qualified takes his or her turn at 
assignments or deployments to various geographical regions and 
positions. These assignments and deployments include duty in imminent 
danger and hostile fire areas or in combat zones, without regard to 
relationship to other Service members.
    The nature of an all-volunteer force shapes our assignment and 
deployment policies. Our Soldiers voluntarily entered the profession of 
arms, cognizant of the possibility of assignment to hazardous duty for 
themselves or any other Family member who may be serving. Entering the 
military is a voluntary acceptance of the risk that they or a Family 
member might be killed, disabled, missing in action, or captured while 
serving in the defense of the Nation. It is this sense of shared 
sacrifice that helps bind the military together, enhances morale, and 
is the basis of an effective fighting force.
    The underlying principles of equality and voluntary acceptance of 
the inherent dangers associated with military service form the basis 
for current Family assignment policy. Currently, there is no specific 
DoD or Army policy that precludes the assignment or deployment of 
multiple Family members to combat zones at the same time. This includes 
both a single parent with custody of children and members of a dual-
military couple with Family members. As such, current DoD and Army 
policy requires that dual-military couples with Family members and 
single parents with custody of children have an approved Family Care 
Plan (FCP) on file, which is the means by which Soldiers provide for 
the care of their Family members when military duties prevent the 
Soldier from doing so. The plan includes proof that guardians and 
escorts have been appointed and thoroughly briefed on the 
responsibilities they will assume during the Soldier's absence. 
Soldiers without approved plans may be considered for separation from 
the Service.
    While these policies may seem inadequate or harsh, they are not 
absolute. DoD tempers these policies in an attempt to ensure that no 
single Family is asked to bear an inordinate share of the burden of 
armed conflict. The following are examples of relief available:
    (1) Existing policy addresses the concurrent assignment of multiple 
Family members to the same unit or ship. The policy provides for 
reassignment of all but one member to a different unit or ship. 
Approval may not restrict the concurrent assignment to combat zones or 
imminent danger/hostile fire areas, but would ensure they are not 
serving in the same unit.
    (2) Consideration will be given a request for a combat deferment or 
exemption based on the Soldier or the Family experiencing severe 
humanitarian or compassionate problems.
    (3) Soldiers who acquire Sole Surviving Son and/or Daughter status 
are exempt from assignment/deployment to a combat zone or imminent 
danger/hostile fire area. In addition, if a service member of a Family 
is killed or dies while serving in a designated hostile fire area, 
other service members of the same Family shall be exempt, on request, 
from serving in designated hostile fire areas or if serving in such an 
area shall be reassigned from there.
    (4) A married Soldier who becomes a parent or a sole parent may 
apply for separation under hardship if evidence exists that the role of 
the parent and Soldier are incompatible and that the Soldier cannot 
fulfill his or her military obligation without neglecting the child or 
children.
    The current policy on simultaneous deployments of Family members, 
the equitable assignment policy, and the built-in exception provisions 
are longstanding, have proven adequate, and should be retained.
    The Army is also taking steps to minimize the impact of deployments 
on military children. The Family and Morale Welfare and Recreation 
Command ensures that children of dual-military parents receive priority 
at all child development centers. Families that serve as guardians for 
children of deployed parents have been granted access to military 
commissaries. Resources are made available to families through the 
Military Child Education Coalition and through Military and Army 
OneSource, which provide 24/7 toll-free assistance as well as short-
term, non-medical counseling options. The Army Medical Command (MEDCOM) 
has established a Military Child and Adolescent Center of Excellence at 
Madigan Army Medical Center at Fort Lewis, Washington to promote 
optimal wellness and resilience in military children and adolescents 
through direct support of interdisciplinary, integrated systems of 
care, advocacy, training of staff, oversight and quality assurance, and 
reduction in stigma. The Center of Excellence is developing a better 
understanding of the unique impacts of deployment on children. It has 
facilitated research on the impact of parental combat deployment on 
children and families and presented research and findings at public 
forums to increase awareness. MEDCOM is in the process of identifying 
other sites for expansion of the concept. [See page 28.]
?

      
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              QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                              May 15, 2009

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                 QUESTIONS SUBMITTED BY MS. SHEA-PORTER

    Ms. Shea-Porter. I read the following submitted testimony by Allen 
Middleton, the Acting Principal Deputy Assistant Secretary of Defense 
for Health Affairs: ``With regard to environmental health protection, 
Service Occupational and Environmental Health specialists routinely 
monitor air, soil, water, and other aspects of the environment in 
theater to detect and prevent hazardous exposures before they occur. To 
date, more than 11,000 environmental samples from Iraq and Afghanistan 
have been collected and analyzed, and new samples are constantly 
reassessed. Findings to date indicate a low risk to our Forces for any 
long-term health effects from environmental exposures.'' However, U.S. 
bases throughout Iraq and Afghanistan dispose of large quantities of 
waste through burning in open pits. Fumes from these pits produce 
toxins that can present an acute health risk to our Service members, 
and these toxins include carcinogens like dioxin. The Disabled American 
Veterans has identified over 200 veterans who say exposure to these 
burn pits has made them seriously and often chronically ill. I am very 
concerned about the risks of the continuing use of burn pits for the 
health of our Service members. This practice would never be allowed in 
the United States of America. Could you please comment on the 
Department's plans to address this potentially dangerous situation that 
could have serious impact on our Service members' heath?
    Mr. Middleton. The Department of Defense (DoD) takes its 
responsibility to protect the health of its personnel seriously and is 
very aware of the heath concerns relating to burn pit smoke at many of 
our forward operating bases in Iraq and Afghanistan. The Army, Navy, 
and Air Force preventive medicine teams have gathered and analyzed more 
than 17,000 air, water, and soil samples in the U.S. Central Command 
area of responsibility since the start of Operation Enduring Freedom. 
The purpose of the monitoring was, and continues to be, determining 
potential environmental health risks and identifying any hazards 
requiring mitigation to ensure our personnel are operating in a safe 
environment.
    In 2006-2007, Joint Base Balad was selected for a screening health 
risk assessment focused on burn pit smoke because it was the largest 
burn pit in theater and the large number of U.S. Service members that 
worked and lived close to the emanating smoke. When the health risk 
assessment began in early 2007, before the currently operating 
incinerators were in place, 163 air samples were taken and analyzed for 
30 different parameters providing over 4,000 data points. The screening 
health risk assessment, using worst case exposure assumptions 
(breathing the smoke for 24 hours a day, 7 days a week for up to a 
year) and conducted in accordance with many of the Environmental 
Protection Agency methods, indicated the risk of long-term (including 
cancers) and significant short-term health effects for exposure to 
those chemicals was unlikely. In February 2008, the Defense Health 
Board, a Federal independent advisory committee, provided a third party 
review of the Joint Base Balad Burn Pit Risk Assessment to ensure its 
methodology was correct and its conclusions valid. This board of 
medical experts, including university professors and renowned 
scientists in the fields of epidemiology, preventive medicine, and 
toxicology determined, ``Given the data available, the screening risk 
assessment provides an accurate determination of airborne exposure 
levels for Service members deployed to Balad Air Base.'' They went on 
to conclude that no significant short- or long-term health risks and no 
elevated cancer risks should be anticipated among personnel deployed to 
Joint Base Balad. The DoD continues to closely assess any health 
hazards that may be associated with the burn pit smoke to ensure that 
our personnel are not exposed to hazardous agents that present a 
significant health risk.
    Over the past year, U.S. Central Command has made a concerted 
effort to reduce dependence on burn pits. Currently, 17 solid waste 
industrial incinerators are operational, including three at Joint Base 
Balad. Twenty-two incinerators are under construction with completion 
dates ranging through December 2009. Recycling plastics and aluminum 
and use of landfills to reduce the amount of solid waste for disposal 
have been implemented at a number of our bases. Since January 2009, 
used cooking oils and grease from Joint Base Balad have been sent to a 
local Iraqi rendering facility, reducing the amount of burned material. 
Furthermore, there are two hazardous waste and 24 medical waste 
incinerators operating in Iraq with nine additional medical 
incinerators in the acquisition process. Despite these measures, we 
will continue to need burn pits during contingency operations to 
control wastes and ensure waste does not pose a health hazard nor 
provide a breeding ground for disease-carrying vectors. To this extent, 
much effort has gone into locating or relocating pits to remote areas 
of bases to minimize smoke exposures, training personnel on proper 
operation of the burn pits, developing and circulating correct 
operating procedures, and assessing burn pit operations to include 
corrective actions.
    Ms. Shea-Porter. As you may know, sexual assaults in Iraq and 
Afghanistan rose 26 percent from 2007 to 2008. In previous hearings on 
this issue, we were informed that rape kits were not available at all 
forward operating bases because there are insufficient personnel to 
administer the rape kits. What steps are being taken to resolve this 
issue?
    Mr. Middleton. The ability of our providers to take care of rape 
victims is not hindered by lack of availability of sexual assault 
forensic examination (SAFE) kits or other medical supplies. However, 
not all forward operating bases have the capability to conduct a SAFE 
because of training and other support requirements. Normally, a SAFE is 
conducted at a Combat Support Hospital located at Division level. 
However, Level II medical treatment facilities (MTFs) within the 
Division, when they have properly trained personnel and when approved 
by the Multi-National Corps-Iraq Surgeon, can also conduct SAFEs. 
Deployed Sexual Assault Response Coordinators (DSARCs) and Uniformed 
Victim Advocates (UVAs) arrange for examinations and medical care for 
victims who make restricted or unrestricted reports of sexual assault 
in deployed environments. A victim at a Forward Operating Base may 
require evacuation to a facility where a SAFE can be completed by 
trained provider. The DSARC or UVA facilitates transport.
    To ensure continuity of care at designated MTFs, the facility must 
meet the following requirements:

    (a)  SAFE-trained medical provider assigned

    (b)  Mental health support

    (c)  Criminal Investigation Division reporting capability

    (d)  Victim advocacy

    (e)  Chaplain support

    (f)  Judge Advocate/Legal support

    (g)  Appropriate laboratory support

    Ms. Shea-Porter. As you may know, sexual assaults in Iraq and 
Afghanistan rose 26 percent from 2007 to 2008. In previous hearings on 
this issue, we were informed that rape kits were not available at all 
forward operating bases because there are insufficient personnel to 
administer the rape kits. What steps are being taken to resolve this 
issue?
    General Schoomaker. The ability of our providers in all operational 
environments to conduct the victim sexual assault forensic examination 
(SAFE) is not hindered by lack of availability of a SAFE kit or other 
medical supplies. Instead, because of their mission and location in 
theater, not all forward operating bases have the capability to conduct 
the SAFE.
    Normally SAFE care and examination is conducted at the Level III, 
Combat Support Hospital. However, Level II Medical Treatment 
Facilities, when approved by the theater Surgeon, can conduct victim 
SAFE. To ensure continuity of care, designated Level II MTFs must meet 
the following requirements:

    (a)  SAFE medical provider assigned

    (b)  Mental health support

    (c)  CID reporting capability

    (d)  Victim advocacy

    (e)  Chaplain support

    (f)  Judge Advocate/Legal support

    (g)  Appropriate laboratory support

    Level I facilities (Battalion Aid Stations) are designed to 
stabilize Soldiers. The focus of these facilities is on resuscitative 
care and lifesaving interventions. When sexual assault victims present 
at Level I or Level II facilities without SAFE capacity, the healthcare 
staff stabilizes the victim, orders priority MEDEVAC to a Level III 
facility, and monitors the victim until his/her departure.
    Ms. Shea-Porter. As you may know, sexual assaults in Iraq and 
Afghanistan rose 26 percent from 2007 to 2008. In previous hearings on 
this issue, we were informed that rape kits were not available at all 
forward operating bases because there are insufficient personnel to 
administer the rape kits. What steps are being taken to resolve this 
issue?
    Admiral Robinson. The Bureau of Medicine and Surgery (BUMED) has 
oversight over all CONUS and OCONUS Military Treatment Facilities 
(MTF), and ensures sexual assault kits are in stock and available in 
the event of a sexual assault. CENTCOM (Central Command) has 
responsibility for the availability of sexual assault kits in the 
deployed regions of Iraq and Afghanistan. Questions about SAPR in 
CENTCOM (including availability of kits) should be referred to CENTCOM 
Surgeon.
    BUMED is taking steps to improve the effectiveness of SAPR Navy-
wide. The BUMEDINST 6010.11, (SAPR) instruction, was approved by the 
Surgeon General of the Navy and published in June, 2009. The 
instruction gives very clear and concise guidance on the process and 
protocol for care of the sexual assault victim, and on performing an 
appropriate exam with follow-up. It also provides the information 
necessary for obtaining sexual assault exam kits.
    BUMED has initiated an aggressive training program to ensure 
widespread training in the sexual assault exam and evidence collection. 
We have already completed the sexual assault forensic exam (SAFE) 
training curriculum at the Uniformed Services University of the Health 
Sciences, Naval Hospital Okinawa, and Naval Hospital Naples; and 
several Nurses and Physicians have been trained at each facility. 
Arrangements are being made for training at several other MTFs at this 
time.
    Ms. Shea-Porter. As you may know, sexual assaults in Iraq and 
Afghanistan rose 26 percent from 2007 to 2008. In previous hearings on 
this issue, we were informed that rape kits were not available at all 
forward operating bases because there are insufficient personnel to 
administer the rape kits. What steps are being taken to resolve this 
issue?
    General Roudebush. Since the Air Force established full-time Sexual 
Assault Response Coordinator (SARC) positions at primary operating 
locations within combat areas of interest in 2006, there is no known 
instance of an inability to provide a Sexual Assault Forensic 
Examination (SAFE) kit for a victim of sexual assault. As identified in 
the Air Force previous annual reports to DOD on the Sexual Assault 
Prevention and Response Program (SAPR), medical functions maintain 
availability of SAFE kits in the deployed areas. During Fiscal Year 
2008, the Air Force had 154 emergency room physicians trained to 
complete forensic examinations. Emergency physicians are fully 
qualified to perform sexual assault forensic exams without additional 
training.
    Additionally, for the combat areas of interest, the Air Force 
Office of Special Investigations field detachments are required to 
retain SAFE kits on-hand as part of their technical investigative 
supplies and have secured suitable evidence storage capability for 
sexual assault cases in Iraq and Afghanistan. The full-time SARCs at 
Air Force Air Expeditionary Wing (AEW) locations oversee any 
geographically-separated unit that is attached to a main operating 
location controlled or hosted by the Air Force. Each deployed location 
has ensured that SARCs have sufficient supplies and materials to 
provide assistance to victims of sexual assault. SARCs in the deployed 
environment utilize trained victim advocates to enhance victim 
response. Restricted reporting is an option available in the deployed 
environment and has been utilized by sexual assault victims. Airlift 
and ground transportation are available and have also been used to 
assist victims/get victims proper care in a timely manner, to include 
availability of processing SAFE kits.

                                  
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