[Senate Hearing 111-701, Part 6]
[From the U.S. Government Publishing Office]



                                                   S. Hrg. 111-701 Pt. 6
 
DEPARTMENT OF DEFENSE AUTHORIZATION FOR APPROPRIATIONS FOR FISCAL YEAR 
                                  2011

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


                                HEARINGS

                               before the

                      COMMITTEE ON ARMED SERVICES
                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             SECOND SESSION

                                   ON

                                S. 3454

     TO AUTHORIZE APPROPRIATIONS FOR FISCAL YEAR 2011 FOR MILITARY 
ACTIVITIES OF THE DEPARTMENT OF DEFENSE, FOR MILITARY CONSTRUCTION, AND 
   FOR DEFENSE ACTIVITIES OF THE DEPARTMENT OF ENERGY, TO PRESCRIBE 
    PERSONNEL STRENGTHS FOR SUCH FISCAL YEAR, AND FOR OTHER PURPOSES

                               __________

                                 PART 6

                               PERSONNEL

                               __________

                  MARCH 10, 24; APRIL 28; MAY 12, 2010

                               __________

         Printed for the use of the Committee on Armed Services


        Available via the World Wide Web: http://www.fdsys.gov/




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                      COMMITTEE ON ARMED SERVICES

                     CARL LEVIN, Michigan, Chairman

ROBERT C. BYRD, West Virginia        JOHN McCAIN, Arizona
JOSEPH I. LIEBERMAN, Connecticut     JAMES M. INHOFE, Oklahoma
JACK REED, Rhode Island              JEFF SESSIONS, Alabama
DANIEL K. AKAKA, Hawaii              SAXBY CHAMBLISS, Georgia
BILL NELSON, Florida                 LINDSEY GRAHAM, South Carolina
E. BENJAMIN NELSON, Nebraska         JOHN THUNE, South Dakota
EVAN BAYH, Indiana                   ROGER F. WICKER, Mississippi
JIM WEBB, Virginia                   GEORGE S. LeMIEUX, Florida
CLAIRE McCASKILL, Missouri           SCOTT P. BROWN, Massachusetts
MARK UDALL, Colorado                 RICHARD BURR, North Carolina
KAY R. HAGAN, North Carolina         DAVID VITTER, Louisiana
MARK BEGICH, Alaska                  SUSAN M. COLLINS, Maine
ROLAND W. BURRIS, Illinois
JEFF BINGAMAN, New Mexico
EDWARD E. KAUFMAN, Delaware

                   Richard D. DeBobes, Staff Director

               Joseph W. Bowab, Republican Staff Director

                                 ______

                       Subcommittee on Personnel

                      JIM WEBB, Virginia, Chairman

JOSEPH I. LIEBERMAN, Connecticut     LINDSEY GRAHAM, South Carolina
DANIEL K. AKAKA, Hawaii              SAXBY CHAMBLISS, Georgia
E. BENJAMIN NELSON, Nebraska         JOHN THUNE, South Dakota
CLAIRE McCASKILL, Missouri           ROGER F. WICKER, Mississippi
KAY R. HAGAN, North Carolina         GEORGE S. LeMIEUX, Florida
MARK BEGICH, Alaska                  DAVID VITTER, Louisiana
ROLAND W. BURRIS, Illinois           SUSAN M. COLLINS, Maine
JEFF BINGAMAN, New Mexico

                                  (ii)


                            C O N T E N T S

                              ----------                              

                    CHRONOLOGICAL LIST OF WITNESSES
        Active, Guard, Reserve, and Civilian Personnel Programs
                             march 10, 2010

                                                                   Page

Stanley, Hon. Clifford L., Under Secretary of Defense for 
  Personnel and Readiness........................................     6
Lamont, Hon. Thomas R., Assistant Secretary of the Army for 
  Manpower and Reserve Affairs...................................    30
Garcia, Hon. Juan M., III, Assistant Secretary of the Navy for 
  Manpower and Reserve Affairs...................................    38
Ginsberg, Hon. Daniel B., Assistant Secretary of the Air Force 
  for Manpower and Reserve Affairs...............................    42
Barnes, Master Chief Joseph L., USN (Ret.), National Executive 
  Director, Fleet Reservse Association...........................    71
Moakler, Kathleen B., Government Relations Director, National 
  Military Family Association....................................    77
Cline, Master Sergeant Michael, USA (Ret.), Executive Director, 
  Enlisted Association of the National Guard of the United States    96
Holleman, Deirdre Parke, Executive Director, The Retired Enlisted 
  Association....................................................    98
Strobridge, Steven P., USAF (Ret.), Director of Government 
  Relations, Military Officers Association of America............   100

       Military Health System Programs, Policies, and Initiatives
                             march 24, 2010

Cardin, Hon. Benjamin L., U.S. Senator from the State of Maryland   181
Rice, Charles L., M.D., Performing the Duties of the Assistant 
  Secretary of Defense for Health Affairs, and Acting Director, 
  Tricare Management Activity....................................   185
Hunter, RADM Christine S., USN, Deputy Director, Tricare 
  Management Activity............................................   192
Schoomaker, LTG Eric B., USA, Surgeon General of the U.S. Army, 
  and Commander, U.S. Army Medical Command.......................   194
Robinson, VADM Adam M., Jr., USN, Surgeon General of the U.S. 
  Navy, and Chief, Navy Bureau of Medicine and Surgery...........   218
Green, Lt. Gen. Charles B., USAF, Surgeon General of the U.S. Air 
  Force..........................................................   227
Jeffries, RADM Richard R., USN, Medical Officer of the U.S. 
  Marine Corps...................................................   235

  Military Compensation and Benefits, Including Special and Incentive 
                                  Pays
                             april 28, 2010

Carr, William J., Deputy Under Secretary of Defense for Military 
  Personnel Policy...............................................   313
Farrell, Brenda S., Director, Defense Capabilities and 
  Management, Government Accountability Office...................   317

                                 (iii)

Murray, Carla Tighe, Senior Analyst, National Security Division, 
  Congressional Budget Office....................................   323
Hosek, James R., Director, Forces and Resources Policy Center, 
  RAND National Security Research Division.......................   330

                       Reserve Component Programs
                              may 12, 2010

McCarthy, Hon. Dennis M., Assistant Secretary of Defense for 
  Reserve Affairs................................................   369
McKinley, Gen. Craig R., USAF, Chief, National Guard Bureau......   378
Wyatt, Lt. Gen. Harry M., III, USAF, Director, Air National Guard   379
Carpenter, MG Raymond W., ARNG, Acting Director, Army National 
  Guard..........................................................   380
Stultz, LTG Jack C., USAR, Chief of Army Reserve; and Commanding 
  General, U.S. Army Reserve Command.............................   396
Debbink, VADM Dirk J., USN, Chief of Navy Reserve; and Commander, 
  Navy Reserve Force.............................................   401
Kelly, Lt. Gen. John F., USMC, Commander, Marine Forces Reserve; 
  and Commander, Marine Forces North.............................   409
Stenner, Lt. Gen. Charles E., Jr., USAF, Chief of Air Force 
  Reserve; and Commander, Air Force Reserve Command..............   419
Stosz, RADM Sandra L., USCG, Acting Director of Reserve and 
  Training, U.S. Coast Guard.....................................   428


DEPARTMENT OF DEFENSE AUTHORIZATION FOR APPROPRIATIONS FOR FISCAL YEAR 
                                  2011

                              ----------                              


                       WEDNESDAY, MARCH 10, 2010

                               U.S. Senate,
                         Subcommittee on Personnel,
                               Committee on Armed Services,
                                                    Washington, DC.

        ACTIVE, GUARD, RESERVE, AND CIVILIAN PERSONNEL PROGRAMS

    The subcommittee met, pursuant to notice, at 10:33 a.m. in 
room SR-232A, Russell Senate Office Building, Senator Jim Webb 
(chairman of the subcommittee) presiding.
    Committee members present: Senators Webb, Hagan, Begich, 
Graham, and Chambliss.
    Majority staff members present: Jonathan D. Clark, counsel; 
Gabriella Eisen, counsel; and Gerald J. Leeling, counsel.
    Minority staff members present: Diana G. Tabler, 
professional staff member; and Richard F. Walsh, minority 
counsel.
    Staff assistants present: Jennifer R. Knowles and Brian F. 
Sebold.
    Committee members' assistants present: Juliet Beyler and 
Gordon Peterson, assistants to Senator Webb, Lindsay Kavanaugh, 
assistant to Senator Begich; Clyde Taylor IV, assistant to 
Senator Chambliss; and Adam Brake, assistant to Senator Graham.

        OPENING STATEMENT OF SENATOR JIM WEBB, CHAIRMAN

    Senator Webb. Good morning. The subcommittee will come to 
order.
    The subcommittee meets today to receive testimony on the 
Active, Guard, Reserve, and civilian personnel programs in 
review of the National Defense Authorization Request for Fiscal 
Year 2011 and the Future Years Defense Program.
    We will have two panels today. The first panel's witnesses 
are the senior civilian officials in the Department of Defense 
(DOD) and the military departments who are responsible for 
personnel matters. I welcome The Honorable Clifford Stanley, 
Under Secretary of Defense for Personnel and Readiness; The 
Honorable Thomas Lamont, Assistant Secretary of the Army for 
Manpower and Reserve Affairs; The Honorable Juan Garcia, 
Assistant Secretary of the Navy for Manpower and Reserve 
Affairs; and The Honorable Daniel Ginsberg, Assistant Secretary 
of the Air Force for Manpower and Reserve Affairs.
    Nobody wants to sit in this center seat, here? [Laughter.]
    Dr. Stanley, feel free to be the major focal point of the 
room. [Laughter.]
    Our second panel will include witnesses drawn from 
associations that represent and advance the interests of Active 
Duty, Reserve, and retired servicemembers and their families. 
I'll introduce our second panel when it convenes, but I wish to 
express my appreciation to all our witnesses for joining us 
this morning.
    This is my first hearing as chairman of this subcommittee. 
The subcommittee's jurisdiction extends to virtually all 
matters of personnel policy--compensation, military healthcare, 
military nominations, civilian personnel. I'd like to say, at 
this point, that I intend for this subcommittee to exercise 
continuous and active oversight of all our military personnel 
matters, through hearings, through consideration of the 
Department's budget and legislative proposals, and also through 
day-to-day interaction with you and people who work with you, 
and with our committee staff, as well. This hearing is one 
part, and one part only, of that process.
    There's no greater responsibility for Congress and military 
leaders, as our witnesses all know, than to care and provide 
for our servicemembers and for their families. This is a 
concept of stewardship that I, and I think all of my 
compatriots up here, feel about very strongly.
    I grew up in the military, as many of you know. I know what 
it's like to have a parent deployed. I also know what that 
means, in terms of the responsibilities and the challenges of 
family members. I can remember, at one point, when--my father 
was career Air Force--I went to a different school in the fifth 
grade, sixth grade, seventh grade, three different schools in 
the eighth grade, the ninth grade, two different schools in the 
tenth grade, from England to Missouri to Texas to Alabama to 
California to Nebraska, and I know how that stresses the 
families, and I know how important it is for us to always keep 
that in mind.
    I had the honor of serving with the Marine Corps infantry 
in Vietnam. I understand a lot of the stresses of what it means 
to be deployed in combat. I'm a father of a Marine NCO who had 
some hard time in Iraq, and also the father-in-law of a Marine 
infantry sergeant, who is now, at the age of 24, looking to be 
deployed for the fourth time, coming this July.
    That, coupled with the experience that I was able to gain 
through 5 years in the Pentagon--one as a Marine officer, three 
having responsibility for our Guard and Reserve programs, about 
which I feel very strongly, and the other as Secretary of the 
Navy--we got a very good look, in the 1980s, at the evolution 
of the total-force concept, where the manpower challenges came 
from, force-structure issues, and those sorts of things, and 
they will come to play here, in this subcommittee, as we move 
forward.
    We're very cognizant of the fact DOD, supported by this 
committee, has instituted many innovative programs over the 
past several years in order to deal with the challenges that 
have occurred since September 11, 2001.
    I would mention, briefly, since this is my first hearing as 
chairman of this subcommittee, that the Commonwealth of 
Virginia has a long history, in terms of taking care of, and 
being host to, one of the largest Active Duty and retired 
military populations in our country, and I'm honored to serve 
in the tradition of John Warner, who is no longer in the 
Senate, but gave tremendous service to this committee and also 
to the people of Virginia, in this area.
    Our military is now engaged in its 9th year of combat 
operations since September 11. Our Guard and Reserve components 
have played critical roles during this period, in ways that 
were not envisioned at the inception of the All-Volunteer Force 
and, quite frankly, were not envisioned when I was Assistant 
Secretary of Defense for Reserve Affairs.
    It's also important for us to remember that the All-
Volunteer Force is not an all-career force. Sometimes we lose 
that focus when we have people from the Pentagon coming over 
here talking to us about programs. The Services do a very fine 
job of attending to the needs of its career force, but we 
should always keep in mind our stewardship to those who feel, 
in the citizen-soldier tradition of this country, that they 
should come in and obligate themselves for one enlistment, and 
return to their communities.
    The data that we received when we were formulating the GI 
Bill was that 75 percent of the Army enlisted folks, and 70 
percent of the Marine Corps, and roughly half of the other two 
Services, leave the military on or before the end of their 
first enlistment. Those numbers may have varied a bit with the 
economic conditions right now, but those are the people that we 
should never forget when we come up--in talking about these 
other programs.
    I'm look forward, greatly, to serving with our 
subcommittee's ranking member, Senator Graham, in addressing 
these challenges, and to ensure the long-term viability of the 
All-Volunteer Force, not simply in numbers, but also in 
quality. Everyone in this room is very familiar with Senator 
Graham's service, not only on this committee, but also to our 
country, continuing to serve as a colonel in the Air Force 
Reserve. He brings valuable perspective, I think, as everyone 
has seen, as we've attempted to work through the issues of the 
Guantanamo Bay detainees and many other areas. He's served 
regularly on Active Duty, and his duties have allowed him to 
keep his finger on the pulse of the men and women in our 
military today. He and I have collaborated on a number of 
important issues over the past 3 years, and I welcome this 
opportunity to work with him even more closely during the 
months and years ahead.
    The All-Volunteer Force is stressed by the past 9 years of 
conflict. Having experienced multiple deployments, extended 
deployments to Afghanistan, Iraq, this is especially true of 
our ground forces. We're entering uncharted territory, in terms 
of the long-term consequences of past rotation cycles and an 
unsatisfactory deployment-to-dwell ratio that is only now 
beginning to be corrected. Despite authorizing more than 55,000 
additional Active-Duty servicemembers in the last year, today's 
dwell times are still inadequate to ensuring the vital 
recuperation, revitalization, and reset of the force and their 
families. I'm concerned about that impact on the resilience of 
the force, and we'll have some questions, during your 
testimony, with respect to those issues.
    This subcommittee faces a very clear and immediate 
challenge, and that is in addressing the rising costs of 
personnel. The combination of rising end strengths and an 
increasing compensation package continues to send personnel-
related costs soaring. As Secretary Gates recently said, ``The 
costs of healthcare are eating the Department alive.'' The 
total personnel-related budget in the Department's fiscal year 
2011 request, including the cost of providing healthcare to 
servicemembers, their families, and retirees, amounts to $178 
billion, or 32 percent of the overall DOD base budget. By 
contrast, when I was Secretary of the Navy in 1987, I think the 
entire Navy budget was right about $100 billion. Compare that 
with the fiscal year 2003 total personnel-related spending, 
including healthcare, amounted to $114 billion. That's an 
increase of 56 percent from fiscal year 2003 to fiscal year 
2011. By all accounts, that growth is going to continue.
    Though these challenges are steep, we should also be 
thankful for the successes that the Department and our Services 
have enjoyed. The combination of patriotism, a stagnant 
economy, a robust compensation package, including retirement, 
healthcare, and education benefits, have allowed the Services 
to achieve historic highs in recruiting and retention.
    The quality of our people has also been sustained. Waivers 
are down across the Services, test scores are up, and the vast 
majority of new recruits are high school graduates, a higher 
percentage than just a couple of years ago. These are all 
strong indicators of the quality of character and service that 
our people in uniform exhibit, across the board, day after day.
    I look forward to hearing from both panels this morning. I 
would encourage you to express your views candidly and, in 
addition relating to what you see going well, to address your 
concerns in those issues that you believe this subcommittee 
needs to pay attention to. I, along with Senator Graham and our 
colleagues, are dedicated to the prospect of ensuring that our 
military remains the very best in the world.
    Senator Graham.

              STATEMENT OF SENATOR LINDSEY GRAHAM

    Senator Graham. Thank you, Mr. Chairman.
    As I listened to your opening statement, it really struck 
me that, of all of the people in the Senate, you're clearly, I 
think, the most qualified person to lead this subcommittee 
right now, in the sense of your understanding the personnel 
issues and just your personal history.
    I want to also acknowledge that Senator Nelson was a 
complete joy to work with, and he's gone to another 
subcommittee. But, Mr. Chairman, I promise, when it comes to 
the troops, we'll be as bipartisan as possible. I think we've 
proven, between the two of us, that we can disagree, but also 
find common ground on things that really do matter.
    I was on a plane not long ago, and on that one plane I had 
a young man come up to me who had just gotten out of the 
military, he's going to Harvard, and he mentioned the GI bill 
that you authored and we worked together to pass. It really is 
working. There's a lot of implementation problems, but the fact 
that this young man is able to get most of his college 
education paid for, if not all, for serving 4 years, going to 
Harvard, I think, is a testament to that bill. The guy sitting 
right by me was a 28-year service Air Force colonel who is 
going to transfer his benefits to his youngest daughter going 
to college, and he was just telling me how much that meant to 
his family. So, what we're able to accomplish there, with your 
leadership, is really helping people.
    The one thing I would suggest is, the President's budget--
I'm going to try to support as much as possible. The 1.4-
percent pay raise is the least we can do. We all wish it would 
be more, but we do have budget problems up here. The 
sustainability of healthcare is the issue, I think, for us on 
this committee, and maybe the Congress as a whole, because, as 
you talked about your time with the Navy, the budgets have 
grown, the obligations are great, so few people are doing so 
much for so long. Here we are, 9 years almost into this war, 
and we're growing the military. I think that's a wise thing to 
do. Personnel costs are 30-something percent of the budget, but 
the healthcare component is 8 percent of the budget, growing, 
it's going to be hard to sustain that. We haven't had a premium 
increase in TRICARE since 1995. I want to do everything I can 
to help the families and retirees and military members, but 
eventually we're going to have to deal with that problem: How 
do you sustain the growth of TRICARE and other medical benefits 
within the budget before you start taking away from the 
warfighter? That means some hard decisions are to come.
    When it comes to ``Don't Ask, Don't Tell,'' I think we all 
are waiting to see what this survey shows, and try to make an 
intelligent decision based on input from the military, and I 
would just urge my colleagues to let that run its course.
    With that, Mr. Chairman, I will listen to the witnesses and 
look forward to working with you. Again, I think, between the 
two of us and the members of this committee, we can do some 
good things for our men and women in uniform.
    One last thought. Senator Chambliss has a bill that I've 
been working with to lower retirement age for Guard and Reserve 
members who have served on Active Duty since September 11, 
2001. For every year they would serve, or 90 days they would 
serve, they could retire a bit earlier, all the way down to 55. 
That has a cost associated with it, but I think it's an idea 
whose time has come, and I look forward to working with you to 
see if we can make that possible.
    Mr. Chairman, I look forward to being your ally and 
colleague on this. Now is the time for me to shut up and let 
the people who are in charge talk.
    Senator Webb. Let me say that I can't think of a better 
person to be working with than Senator Graham on these issues, 
as well.
    Senator Graham. Thank you.
    Senator Webb. We've received statements for the record from 
the Fleet Reserve Association, the Reserve Officer Association, 
and, without objection they will be included in the record at 
this point.
    We've also received a statement for the record from Senator 
Bill Nelson, who could not be here, and, without objection, 
that will be included in the record after the principal 
statements of our witnesses.
    [The prepared statement of Senator Bill Nelson follows:]
               Prepared Statement by Senator Bill Nelson
    Mr. Chairman, thank you for allowing me to speak about one of the 
last injustices plaguing the veterans' benefits system. I am talking 
about the offset between the Department of Defense (DOD) Survivor 
Benefit Plan (SBP) annuity and the Department of Veterans Affairs (VA) 
Dependency and Indemnity Compensation (DIC) benefit.
    SBP is an annuity paid by the DOD to survivors when either a 
military retiree pays a premium as income insurance for their survivors 
or when a servicemember dies on active duty. DIC is a survivor benefit 
paid by the Veterans Administration. Survivors receive DIC when 
military service caused the servicemember's death.
    There is a longstanding problem in our military survivor benefits 
system, the requirement for a dollar-for-dollar reduction of survivor 
benefits from the SBP paid by DOD by the amount of DIC received from 
the VA. I have fought for 9 years to eliminate the offset for SBP 
beneficiaries whose loved ones purchased or earned this annuity.
    Following the bloodiest of America's wars, President Abraham 
Lincoln, in his second inaugural address, said that one of the greatest 
obligations in war is to ``finish the work we are in; to bind up the 
Nation's wounds; to care for him who shall have borne the battle, and 
for his widow, and his orphan.''
    To truly honor our servicemembers, we all agree that the U.S. 
Government must take care of our veterans, their widows and orphans. In 
keeping with that moral principle, we must repeal the unjust offset 
that denies widows and orphans the annuity their deceased loved ones 
have earned on active duty or purchased for them.
    In the 2008 National Defense Authorization Act, we cracked the door 
to eliminating the offset. In conference negotiations with the House, 
we made some progress when we got a ``special payment'' of $50 per 
month, which will increase to $310 per month by 2017 because of money 
savings found in Tobacco Legislation passed last year.
    Our efforts have been important steps in the right direction, but 
they are not enough. We must meet our obligation to the widow and 
orphan with the same sense of honor as was the service their loved one 
had rendered. We must completely eliminate the SBP-DIC offset.
    I commend many of the organizations represented by the witnesses 
today for the support they have shown and hard work put in for full 
repeal of the offset. I ask DOD to work with Congress to honor the 
retirees, the fallen, and their families, and budget for full repeal of 
the SBP-DIC offset.
    Thank you, Mr. Chairman.

    Senator Webb. With that, we would begin with Dr. Stanley, 
and then move to Mr. Lamont, Mr. Garcia, and Mr. Ginsberg, in 
that order.
    Dr. Stanley, welcome.

   STATEMENT OF HON. CLIFFORD L. STANLEY, UNDER SECRETARY OF 
              DEFENSE FOR PERSONNEL AND READINESS

    Dr. Stanley. Good morning, Senator Webb and Senator Graham 
and other distinguished members of the subcommittee.
    First of all, let me just say I'm honored to be here, and 
particularly with colleagues and, in some cases, just meeting 
today.
    As I speak to you concerning DOD's personnel programs and 
readiness, for the past 3 weeks, as the Under Secretary of 
Defense, I've had the honor of working and interacting with 
some of the greatest men and women in uniform, DOD civilians, 
contractors, and their great families. It is truly a privilege 
to serve them in this position.
    I first want to thank you for your support of these men and 
women over the years. They have fought our wars, protected our 
interests and our allies around the globe. I look forward to 
working closely with this committee to improve support for 
those in uniform, the civilian employees of the Department, and 
their families.
    Just a few short months ago, I appeared before you as 
President Obama's nominee to be the Under Secretary of Defense 
for Personnel and Readiness. At that time, I emphasized several 
top priorities: the All-Volunteer Force, support to wounded 
warriors, personnel readiness, family programs, and the stress 
that is affecting our military today.
    In terms of military personnel, the Services are 
experiencing historic success in recruiting and retention. It 
is a tribute to both the dedication of our military personnel 
and to the patriotism of our Nation's citizens that we continue 
to maintain an All-Volunteer Force of unprecedented quality 
after more than 8 years in active combat operations.
    I am happy to report that in fiscal year 2009, the Services 
have had the most successful recruiting year of all the All-
Volunteer Force era. All four Active Services and all six 
elements of the Reserve component achieved both numerical and 
recruit quality targets for the first time, which is a banner 
year. To continue to secure sufficient personnel for the Armed 
Forces, the Department must provide a compensation package 
comparable and competitive to the private sector at the same 
time we balance the demands of an All-Volunteer Force in the 
context of growing equipment and operational costs.
    The Department continues this commitment through the 
President's request for a 1.4-percent increase in military pay 
for all servicemembers in the fiscal year 2011 budget, an 
amount that equals earning increases in the private sector, as 
measured by the Employment Cost Index. Of note, from the 
January 1, 2002, through the January 1, 2010, pay raises, 
military pay rose about 42 percent, and the housing allowance 
rose by 83 percent. During the same period, private-sector 
wages and salaries rose only 32 percent.
    While there is little question that those increases were 
necessary in the past, rising personnel costs could 
dramatically affect the readiness of the Department. We are at 
a point where discretionary spending offers the best ability to 
target specific skills, and the quality and quantity of those 
filling such positions. I believe the Services still require 
the use of special pay and bonuses to ensure sufficient 
operational readiness and our mission.
    Our military forces maintain an exceptionally high level of 
readiness, but multiple deployments to Iraq and Afghanistan 
have certainly increased the stress on our servicemembers and 
their families. We have a number of initiatives underway to 
address this stress, and have set clear limits and goals for 
the deployment lengths and the amount of time, or ``dwell,'' 
between deployments.
    To that end, we have limited our unit deployments to 1 year 
in theater, a minimum of 1 year between deployments for our 
Active component. Our goal is to increase the time between 
deployments to 2 years for every year deployed, commonly called 
a 1-to-2 dwell ratio. For the Reserve component, we have 
limited the mobilization period to 1 year, and we strive to 
have a minimum 3-year break between mobilizations. The goal of 
the Reserve component dwell ratio is 1 year mobilized, with a 
5-year break between mobilizations, or a 1-to-5 dwell ratio. 
Although we are not there yet, we are making progress toward 
those goals.
    The Department is focused on care for our wounded, ill, and 
injured military members. As Secretary Gates stated last month, 
aside from winning the wars themselves, this is the 
Department's highest priority. Initiatives are currently 
underway to achieve a seamless transition from Active Duty to 
veteran status, and to increase cooperation between DOD and the 
Department of Veterans Affairs (VA). In addition, efforts to 
create a Disability Evaluation System that is simpler, faster, 
fairer, and more consistent are underway.
    Finally, in support of President Obama's commitment, the 
Department is partnering with the VA to establish Virtual 
Lifetime Electronic Records that will improve veteran care and 
services through increased availability and administrative and 
health information.
    We are also committed to further improving support to our 
military families. For fiscal year 2011, we have requested for 
a 41-percent increase in family assistance baseline funding 
across the Department to ensure that we are on target, in the 
sense of investing in programs that are needed by 
servicemembers and their families. We have initiated an 
extensive strategic planning process to address the current 
issues facing family readiness programs. This begins with a 
thorough assessment of existing needs, programs, and related 
issues.
    Unfortunately, we have had stumbles in this area. As I'm 
sure you're aware, we announced a temporary pause to the My 
Career Advancement Account (MyCAA) program on February 16, 
2010. Due to unforeseen, unprecedented, but welcome, demand in 
enrollments that overwhelmed the infrastructure, we nearly 
reached the budget threshold. While it was necessary to pause 
the program immediately, we failed to communicate properly the 
reasons for the pause. Over the past few weeks, DOD has worked 
tirelessly on mapping out solutions, for both the short and 
long term, that honors our commitment to our military spouses 
while accounting for fiscal realities.
    Our proposals are in the final stage of approval and we 
hope to restart the program very soon. We know we must make a 
concerted effort to restore our credibility and confidence with 
our military spouses, servicemembers, and the American public.
    Our military has proven its resilience during the most 
challenging of times, but the stress on the force is obvious. 
The Department's civilian and military leadership remain 
focused on employing numerous strategies to reduce the 
incidence of suicide in the Armed Forces. In calendar year 
2009, there were a total of 312 suicides, 285 Active component 
and 26 in the Reserve component, marking an increase, up from 
268 in 2008. I know this committee shares our belief that even 
one suicide is too many.
    There are many other critical issues facing the Department 
and this Nation, and I am exceedingly grateful to this Congress 
and this committee for their continuous commitment to 
supporting our men and women in DOD.
    I look forward to your questions and thank you for your 
time.
    [The prepared statement of Dr. Stanley follows:]
             Prepared Statement by Hon. Clifford L. Stanley
    Mr. Chairman and members of this distinguished subcommittee, thank 
you for inviting us to testify before you.
    As I humbly assume my role as the new Under Secretary of Defense 
for Personnel and Readiness, I am resolute in my determination to 
honor, protect and improve the lives of U.S. airmen, soldiers, sailors, 
and marines. I am here today to describe our mission as I see it and 
share my thoughts on how compassion, excellence and heightened sense of 
urgency will help me and my organization fulfill our duty.
    I am mindful we are at war and we must prevail. We win when we help 
our troops succeed in combat, and be healthy and happy with their 
families when at ease. We win when our troops can be confident their 
families have easy access to the resources and support they need while 
their loved ones are deployed. Maintaining our incredible All-Volunteer 
Force is our highest priority as we strive to recruit, attract, retain, 
and reward American's best and brightest, and their families.
                              active duty
Recruiting
    After more than 5 years of the most challenging recruiting 
environment since the inception of the All-Volunteer Force (AVF) in 
1973, the Services emerged in fiscal year 2009 with the most successful 
recruiting year of the AVF era--all four Active Services and all six 
Reserve components achieved both numerical and recruit quality targets 
for the first time, a banner year. Previous years were marked by a 
growing economy, low unemployment, reluctance of influencers of youth 
to recommend military service, propensity among youth themselves at an 
all-time low, and recruiting goals of the Army and Marine Corps 
increasing. Yet since 2005, the Services met or exceeded recruiting 
goals--the AVF concept has proven itself amidst some of the greatest 
stressors it could face.
    The recruiting environment has now changed. Unemployment has risen 
considerably. Generally, times like this make recruiting less 
challenging, and a regrettable trend in national unemployment operates 
to the advantage of those who are hiring, including the U.S. military. 
In addition, interest in the military among young people has increased.
    On the other hand, challenges remain--the lower likelihood of 
influencers of youth (e.g., parents and teachers) to recommend service, 
a large and growing proportion of youth population who are ineligible 
to serve in the military principally as a consequence of rising 
obesity, high numbers of youth going to college directly from high 
school, and the continuing concerns about overseas contingency 
operations with its concomitant high operations tempo, particularly the 
announced increases in force levels in Afghanistan. Therefore, we are 
in uncharted waters--with significant factors, both negative and 
positive, directly affecting military recruiting efforts.
    As a result, we continually review our recruiting programs to align 
funding and policies with current realities, recognizing that stable 
and adequate investments in recruiting resources are necessary to 
maintain success, especially in the long term. These reviews have 
allowed the Services to reduce recruiting resources in fiscal year 2010 
and 2011. While this results in a decreasing reliance on bonus 
incentives to meet recruiting goals, each Service knows it must be 
judicious in its cuts--reducing budgets gradually, and in the right 
places--using those targeted incentives to ensure we attract high 
quality youth into our most critical skills. We are mindful of the 
past, when fluctuating resources--up in tough recruiting environments, 
down in favorable ones--jeopardized recruiting missions, often 
resulting in sporadic failures.
    The recruiting environment is less challenging today, but we know 
that a tough recruiting environment will return. If we enter those 
difficult recruiting periods with insufficient resources and 
inexperienced recruiters, it will only exacerbate the problem and 
contribute to the ``boom and bust'' recruiting cycle which has 
characterized the past. Such a cyclical resourcing strategy also 
ignores the ongoing and significant role recruiting resources--
particularly advertising--have on both youth and influencer awareness, 
attitudes, and propensity. Therefore, it is imperative that we 
stabilize necessary recruiting resources. We appreciate this 
committee's untiring support of our recruiting programs and look 
forward to working together to ensure future success.
    As previously stated, fiscal year 2009 was a banner year for active 
duty recruiting. Altogether, the Services exceeded their goal of 
163,880 accessions by 5,088, accessing 159,374 first-term enlistees and 
an additional 9,594 individuals with previous military service.
    Fiscal year 2010 active duty recruiting efforts, to date, are even 
better. Through December, all Services met or exceeded both quantity 
and recruit quality objectives for the active force, with the Army 
achieving 13,977 of its 13,716 recruiting goal, for a 102 percent year-
to-date accomplishment (Table 1). Especially notable is the fact that 
for the second year in a row, after 4 years of falling below the 90 
percent DOD Benchmark for High School Diploma Graduates, the Army is 
now exceeding that measure, with an impressive 99.9 percent of new 
recruits holding that credential.
      
    
    
      
    We should not lose sight of the fact that, although the overall 
youth population is large, only a relatively small proportion of 
American youth is qualified to enlist. It is an unfortunate fact that 
much of the contemporary youth population is currently ineligible to 
serve. Medical disqualification, with obesity a large contributing 
factor, removes 35 percent, drug or alcohol abuse removes 18 percent, 
and another 23 percent do not meet our standards for reasons such as 
criminal misbehavior, have more dependents than can reliably be 
accommodated in the early career, or low aptitude scores. Another 
estimated 10 percent are qualified, but are attending college.
    To expand the recruiting pool and assist the Services in meeting a 
special category of critical readiness needs, the Department initiated 
a 1-year pilot program, Military Accessions Vital to National Interest 
(MAVNI), allowing the enlistment of up to 1,000 of a select group of 
non-U.S. citizens who had been in the United States for at least 2 
years. Enlistments under this pilot are open only to health care 
professionals in critically short specialties and individuals with 
language skills and cultural backgrounds in a limited list of 
languages. We are currently reviewing results of this pilot program.
    But, given the overall limited pool of eligible youth, our 
continuing recruiting success does not come easily. It remains the 
result of long hours and hard work by the 15,100 dedicated and 
professional, active-duty military recruiters. These recruiters often 
are the sole representative of our military forces in local 
communities, and they have both my and the Department's most sincere 
respect and gratitude.
    This past August, we implemented the post-September 11 GI Bill--the 
most extensive restructuring of post-service education benefits since 
the introduction of the original World War II GI Bill. As I am sure you 
are aware, the Montgomery GI Bill (MGIB) has been a cornerstone of our 
active-duty military recruiting efforts since 1985. There is little 
doubt that the MGIB has met or even exceeded the expectations of its 
sponsors when it was enacted, and has been a major contributor to the 
success of the All-Volunteer Force.
    This new post-September 11 GI Bill should enhance our recruiting 
efforts even more. However, we remain cautious about the impact of such 
a major, new benefit on retention, particularly first-term retention. 
We hope that the provision in the new program that allows career 
servicemembers to share or transfer their GI Bill with immediate family 
members, long requested by both members and their families, will 
mitigate negative retention impacts. Early results look favorable, with 
over 100,000 career servicemembers already requesting authority to 
share their earned educational benefits with their family members. We 
are monitoring the effects of this implementation very closely.
Military Decorations and Awards
    The Department continues to work in concert with the Services to 
appropriately recognize and laud the accomplishments, both valorous and 
non-valorous, of our soldiers, sailors, marines, and airmen. In the 
AVF, appropriately recognizing the accomplishments of our 
servicemembers is fundamental to maintaining esprit-de-corps and a 
motivated force. It is most important that the Services recognize the 
significant acts and achievements of our servicemembers while 
simultaneously maintaining the time-honored prestige of our most 
revered military decorations such as the Medal of Honor, Distinguished 
Service Cross, Navy Cross, Air Force Cross, and Silver Star. I am aware 
of the concern from some Members of Congress in regard to the award of 
valor decorations and will closely examine the results of the ongoing 
review and report on the Medal of Honor awards process as requested in 
the House Armed Services Committee report language that accompanied the 
National Defense Authorization Act of Fiscal Year 2010.
Leave and Liberty Enhancements
    Given the ongoing operations tempo associated with Operations Iraqi 
Freedom and Enduring Freedom, the Department is acutely aware of the 
need to provide all soldiers, sailors, marines, and airmen with 
adequate leave and liberty opportunities, especially during and after 
deployments, for respite and reintegration, respectively. 
servicemembers serving in Iraq and Afghanistan are provided a much 
needed break from combat through the Rest and Recuperation (R&R) leave 
program. This vital program provides servicemembers, who are on long 
deployments, government funded transportation to the airport closest to 
their leave destination, and allows them to take 15 days of respite 
leave in an area of their choosing. For those servicemembers serving in 
the most dangerous and arduous areas of the combat zone, the R&R leave 
is not chargeable which not only recognizes their stressful duty but 
also provides more accrued leave to utilize upon redeployment for 
reintegration into their family and community. Additionally, the Post 
Deployment/Mobilization Respite Absence (PDMRA) program provides Active 
and Reserve component members who are deployed or mobilized above and 
beyond the Secretary of Defense's established deployment--dwell time 
ratios with respite nonchargeable administrative absence upon return 
from deployment or mobilization.
    I thank Congress for passing legislation, through the NDAA for 
Fiscal Year 2010, which allows our servicemembers to temporarily 
increase, from 60 to 75, the number of leave days authorized for carry 
over from 1 fiscal year to the next. This provision will reduce the 
frequency of lost leave for those servicemembers who have fewer 
opportunities to take longer leaves due to the persistent operational 
demands. The Department continues to monitor leave balances and lost 
leave to preclude avoidable loss of the benefit.
Retention
    For fiscal year 2009, the Department was very successful in 
attaining enlisted retention goals. All Active components met or 
exceeded their respective retention goals in every measurable category. 
The Services and the Department anticipate continued success in the 
upcoming year and are already meeting or exceeding the monthly goals 
for early fiscal year 2010.
    Despite the overall strength of enlisted retention over the last 
few years, there remain critical shortages in many low density/high 
demand skills and other ``hard-to-retain'' skills, such as explosive 
ordnance disposal specialists, linguists, intelligence and 
counterintelligence analysts, and pararescue operators, that justify 
the continuation and application of the statutory bonus authorities. 
The Selective Reenlistment Bonus (SRB) and the Critical Skills 
Retention Bonus (CSRB) are among the most effective and are authorized 
by 37 U.S.C. 308 and 37 U.S.C. 355, respectively, as incentives to 
attract/retain qualified personnel in critical military specialties.
    The Department's process to manage bonuses is very well defined. A 
skill is critical if it meets one or more of the following: (a) 
technical skills requiring high training and/or replacement costs; (b) 
skills in high demand in the civilian sector; (c) challenging to 
recruit into; (d) crucial to combat readiness or capabilities; and (e) 
low density/high demand (those skills that are in high demand for 
current operations yet are low density due to less requirements during 
peacetime). All requests from the Services must have a rigorous 
business case that clearly outlines the need for the bonus for that 
skill, payment amount and method, and expected retention results. 
Designations do not exceed 3 years, subject to congressional extension 
of the statutory bonus authority. The complementary authority of the 
CSRB is the Selective Reenlistment Bonus (SRB). The SRB is under the 
authority of the Service Secretaries and is not centrally managed by 
the Department. However, applications of the bonus authorities are 
reviewed at the Department and sent as an annual report to Congress.
Stop Loss
    The Army is the only Service with members currently extended under 
the Stop Loss authority. From a peak of 15,758 in 2005, the Army 
reduced the number of soldiers affected by Stop Loss to approximately 
8,000 at the end of December 2009. The Department is progressing as 
planned to completely end the use of the Stop Loss authority. Army 
units deploying after January 1, 2010, are no longer using the Stop 
Loss authority. The Department further expects to reduce the number of 
servicemembers on Stop Loss to less than 6,600 by June 2010. This is a 
50 percent reduction from February 2009 (date that the Secretary of 
Defense announced the milestones to end Stop Loss). All use of the Stop 
Loss authority will end by March 2011.
    Two Stop Loss Special Pays have been enacted which allow a payment 
of up to $500 per month for members whose active duty (retroactive to 
September 11, 2001) is or was extended by use of the Stop Loss 
authority. These pays were appropriated and authorized by the Congress, 
with the Department's support, to mitigate the impact and disruption 
that extensive use of Stop Loss had and has on the lives of 
servicemembers and their families. The Department implemented both 
pays, active and retroactive, and appreciates the support of Congress 
to compensate members for the unique circumstances presented by the use 
of this policy, while still preserving our ability to react with 
discretionary authority as dictated by future circumstances.
Separation Policy
    The Department continues to improve military discharge policies in 
response to conditions of the current war and its effects on those who 
serve. As we reported to Congress earlier, one such improvement is the 
addition of increased rigor when using a personality disorder as the 
basis for administratively separating servicemembers who had deployed 
to imminent danger areas. This more rigorous process now includes a 
review by the Surgeon General of the Military Department concerned, 
yielding greater confidence that servicemembers who should be separated 
due to post-traumatic stress disorder (PTSD) or traumatic brain injury 
(TBI) are appropriately processed for disability separation as opposed 
to personality disorder. The immediate evidence of the positive effect 
of the increased rigor is that the number of personality discharges has 
decreased from 81 at the policy's promulgation in September 2008 to an 
average of 16 per month in 2009. Also, in response to section 512 of 
the NDAA for Fiscal Year 2010, the Department is prescribing policy 
regarding a more in-depth medical examination to assess whether the 
effects of PTSD or TBI relate to the basis for an administrative 
separation for those servicemembers who are pending discharge or who 
were discharged under conditions other than honorable.
End Strength Management
    Meeting end strength is a priority of the Department. The table 
below depicts the fiscal year 2009 Active Duty authorizations 
(prescribed and actual) and fiscal year 2010 authorized levels which 
the Department intends to achieve. The Secretary of Defense has 
authority granted under the terms of the President's national emergency 
declaration to increase statutory strength levels prescribed by the 
National Defense Authorization Act if needed. The Services have 
implemented recruiting, retention, and force shaping policies and 
programs to achieve end strengths for fiscal year 2010. The Department 
appreciates the congressional support of the fiscal year 2010 end 
strength levels. These end strengths will provide the ground forces to 
meet strategic demands, eliminate the need for the use of Stop Loss, 
and mitigate persistent capability shortfalls which will reduce stress 
and demands on servicemembers and families by increasing dwell time.
      
    
    
Force Development
    The Department continues to emphasize joint officer development and 
has made great strides in implementing the extraordinary authorities 
authorized in the 2007 NDAA. Active and Reserve component participation 
continues to grow, and the adjudication of over 3,200 joint experiences 
from nontraditional joint duty assignments attests to the Department's 
ability to recognize joint experiences whenever and wherever they 
occur.
    Joint officer management is not the only area of significant 
improvement for the officer corps. We appreciate the authorities 
provided by Congress in the fiscal year 2009 and 2010 NDAAs that allow 
the development of general and flag officers with the joint knowledge 
and skills necessary to lead and counter emerging threats. This 
landmark general and flag officer management legislation apportioned 
general and flag officer authorizations between internal and external 
Military Service requirements, ensuring the statutory responsibilities 
of the military departments and the joint warfighter can be met.
    The enactment of conforming legislation from the Department's 2010 
legislative package is also serving to dramatically accelerate the 
development of joint experience in the Reserve components. The 
legislation expanded on the previously enacted statutory framework 
affording the Military Departments the opportunities to purposefully 
develop officers from the Reserve components for senior posts in joint 
warfighting organizations. This delivered on the promise of the charter 
Goldwater-Nichols legislation by institutionalizing joint officer 
development through the senior officer grades regardless of component.
Compensation
    The Department and Congress continue their strong commitment to 
provide a secure standard of living and quality of life to those who 
serve in uniform. Today, we find ourselves empowered with a never 
before seen set of flexible and targetable pay authorities which enable 
the Department to dynamically address recruiting and retention and 
achieve specific and desirable effects. We also find ourselves with 
large fixed costs encompassed in our entitlements, and the prospect of 
continued growth in that area. To secure sufficient personnel for the 
Armed Forces, the Department must provide a compensation package 
comparable and competitive in the private sector while at the same time 
balancing the demands of an All-Volunteer Force in the context of 
growing equipment and operations costs.
    The Department continues this commitment through the President's 
request for a 1.4 percent increase in military pay for all 
servicemembers in the fiscal year 2011 budget--an amount that equals 
earnings increases in the private sector as measured by the Employment 
Cost Index. Of note, since January 1, 2002 through the January 1, 2010 
pay raise, military pay has risen by 42 percent, the housing allowance 
has risen by 83 percent, and the subsistence allowance has risen by 40 
percent. During this same period, private sector wages and salaries 
have only risen by 32 percent. Government Accountability Office (GAO) 
is currently auditing the overall adequacy of military pay, as well as 
the appropriateness of the benchmarks used to measure any gaps relative 
to the private sector and its report is due April 2010. We are 
confident regular military compensation will compare favorably with pay 
in the private sector. While there is little question that those levels 
of increase were necessary in the past, the Department now finds itself 
at a point where discretionary spending offers the best ability to 
target specific skills, and the quantity and quality of those filling 
such positions.
    Collateral to the GAO review, the President recently commissioned 
the eleventh Quadrennial Review of Military Compensation. The four 
themes he has asked the panel to focus on continue the thesis of 
tailoring pays beyond entitlements to target groups and behaviors. This 
review, in general terms, will be looking at the compensation package 
for service performed in combat of hostile areas; compensation for our 
Reserve components in light of current and planned utilization; 
compensation benefits available to our wounded, those who care for them 
and the survivors of those fallen; and the pay and incentives for some 
of our most critical fields, including mental health professionals, 
special operators, operators of remote systems and those with 
specialized linguistic skills. With the recently consolidated pay 
authorities, I am confident in saying Congress has given us the tools 
we need to address each of these areas; what remains is identifying the 
best combination of the pays to achieve the ideal combination of outlay 
to impact. The Department, as always, welcomes the continuance of these 
authorities, but would be generally opposed to continued entitlement 
growth beyond indexed levels in the absence of specific goals and 
outcomes supported by studies such as those just discussed.
    Similar to our efforts to target and define the impacts of each pay 
with our active personnel, we must continue to ensure we support those 
who have already served, but again, we must do so in an equitable 
manner and one that is consistent with the overall demands of the 
Department. As an example, the Department continues to oppose efforts 
to eliminate the offset between the Survivor Benefit Plan (SBP) and 
Dependency Indemnity Compensation (DIC) programs. Allowing concurrent 
receipt of SBP and DIC without offset would create an inequity with one 
select group receiving two survivor annuities, while survivors of most 
military retirees and survivors of veterans who died of service 
connected cause, but were not retired, would receive only one or the 
other. At the same time, in seeking that broader equity and Department-
wide impact, we see a win-win opportunity in expanding the concurrent 
receipt program to include military disability retirees with less than 
20 years of service regardless of disability rating. This expansion 
would cover our most challenged retirees by allowing them to receive 
retired pay for their years of service performed and VA disability 
compensation for their future reduced earning capability.
    Overall, the state of military compensation is healthy. We have 
improved our overall entitlements to the point that all of our 
personnel are paid at or above the 70th percentile of their civilian 
counterparts. We have eliminated out-of-pocket expenses for housing to 
fully cover, on average, the costs of comparable civilian housing.. We 
have gained a new and dynamic set of authorities which we are in the 
midst of implementing. For the first time, we truly have the ability to 
target pay with pinpoint accuracy to achieve desired aims and maximize 
effects of dollars spent. Our challenge today is to maintain this 
position without imposing greater long term bills, while using our 
targetable tools to shape and manage our force.
Legislative Fellowship Program:
    The Legislative fellowship program is a unique and excellent 
opportunity for members with great potential to serve to learn the day-
to-day functions of the Legislative Branch of Government and is a 
valuable experience in the professional development of career military 
members or civilian employees in the Department. The Services and 
Components assign their Legislative Fellows to appropriate follow-on 
tours, which the Department monitors for each Fellowship cycle. Typical 
of the follow-on assignments are positions in: the House and Senate 
Liaison Divisions of the Services; the Office of the Secretary of 
Defense (Legislative Affairs); the Combatant Command Headquarters with 
duties associated with interacting with Congress; Service primary 
staffs responsible for legislation development and interaction with 
Congress; and the Staffs of senior leaders. The Secretary of Defense 
established the maximum number of Legislative Fellows at 100. The 100 
Legislative Fellowships are broken out in calendar year 2011 as 
follows: 


      
    Legislative Fellows serve no more than 12 months in the House or 
Senate. The Legislative Fellowship Program is the only program that 
authorizes Department of Defense personnel to work in Congress on a 
more than temporary basis and the program and policies are clearly 
promulgated in a DOD Instruction. Legislative Fellows are selected 
under Service competitive selection process and approved by the OUSD 
(P&R).
                           reserve component
    Achieving the defense strategy articulated in the Quadrennial 
Defense Review (QDR) requires a vibrant National Guard and Reserve 
seamlessly integrated into the Total Force. National Guard and Reserve 
units and individual members are heavily utilized across the full 
spectrum of current military operations, ranging from combat missions 
in support of the global war on terror to homeland emergencies. The 
Guard and Reserve have demonstrated their readiness and ability to make 
sustained contributions, and to prevail in today's wars, the Reserve 
components must serve in an operational capacity--available, trained, 
and equipped for predictable routine deployment--as well as a strategic 
capacity. Preventing and deterring conflict will likely necessitate the 
continued use of some elements of the Reserve Component (RC) in an 
operational capacity well into the future, especially in high-demand 
skill sets. Accordingly, the Department will use the Guard and Reserve 
where needed as an operational Reserve, rather than the ``force of last 
resort,'' to fulfill requirements for which they are well suited in the 
United States and overseas. Today's Citizen Warriors have made a 
conscious decision to serve, with full knowledge that their decision 
means periodic recalls to active duty under arduous and hazardous 
conditions.
    Consistently averaging about 140,000 National Guard and Reserve 
members mobilized to support ongoing operations on a daily basis, the 
Reserve components continue to make significant contributions to the 
national defense. The fiscal year 2011 budget provides about $50 
billion for pay, training, equipping, and facilities to support the 
Reserve components of the Army, Navy, and Air Force in their respective 
Reserve components as operational Reserve Forces. The budget includes 
an across-the-board pay raise of 1.4 percent, along with pay and 
allowances for over 1 million personnel. Operating funds support 
necessary training requirements to ensure deploying personnel are fully 
mission-ready.
    The fiscal year 2011 budget request supports the Department's Ready 
Reserve totaling about 1.1 million members contributing about 43 
percent of the total military end strength at a cost of about 9 percent 
of the total base budget. The Ready Reserve consists of the Selected 
Reserve (about 838,300), the Individual Ready Reserve (IRR) about 
(250,000), and the Inactive National Guard (ING) (about 2,000). This 
budget request includes about $53.3 billion to fund pay and allowances 
and costs of Reserve component training, incentives, equipment 
operation and maintenance costs, and readiness training costs for 
eligible military personnel. This amount includes $5.5 billion for 
Reserve component equipment procurement, which is funded by the 
military departments as a subset of their Active component procurement 
budget.
    Managed as strategic and operational forces, the total Reserve 
component structure operates across the continuum of military missions 
performing both strategic and operational roles in peacetime, wartime, 
contingency, domestic emergencies and homeland defense operations. As 
such, the Services organize, resource, equip, train, and utilize their 
Guard and Reserve components to support mission requirements to the 
same standards as their Active components. The budget supports 
preparation of both units and individuals to participate in missions, 
across the full spectrum of military operations, in a cyclic or 
periodic manner that provides predictability for the combatant 
commands, the Services, servicemembers, their families, and civilian 
employers, while potentially increasing the Department's overall 
capacity and reducing costs.
    To help reduce Active component ``dwell to deployment'' ratio, all 
Reserve components are moving towards a more rotational process, 
characterized by a period of active service thereby relieving active 
force burden, and then followed by an extended period at home. The 
current mobilization policy issued in January 2007 by the Secretary of 
Defense mandated involuntary mobilizations be limited to no more than 
12 months, which does not include individual skill training days 
required for mobilization or deployment or terminal leave. The 
Secretary of Defense also set a goal of not more than 1 year mobilized 
in any 6 year period for the Reserve components. The Services are 
moving toward this goal as quickly as possible given current 
operational requirements. Unlike before, when the RCs were usually 
funded at less than full readiness because they were not first to 
fight, specific units now must be fully resourced in any given year. 
This new train-mobilize-deploy construct means that the RCs must be 
ready, manned, trained, medically and dentally prepared, and equipped 
when their scheduled availability comes up, and they must be funded 
accordingly.
Resourcing Operational Reserve Forces
    Managing the Reserve components as operational forces affects 
training schedules and funding requirements, including medical 
readiness. In the past, normal training profiles meant training about 2 
days per month plus 14 to 15 days of active duty for training annually, 
during which time Reserve component personnel were required to train to 
the same standards as their Active counterparts. While that training 
profile remains for some units, current Department policy states that 
for those with planned deployments, training days prior to mobilization 
must increase. This training profile, with more training pre-deployment 
and less post-deployment, minimizes mobilized time away from families 
and civilian jobs and will require a different resourcing approach. In 
general, the land based (Army and Marine Corps) Reserve components 
train according to this new profile, meaning that funds which had been 
consumed after mobilization from the active accounts are now required 
and expended prior to mobilization from the Reserve accounts. This 
change in training profiles means a simple comparison to prior year 
execution funding models can be misleading. For fiscal year 2011, 
Congress has authorized Reserve component military personnel budgets to 
be consolidated into a single budget activity, allowing much improved 
management of Reserve component assets and more agile fund allocation. 
This flexibility is especially crucial for managing funds for the new 
operational Reserve, and the Department greatly appreciates this 
Congressional approval.
Equipping and Basing Operational Reserve Forces
    The fiscal year 2011 budget requests $5.5 billion for Reserve 
component equipment, and provides greater transparency and more robust 
funding for vital equipment needs as the Department continues to ensure 
that deployed and next-to-deploy units, whether in the active or 
Reserve component, receive the highest equipping priority. Effective 
and realistic readiness training at home requires that the National 
Guard and Reserve have access to equipment compatible with the active 
components and used in the assigned operational environment. 
Modernization, mission transformation, equipment replacement due to the 
war losses, and homeland defense are all catalysts for a new approach 
to equip the Reserve components.
    In the past, the Reserve components often relied on cascaded or 
``hand-me-down'' equipment from the Active components and they often 
were short in their equipment inventories. The fiscal year 2011 budget 
contains funds needed for Reserve component equipment procurement to 
continue that transition, repair and replace war-damaged equipment, and 
to correct longstanding deficiencies. The budget request includes funds 
for equipment that will not only improve combat readiness but will also 
allow the National Guard to further improve its ability to respond to 
local domestic emergencies.
    Additionally, the Guard and Reserves previously have been a low 
priority for receiving new equipment. But today that standard has 
changed and these Forces receive the same equipment as their Active 
counterparts. We have achieved major progress in programming funds and 
equipping our Reserve components for an operational role. With this 
operational role comes the requirement for equipment transparency in 
form of increased visibility and accountability for the National Guard 
and Reserve in the programming and budgeting process. 
Institutionalizing this process will ensure an adequate mission 
capability for foreign and domestics responses and we are proceeding in 
that direction.
    The Reserve components request $1.4 billion for military 
construction (MILCON) projects. These projects will meet both current 
and new mission requirements for RC operations, readiness, and training 
facilities.
                         readiness and training
Deployment and Dwell
    Multiple deployments to Iraq and Afghanistan have certainly 
increased the stress on our servicemembers and their families. We have 
a number of initiatives underway to address this stress, and have set 
clear limits and goals for deployment lengths and the amount of time or 
``dwell'' between deployments.
    To that end, we have limited unit deployments to 1 year in theater, 
with a minimum of 1 year between deployments for our Active component. 
Our goal is to increase the time between deployments to 2 years for 
every year deployed, commonly called a 1:2 ``dwell'' ratio. For the 
Reserve component, we have limited the mobilization period to 1 year, 
and strive to have a minimum 3 year break between mobilizations. The 
goal for Reserve component dwell ratio is 1 year mobilized with a 5 
year break between mobilizations, or a 1:5 dwell ratio.
    Dwell time is driven by the number of forces deployed for missions 
around the world against the supply of available forces. We have 
increased the supply of forces by increasing the end strength for the 
Army, the Marine Corps, and Special Operations Forces. We also expect 
to make progress toward meeting the dwell goals as we drawdown forces 
in Iraq.
Defense Mishap Reduction Initiative.
    As Chair of the Defense Safety Oversight Council (DSOC), I have 
been chartered to ensure that the Department is making steady progress 
toward the Secretary's goal of a 75 percent reduction in all accidents. 
The Department has made considerable progress to date due to the 
tremendous effort of our military and civilian leaders. From our 2002 
baseline, we have reduced our civilian lost workday rate 41 percent, 
are down 31 percent in our private motor vehicle fatality rate, and 
dropped our Class A aviation accident rate 56 percent.
    The DSOC is supporting the Military Departments' pursuit of the 
Occupational Safety and Health Administration's (OSHA) Voluntary 
Protection Program (VPP) at more than 200 DOD installations and sites. 
We have 30 sites that have already attained OSHA's Star recognition and 
we expect 17 more sites by the end of 2010. Their OSHA Star status 
designates them as exemplary worksites with comprehensive, successful 
safety and health management systems, and improved labor/management 
relations.
    We recently completed a comprehensive, data driven assessment to 
further prevent aircraft crashes, save military lives, and reduce the 
need for replacement aircraft. The task force, consisting of a variety 
of experts from across the Department, recommended that the military 
aviation communities acquire technologies for collision awareness, 
crash survivability, and risk management. As a result of this important 
work, the military departments are making further investments in 
hardware and software that will avert aircraft crashes. With your 
continued support, we can make further progress in preventing injuries, 
fatalities, and aircraft crashes; and be well on our way towards 
attaining the Secretary's accident reduction goal.
                         military health system
Health Budgets and Financial Policy
    The fiscal year 2011 budget reflects several areas of continued 
emphasis, including the modernization of our medical infrastructure and 
full funding and support of our Wounded, Ill and Injured programs. The 
Unified Medical Budget, the Department's total request for health care 
in fiscal year 2011, is $50.7 billion. This includes the Defense Health 
Program, Military Personnel, Military Construction, and Medicare-
Eligible Retiree Healthcare. Major increases in the budget request 
include $0.8 billion for medical and general inflation; $1.2 billion 
for private sector care costs due to an increase in users of TRICARE 
and an increase in utilization of the TRICARE benefit; $0.6 billion for 
enhancements for the Direct Care system; and $0.3 billion for 
modernizing the Department's electronic health record to enable data 
compatibility for the Virtual Lifetime Electronic Record, and 
correcting critical system problems, increasing user satisfaction, and 
improving system reliability and availability.
    Our primary and enduring responsibility is to provide the highest 
quality care to our beneficiaries, using the most current medical 
evidence to drive our clinical decisionmaking; and one of our 
fundamental tenets is that quality of care is also cost-effective. In 
addition, there are a number of actions we have undertaken and will 
continue in fiscal year 2011 to continue to provide value to the 
Department and the taxpayer. The ways we are addressing cost 
effectiveness in fiscal year 2011 include:

         continued implementation of Federal Ceiling Pricing of 
        retail pharmaceuticals ($842 million savings);
         continued implementation of the Outpatient Prospective 
        Payment System, which reduces the reimbursement paid for 
        outpatient care at inpatient private sector care facilities 
        ($366 million savings)
         standardization of medical supply chain management 
        across the full range of military health care operations ($27 
        million savings);
         increasing efforts to identify and detect fraud, 
        waste, abuse, and overpayments to civilian medical providers 
        ($68 million savings); and
         additional VA and DOD facilities sharing--most notably 
        the first fully integrated Joint DOD/DVA healthcare 
        collaboration consisting of the North Chicago Veterans Affairs 
        Medical Center and the Navy Ambulatory Care Center, Great 
        Lakes, IL.
Health Affairs/TRICARE Management Activity Strategic Direction
    In 2002, the assistant Secretary of Defense for Health Affairs 
(ASD/HA) aligned policy and program execution strategies under Health 
Affairs/TRICARE Management Activity (HA/TMA). In HA/TMA, as in most 
organizations, the bridge from strategy to execution was challenging, 
and the organizational alignment, still in effect today, was intended 
to streamline processes for faster and more effective execution of 
policies and programs. Under this arrangement, HA is setting clear 
strategic direction for the Military Health System (MHS) in partnership 
with the Services.
    For the past 12 months, HA/TMA has worked closely with the Service 
Surgeons General on initiatives that have coalesced around a strategic 
initiative known as the ``Quadruple Aim.'' Borrowing liberally (and 
with permission) from the nonprofit Institute for Healthcare 
Improvement's (IHI) ``Triple Aim,'' the Department is focusing on four 
strategic imperatives:

         Readiness - Ensuring that the total military force is 
        medically ready to deploy and that the medical force is ready 
        to deliver health care anytime, anywhere in support of the full 
        range of military operations, including humanitarian missions.
         Population Health - Improving the health of a 
        population by encouraging healthy behaviors and reducing the 
        likelihood of illness through focused prevention and the 
        development of increased resilience.
         Experience of Care - Providing a care experience that 
        is patient and family centered, compassionate, convenient, 
        equitable, safe, and always of the highest quality.
         Responsibly managing the total health care costs - 
        Creating value by focusing on measuring and enhancing quality 
        healthcare; eliminating inefficiencies; reducing unwarranted 
        variation; and emphasizing investments in health that reduce 
        the burden and associated cost of preventable disease in the 
        long term.

    There are many important initiatives that will emerge from this 
strategic direction. One of the most vital, because it will have 
effects across all four components of the Quadruple Aim, is the 
``medical home'' concept being piloted by all three Services. This 
approach takes the existing construct of a primary care manager and 
enhances it through improved access to care. Features will include 24/7 
access to a provider through multiple avenues--that will include 
leveraging technology to avoid unnecessary visits or emergency room 
visits. More importantly, it will enhance continuity of care and 
greatly improve satisfaction with service. The early results from pilot 
sites are very encouraging, and we are applying lessons learned from 
these sites to improve the program as we proliferate it across the 
Department.
    With the shared vision of the Quadruple Aim and a revised decision-
making process, the MHS is laying the groundwork for a smooth 
transition under the BRAC-directed co-located medical headquarters in 
the National Capital Area (affecting HA/TMA and the Services' Surgeons 
General staffs). The co-location initiative offers significant 
opportunities to achieve even greater unity of effort.
Mental Health Professionals
    Significant effort has been made to recruit additional mental 
health personnel in order to meet the growing demand for behavioral 
health services in the Department. Since 2007, the number of active-
duty mental health providers has remained relatively constant, yet we 
expect the Consolidation of Special Pay language (10 U.S.C. Sec. 335) 
recently implemented will have a significant effect on retention of 
psychologists and social workers.
    Our work to recruit civilian mental health providers has been very 
effective. Table 3 shows the Services total mental health needs/
requirements as compared to the number of providers on-hand as of the 
third quarter of fiscal year 2009. The Navy and the Air Force compare 
assigned personnel versus requirements. The Army's growing needs are 
not completely reflected by official requirement documents yet, and 
thus they are identified as ``needs.'' Table 4 shows the significant 
improvements in total Mental Health personnel that have been made since 
2007, including in the TRICARE Network.
      
    
    
Suicide Prevention
    The Department's civilian and military leadership remain focused on 
employing numerous strategies to reduce the incidence of suicide in the 
Armed Forces. In calendar year 2009, there were a total of 312 
suicides--285 in regular components and 26 in Reserve Components--
marking an increase from 268 in calendar year 2008. Suicides within the 
Regular Components increased from 235 in calendar year 2008 to 285 in 
calendar year 2009. Demographic risk factors are: male, Caucasian, E-1 
to E-2, younger than 25 years old, GED/less than high school education, 
divorced, and in the Active Duty component. Other factors associated 
with suicide, which are consistent with data from the civilian 
population, are: substance abuse, relationship problems, legal, 
administrative (article 15), and financial problems. Although the 
impact of role of deployment on suicide risk is still under 
investigation, a majority of suicides do not occur in the theaters of 
operation.
      
    
    
      
    When a servicemember has a problem, he or she can, in most cases, 
receive confidential help from military and other mental health 
providers. However, if the individual is unable to perform his/her 
duties, is homicidal or suicidal, or is in a sensitive duty, the 
commander will be notified for safety reasons. Resources available to 
servicemembers and their families include: confidential problemsolving 
counseling through Military OneSource, online information and tools at 
militarymentalhealth.org and afterdeployment.org, confidential pastoral 
counseling with chaplains, Military Family Life Consultants (active 
duty and families), military mental health providers, Service-level 
counseling centers, and access to information and referral to mental 
health professionals through the Defense Centers of Excellence for 
Psychological Health and Traumatic Brain Injury (DCoE) Outreach Center.
    The Department and Services recognize suicide prevention begins 
long before an individual exhibits suicidal ideation. Comprehensive 
programs focus on enhancing resilience and early identification 
designed to reduce psychological health issues or disorders that may 
contribute to suicide risk. Leadership at every level receives training 
on warning signs, resources, healthy lifestyle choices, and actions to 
take if an intervention is deemed necessary. The Suicide Prevention and 
Risk Reduction Committee (SPARRC) is a forum for developing/expanding 
partnerships among the Services, VA, Federal and civilian partners. The 
SPARRC's goal is to improve policies, programs and systems across the 
Department while providing support for medical, line, and community 
leaders. Chaired by DCoE, the SPARRC includes representatives from all 
Services, VA, SAMHSA, Center for Disease Control, Medical Examiners, 
Chaplains, Telehealth/Technology and National Guard/Reserves.
    The Department also collaborates with VA and the Substance Abuse 
and Mental Health Services Administration (SAMHSA) on suicide 
prevention efforts. This includes an annual joint DOD/VA conference on 
reducing the rate of suicides in the Active Duty components, Reserve 
components, and veteran populations. The January 2010 DOD/VA Suicide 
Prevention Conference, ``Building Strong and Resilient Communities,'' 
brought together over 900 servicemembers, family members, and mental 
health professionals throughout DOD, VA, and other Federal agencies. 
The conference highlighted practical tools, personal stories, and 
ongoing efforts in supporting the community.
    The Department's mental health initiatives dovetail with both the 
Readiness and Population Health components of the Quadruple Aim. We 
have developed metrics that we closely monitor to determine if our 
programs are effective and if our policies are being effectively 
implemented. We are also broadening our view of readiness, to include 
perspective on the ``readiness'' of an entire family for a 
servicemember's deployment. In 2010, we will expand our measures to 
include this more expansive view of readiness--and consequently, better 
manage pre-deployment, deployment, and post-deployment activities for 
the Total Force.
    We recognize the number of suicides continues to increase and 
suicide has a multitude of causes, and no simple solution. There are 
many potential areas for intervention, and it is difficult to pinpoint 
the best approach because each suicide is unique. Recognizing this, DOD 
is tackling the challenge using a multi-pronged strategy involving 
comprehensive prevention education, research, and outreach. We believe 
in fostering a holistic approach to treatment, leveraging primary care 
for early recognition and intervention, and when needed, providing 
innovative specialty care. The areas of focus to reduce risk include: 
(1) conducting data collection and analysis to detect contributing risk 
factors; (2) facilitating partnerships across DOD, Federal, and 
civilian organizations to increase collaboration and communication; (3) 
reducing stigma and increasing access to resources to provide needed 
care; and (4) using research to close gaps and identify best practices.
Health Informatics
    The DOD's Electronic Health Record (EHR) continues to be a key 
enabler of military medical readiness; giving healthcare providers 
secure, 24/7, worldwide access to medical records of our highly mobile 
patient population. Across the enterprise, the EHR supports uniform, 
high-quality health promotion and healthcare to more than 9.5 million 
MHS beneficiaries. Using the EHR, our healthcare providers access the 
electronic medical records of MHS beneficiaries from any point of care 
throughout the direct care system.
    The MHS Information Management/Information Technology Strategic 
Plan for 2010--2015 provides the roadmap for improving the EHR, and 
lists EHR improvement as a top IM/IT priority. Using this roadmap, MHS 
will effectively execute its action plan to stabilize the current 
system while transitioning to a suite of EHR applications and 
supporting infrastructure that will improve reliability, speed, user 
interface and data integrity, and achieve higher satisfaction from all 
users. These improvements will enhance IT interoperability within the 
MHS and support planned improvements in electronic health data sharing 
with VA and our private sector care partners.
    For future years, ICIB will prioritize additional health related 
sharing capabilities or usability enhancements to continue the 
advancement of DOD/VA interoperability in a manner that supports 
clinicians in healthcare delivery. The Departments will continue to 
work together to improve and expand upon the interoperability of 
appropriate healthcare data as appropriate and necessary.
Virtual Lifetime Electronic Record (VLER)
    On April 9, 2009, President Obama announced that DOD and VA would 
work together to create of a ``virtual lifetime electronic record'' 
(VLER) for servicemembers and veterans. While the Department and VA 
already share an unprecedented amount of health care information 
between the two systems, a very large portion of health care to our 
beneficiaries comes from private sector contract providers. The DOD, 
VA, and the Department of Health and Human Services are working 
together to promote access of electronic health care information for 
care provided in DOD, VA, and private sector facilities while DOD and 
VA continue to leverage work already done to improve our capabilities 
for sharing information.
    VLER will rely on the Nationwide Health Information Network (NHIN) 
as the mechanism to share standards-based health data between DOD, VA, 
and private sector partners. Well-defined standards are the essential 
foundation for interoperability among systems. These standards will be 
guided by the Department of Health and Human Services (HHS) and will be 
consistent with the NHIN model based on the Federal Health 
Architecture.
    DOD and VA have been active participants and among the leaders in 
the development of the NHIN working with the HHS Office of the National 
Coordinator for Health Information Technology. The NHIN will tie 
together health information exchanges, integrated delivery networks, 
pharmacies, government health facilities and payers, diagnostic 
laboratories, providers, private payers, and other stakeholders into a 
``network of networks.'' The NHIN provides a national standards-based 
mechanism for previously unconnected electronic health records and 
other sources of healthcare information to share information securely 
while respecting and enforcing mandates for guarding patient privacy.
    Working together with HHS and private health care providers, DOD 
and VA are creating a capability that will take a huge step towards 
modernizing the way health care is delivered and services are 
administered for our Nation. VLER will allow health care providers 
access to servicemembers' and veterans' military medical records, 
providing the information needed to deliver high-quality care. VLER 
will do all of this with the strictest and most rigorous standards of 
privacy and security, so that our servicemembers and veterans can have 
confidence that their medical records can only be shared at their 
direction.
    VLER is not a large acquisition program nor will VLER result in one 
single DOD/VA Information Technology (IT) system. Rather, VLER builds 
on the electronic health care systems already in place in DOD, VA and 
the private sector. Even if DOD and VA were to embark on a huge 
acquisition program to implement a single system, they would still not 
be able to access the critical information captured by the private 
sector. The VLER solution is viable for the entire health care 
community and enables each individual entity to develop and maintain 
their own internal systems. It creates an opportunity for competition 
since it uses well-documented standards that can be implemented through 
a variety of electronic health initiatives that can be linked to the 
NHIN.
            military family support and wounded warrior care
    This past year, due to the high level interest in supporting 
military families, resources were increased to institutionalize 
servicemember and family support programs across the Department. A 41 
percent increase in the Defense-wide family assistance baseline funding 
in fiscal year 2011 from fiscal year 2010 will provide lifelines of 
support for servicemembers and their families through outreach to Guard 
and Reserve members and families, Military OneSource 24/7 accessible 
family support assistance, referrals for counseling, financial 
education and training, and access to education, training certification 
opportunities leading to a portable career for spouses.
    To ensure we are on-target in investing in programs needed by 
servicemembers and their families, we initiated an extensive strategic 
planning process to address the current issues facing family readiness 
programs, beginning with a thorough assessment of existing needs, 
programs, and related issues. A variety of methods were used to gain 
input from key players across the system, including family members, 
support professionals, non-governmental organizations, land-grant 
universities, and senior DOD leadership.
Child Care
    Access to child care remains a top priority for the Department. 
Efforts are ongoing to meet the needs of our deployed families, 
including National Guard and Reserve families. We have expanded respite 
child care options through the YMCA program, offering opportunities for 
geographically isolated families to help mitigate the stress 
experienced by the parent at home. These efforts augment the respite 
child care provided by the Military Services.
    We continue to reduce the unmet need for child care, yet are 
cognizant of the ongoing need to recapitalize our aging child and youth 
facilities. We need to eliminate barriers to hiring practices key to 
expanding our partnerships with community child care providers. The 
temporary program to use minor military construction authority for the 
construction of child development centers provided a means to increase 
the availability of quality, affordable child care for servicemembers 
and their families. This authority expired at the end of fiscal year 
2009, and we have proposed legislation to reinstate the authority. The 
legislation would also expand age limit requirements from 5 years old 
to 12 years old to include children in school age care programs, 
broaden the authority to include other family support initiatives 
(e.g., family center, fitness facilities, etc.), and increase the 
funding authority to $15 million for all projects.
Youth Programs
    We are also deeply committed to addressing the needs of our 
military youth. More than 350 dynamic, innovative and successful youth 
programs serve more than 500,000 military connected children and youth 
between the age of 6-18 worldwide. Programs promote positive youth 
development and prepare pre-teens and teenagers to meet the challenges 
of military life, adolescence, and adulthood. Partnerships with other 
youth-serving organizations enable the Department to offer resources in 
a variety of domains, including physical fitness and sports; arts and 
recreation; training in leadership; life skills; career/volunteer 
opportunities; mentoring; intervention; and support services. 
Programming supports character and leadership development, sound 
education choices, healthy life skills, the arts, and sports and 
recreation. Many programs offer summer day camp and youth employment 
opportunities. Twenty-two youth facilities were funded in 2008 and 
2009, totaling $145.6 million in non-appropriated funds; this support 
constitutes a critical aspect of family support. Six youth facilities 
are funded for fiscal year 2010 and fiscal year 2011, totaling $49.7 
million.
Family Advocacy Programs
    The DOD Family Advocacy Program (FAP) plays a key role in 
addressing familial physical, sexual, and emotional abuse and neglect 
involving military personnel in the active component as victims and 
abusers. On each military installation with command-sponsored families, 
there is a FAP that provides services in prevention, identification, 
intervention and treatment of child abuse and neglect and domestic 
abuse. Two key programs, the New Parent Support Program and treatment 
programs for substantiated spouse abusers have been tied to outcomes 
for prevention.
Casualty and Mortuary Affairs Programs
    The Department remains committed to providing the highest quality 
of compassionate and caring assistance to families of fallen 
servicemembers for as long as they determine assistance is needed. 
After which, additional assistance can be obtained by a simple phone 
call or letter written to the appropriate Service Casualty Office. 
Since early 2006, the Department has worked extensively with the 
Military Services; the Department of Veterans Affairs; the Social 
Security Administration; family support organizations; nonprofits 
groups, and more importantly, survivors, to ensure our policies and 
procedures are standardized to the maximum extent possible, more 
customer focused, and flexible enough to address unique situations.
    While the Department has made many enhancements to the Casualty 
Assistance Program, we recognize there is always room for improvement 
and therefore we strive every day to make it better, simpler, more 
respectful, and more compassionate. As the Secretary stated, ``When 
young Americans step forward of their own free will to serve, they do 
so with the expectation that they and their families will be properly 
taken care of should anything happen to them.'' We listen to those we 
serve and to those organizations who have dedicated their existence to 
providing valuable support and services to survivors of the fallen. 
Together, our collaborative efforts will ensure our program will 
continue to be enhanced and our families provided the very best 
assistance possible.
Military OneSource
    Military OneSource (MOS) continues to have a positive impact on 
servicemembers and their families. OneSource offers a 24-hour/365-day 
centralized assistance program to provide diverse information and 
referral services by credentialed counselors to Active Duty, Guard, 
Reserves and their family members, regardless of physical location or 
activation status. Assistance can be provided in many languages. Since 
inception, Military OneSource has experienced exponential expansion. 
Over 739,000 telephone calls were received in fiscal year 2009, more 
than doubling the number of calls received in fiscal year 2008. The 
website received over 4 million visits, almost doubling the number of 
visits received during the prior year. Nearly one in three 
servicemembers uses Military OneSource.
    In general, the most common reasons for which a person sought MOS 
counseling were marital and intimate relationships, stress management, 
family relationships, and anger management. In addition, MOS financial 
counseling support is offered in-person and telephonically. In fiscal 
year 2009, MOS conducted 4,501 financial counseling sessions. The most 
common reasons for which a person sought financial counseling support 
from MOS were budgeting and money management, overextension with bills, 
credit management, loans and consolidating loans, and mortgages and 
refinancing. In fiscal year 2009, OneSource assisted members and 
families with almost 600,000 tax filings at no cost to the family.
    The Wounded Warrior Resource Center (WWRC), accessed via Military 
OneSource, provides immediate assistance to the wounded and their 
families with issues related to health care, facilities, or benefits. 
The WWRC works collaboratively with the Military Services' wounded 
warrior programs and the Department of Veterans Affairs to ensure 
callers are promptly connected to the resources that can help address 
their needs. In fiscal year 2009, 1,200 cases for wounded warriors were 
handled.
Dependents' Education Programs
    A key quality of life issue is the education of military children. 
Servicemembers often make decisions about assignments based on the 
availability of quality educational opportunities for their children. 
The Department of Defense Education Activity (DODEA) provides quality 
pre-kindergarten through 12th grade educational opportunities and 
services to eligible military dependents around the globe where DODEA 
schools are located. Of the approximately 1.2 million military 
dependent children, DODEA educates nearly 85,000 in 192 schools in 12 
foreign countries, 7 States, Guam, and Puerto Rico with 8,700 
educators. DODEA also assists eligible military dependent students 
through a tuition reimbursement program for military assigned to 
overseas locations without a DODEA school.
    The ongoing relocation of military dependent students through force 
structure changes created a need to enrich and expand partnerships with 
military-connected communities to ensure the best possible educational 
opportunities for military dependent children. Through its Educational 
Partnership Initiative, DODEA was given expanded authority to assist 
local education agencies (LEA's) who educate military dependent 
students through efforts focused on highest student achievement. DODEA 
works collaboratively with the Department of Education to ease the 
transition of military students by sharing experience and expertise 
with LEAs who educate larger populations of military dependent 
students.
    Data from the Department of Education reports that there are 300 
LEAs with a military child enrollment of 5 percent or more. Of the 300 
LEAs with 5 percent military child enrollment, 153 of the LEAs are not 
meeting the State academic standards in reading/language arts and/or 
math using annual tests aligned to academic indicators. In addition, 
there is significant research surrounding the psychosocial effects of 
multiple deployments on school performance and student behavior. In 
fiscal year 2009, DODEA extended support through grants focusing on 
enhancing student learning opportunities to 44 school districts serving 
approximately 77,000 military children in over 284 schools.
    Through new technologies, DODEA is developing additional academic 
opportunities for its students. The focused efforts are to expand 
access to education and provide curricular options to eligible students 
within DODEA through the expanded use of distance learning. DODEA plans 
to transition its distance learning program into a virtual school 
program beginning with the implementation of fully accredited virtual 
high school in School Year in 2010-2011. These tools include real-time 
audio and video, document sharing, screen sharing and web collaboration 
to stimulate active teacher-student, student-student and student-
content interaction. A ``virtual hub'' model has been put into place 
that puts the teachers in locations closer to the students to 
facilitate interaction that simulate traditional classroom discussion 
and one-on-one tutoring.
    Beginning in 2008, DODEA implemented a new process for advising 
decision-making that focuses on highest student achievement and a 
thorough review of data, implementation, and effectiveness of programs. 
Part of the advisory process includes educator-led task groups which 
review and analyze data. DODEA task groups are convened for various 
reasons such as instructional and curricular topics, issues of interest 
from the field, or management needs. All task groups spend considerable 
time reviewing and analyzing information and data on a specific issue 
and then, through consensus, developing systemic recommendations sent 
to the Director to guide future educational actions. Currently, DODEA 
has seven on-going task groups.
Korea Tour Normalization
    United States Forces Korea (USFK), through the Tour Normalization 
Program, is aggressively increasing command-sponsored military families 
on the Korean peninsula for the primary purpose of establishing a 
higher quality of life for military families. In addition to the 
housing needs, this impacts educational needs. DODEA anticipates adding 
25 schools in Korea over the next 10 years, providing an end state 
program by 2020 of 31 DODEA schools in Korea. Student growth is 
expected to grow from 4,422 DODEA students currently in the Republic of 
Korea to 21,758 at the end state. This is approximately a 500 percent 
increase in the student population. DODEA is actively working 
programmatic details with USFK and local Military Service communities 
to support this effort.
MWR Support to Troops in Combat
    The ability to communicate with family and friends is the number 
one factor in being able to cope with longer and more frequent 
deployments. We continue to balance the most effective use of available 
bandwidth between mission and personal requirements, including wireless 
access. Currently, servicemembers have free access to the non-secure 
military Internet by using their military e-mail address, including 
aboard ships. They also have free Internet access at over 1,008 MWR 
Internet Cafes in Iraq and Afghanistan with 9,241 computers and 4,101 
Voice Over IP phones (with call rates of less than 4 cents a minute). 
Another 197 cafes, 2,191 computers and 1,154 phones have been funded 
for fiscal year 2010 for use in Afghanistan. To enhance MWR provided 
services, the Exchanges provide personal information services for a 
usage fee for this customer convenience. Back home, computers and 
Internet service located in our family support centers, recreation 
centers, libraries, and youth centers help ensure families can connect.
DOD-State Initiatives
    The Department continues to work with State governments to educate 
their policymakers on the life-challenges faced by servicemembers and 
their families and to ensure that state-level policies do not 
disadvantage military families' transient life style. States have 
addressed several key quality of life issues, to include the impact of 
frequent school transitions experienced by military children, the loss 
income by military spouses as a result of military moves, and the 
enforcement of the congressionally-mandated DOD predatory lending 
regulation. The response from states has affirmed their commitment to 
supporting the well-being of the Nation's fighting force. For example, 
27 States have joined the Interstate Compact on Educational Opportunity 
for Military Children, 36 States now provide eligibility for 
unemployment compensation to military spouses, and 30 States enforce 
the DOD predatory lending regulation. The Department is continuing this 
effort in the 2010 session and has added child custody to the slate of 
issues. In this regard, the Department is asking States to 
appropriately balance the interests of servicemembers who are absent 
due to military service with the best interests of the child by 
ensuring absences caused by military deployments are not the sole basis 
for permanent custody decisions and addressing delegation of visitation 
rights while the servicemember is deployed.
Special Needs
    The establishment of the Office of Community Support for Military 
Families with Special Needs was mandated by NDAA 2010. The purpose of 
the Office is to enhance and support Department of Defense support for 
military families with special needs to ensure parity across the 
Services. The Office will be headed by a member of the Senior Executive 
Services. It will be staffed with personnel in the fields of medicine, 
education, early intervention, social work, personnel and information 
technology, as well as members of the armed services to ensure 
appropriate representation by the military departments. Currently, 
plans are underway to identify the specific mix of staff and to create 
an umbrella Office of Community and Family Support with an emphasis on 
special needs, which will synchronize all family support needs with 
those of families with special needs.
Disability Evaluation System
    The Disability Evaluation System (DES) Pilot simplifies and 
restructures how servicemembers are evaluated for continued service and 
compensation as a result of a wound, injury, or illness. Based on the 
recommendations of several commissions and task forces, DOD and VA 
implemented the DES Pilot on November 26, 2007, at three National 
Capital Region (NCR) locations (Walter Reed, Bethesda, and Malcolm 
Grow). Since November 2007, this program has been administered jointly 
by the DOD and VA. The Pilot eliminates duplicate disability 
examinations and disability ratings by the Departments. The DOD 
determines fitness for duty; the VA examines and rates for disability. 
The rating is used by DOD for unfitting conditions and by VA for all 
service-connected or aggravated conditions. After March 2010, the DES 
Pilot will operate at 27 locations across the continental United States 
and Alaska and encompass 47 percent of all potential servicemembers' 
cases. Compared to the legacy system, case processing time has been 
nearly cut in half (46 percent decrease) for Active and Reserve 
component servicemembers. The Pilot will be expanded to encompass 100 
percent of the DES by December 2012. The DES Pilot Final Report which 
includes the results and recommendations for the DES Pilot-model 
worldwide implementation will be forwarded to Congress by May 31, 2010.
Transition Initiatives
    The Department has several initiatives relating to the Department 
of Defense (DOD) Transition Assistance Program (TAP). We began this 
fiscal year by convening the first Joint Interagency Strategic Working 
Group on the Transition Assistance Program in November 2009. We are 
also working on several employment initiatives with our partners at the 
Department of Labor. As an ex-officio member of the Secretary of 
Labor's Advisory Committee on Veterans Employment, Training and 
Employer Outreach (ACVETEO), the Department is looking at more 
efficient ways to connect employers with transitioning Services 
members, veterans and their spouses. We are also looking at revamping 
the Department of Labor (DOL) TAP Employer Workshop to make it more 
dynamic and ensure it is meeting the needs of our warriors. Finally, we 
continue to collaborate with DOL on how to ensure our wounded, ill and 
injured are being prepared for and get meaningful jobs.
    In addition to our work with DOL, this office assisted with the 
Office of Personnel Management (OPM) strategic plan as well as an 
executive order signed by the President in November 2009, which 
directed all Executive Branch Federal Agencies to increase the hiring 
of veterans. We are pursuing other initiatives like our work with the 
U.S. Interagency Council on Homelessness. The Department is assisting 
the council in developing a Federal Strategic Plan on Homeless. The 
plan will address ideas and ways to end homeless for our veterans, 
families, and youth.
    One of our most exciting initiatives was joining the social network 
community with the launching of the DOD TAP Facebook. We are taking 
advantage of the popularity of social media as another communication 
resource to promote transition services and benefits to military 
personnel and their families.
    Finally, we are working to improve outreach and education to all 
servicemembers to increase their participation in the Benefits Delivery 
at Discharge and Quick Start Programs. These programs allow eligible 
servicemembers to submit their application for disability compensation 
prior to separation or retirement.
                           civilian personnel
National Security Personnel System Transition
    The National Defense Authorization Act for Fiscal Year 2010 (NDAA 
2010) repealed the authority for the National Security Personnel System 
(NSPS) and requires the Department to transition out all employees and 
positions from NSPS to the appropriate non-NSPS personnel and pay 
system no later than January 1, 2012. The law provides no employee will 
suffer any loss of or decrease in pay upon conversion from NSPS.
    Planning for terminating NSPS is well under way with the goal of 
transitioning employees and organizations from NSPS back into their 
pre-NSPS personnel and pay system during fiscal year 2010. The rules of 
the gaining pay and personnel system will be followed in determining 
placement of NSPS employees. Since the majority of the 226,000 
employees covered by NSPS will transition to the General Schedule 
system, government-wide rules issued by the Office of Personnel 
Management (consistent with title 5, U.S.C.) are applicable. Until the 
transition takes place, organizations and employees currently covered 
by NSPS will continue to follow NSPS regulations, policies, and 
procedures. While the Department did not transition any bargaining unit 
employees into NSPS, approximately 900 employees organized after their 
organizations moved into the system. The Department plans to meet with 
representatives of national unions representing these NSPS bargaining 
unit employees to discuss transition issues and will ensure that local 
collective bargaining obligations are fully satisfied as these 
employees transition from NSPS back to the General Schedule. Transition 
timelines are being determined based on organizational readiness as 
evidenced by avoidance of undue interruption to mission and hardship to 
employees; established processes to classify NSPS positions into the 
appropriate non-NSPS personnel system; existence of an appropriate 
performance management system; and information technology capability. 
Prior to their transition out of NSPS, employees will be informed of 
their position classification under the non-NSPS personnel system. With 
limited, approved exceptions, no new appointments to NSPS will be made 
after March 1, 2010. The Department is tracking transition costs as it 
did with NSPS implementation costs. The organization that is guiding 
and directing transition planning and execution is the National 
Security Personnel System Transition Office (NSPSTO). The Director, 
NSPSTO is responsible for the development, coordination, and 
dissemination of supporting procedures, policies, and tools; and for 
developing training products and services for use by the Components in 
training employees and supervisors on all aspects of the transition. In 
addition, the Department is committed to providing open and frequent 
communications during the transition. The NSPSTO has redesigned its Web 
site to publicize up-to-date information on the transition, including 
transition toolkits that contain a variety of products such as 
conversion guides, fact sheets, brochures, articles, frequently asked 
questions, performance management guidance, timelines, and town hall 
briefings on the transition. The website and communications will be 
updated periodically as new information becomes available and new 
products are developed. In addition, the Department will deliver a 
report to Congress at the end of April 2010, as required by NDAA 2010, 
that covers the steps taken for the reclassification of NSPS positions 
and the initial plan for transitioning employees and organizations from 
NSPS; semiannual reports that cover transition progress will also be 
provided until all organizations and employees are out of NSPS.
Civilian Strategic Human Capital Planning and Forecasting
    With over 760,000 civilian employees, in over 600 occupations, 
supporting a myriad of critical missions, it is essential the 
Department have a structured plan to ensure civilian talent is in place 
to meet current and future mission requirements. To meet this demand, 
the Department is leading an enterprise-wide effort to establish a more 
structured, standard approach to Strategic Human Capital Management 
(SHCM), based on a combined effort of competency assessment and 
workforce analysis trending. The Department recognizes the need for a 
civilian workforce with the attributes and capabilities to perform 
seamlessly in an environment of uncertainty and surprise, execute with 
a wartime sense of urgency, and create tailored solutions to multiple 
complex challenges. We are institutionalizing an updated, integrated 
human capital strategy for the development of talent, that is 
consistent with 21st century workforce demands and a new generation of 
workers, and that is competency-focused, performance-based, agile, 
responsive to mission impacts, and focused on employee engagement and 
respect.
Civilian Expeditionary Workforce
    The Department is working to better employ the talents of our 
civilian workforce to meet expeditionary mission challenges, especially 
those not directly related to warfighting. Global security challenges 
require adequate civilian capacity to conduct complex operations, 
including those missions that require close military-civilian planning 
and cooperation in theater. Since 2001, more than 43,000 Department 
civilians have been involved in contingency operations around the 
globe. Currently, approximately 5,100 civilian employees are serving in 
theater. In response to these imperatives, the Department 
institutionalized the Civilian Expeditionary Workforce (CEW) to provide 
deployable civilian experts to support military operations, 
contingencies, emergency operations, humanitarian missions, disaster 
relief, and stabilization and reconstruction operations. The CEW is 
designed to enhance the Department's ability to work alongside and help 
build the capacity of partner defense ministries and provide surge 
support where needed. The CEW encompasses a pre-identified subset of 
the Department's emergency essential and volunteer civilian workforce 
by skill sets and capabilities, who are trained, ready, cleared, and 
equipped for rapid response and quick assimilation into new 
environments.
    Civilians deployed under the CEW receive general and theatre-
specific, urban training, and are eligible for the same health care 
benefits as deployed military personnel, including medical evacuation 
and access to hospital services in-theatre. With the support of 
Congress, the Department has obtained important incentives and benefits 
to help compensate for the inherent risks of deployment. The Department 
continues to identify pertinent issues and propose fully integrated 
solutions to ensure force health protection, surveillance, deployment 
benefits, and medical care for civilians who have been injured, 
wounded, or have contracted diseases while deployed in support of 
contingency operations. We have worked in partnership with the Office 
of Personnel Management, the Department of State, and the Department of 
Labor to ensure all similarly-situated Federal civilians receive 
consistent and equitable benefits commensurate with the risks of 
deployment.
Civilian Leadership Development
    The Department is currently working on the recruitment and 
development of entry-level leaders in conjunction with Section 1112 of 
the NDAA for Fiscal Year 2010, which requires the establishment of a 
DOD Civilian Leadership Program. The Department recognizes the need for 
an improved model to attract, retain, and deliberately develop civilian 
leaders to support pipeline readiness and enhance bench strength. In 
fiscal year 2010, the Department will fully develop the entry-level 
program to grow emerging leaders. We will launch an initial program 
pilot in fiscal year 2011 and expand the pilot and implementation in 
fiscal year 2012. Our communities of initial focus for this effort 
include acquisition and finance specialists to meet the Department's 
needs.
Recruitment for Critical Positions and Competencies
    The Department has an aggressive approach for identifying mission 
critical recruitment requirements, to include health, acquisition, 
linguists and emerging mission-essentials such as IT specialists in 
cyber warfare. We have a plan in place and a robust forecasting model 
that indicates those areas where recruitment surges may be needed. 
Where such surges are indentified, we craft staffing strategies, such 
as expedited hiring authority and scholarship programs, to meet those 
needs. Our integrated approach to Strategic Human Capital Management 
(SHCM) will prove to enhance our ability to analyze demographic trends, 
forecast requirements, assess gaps, and further define recruitment and 
hiring strategies.
Increasing Veterans Opportunities
    The Department values the experience and commitment of our 
servicemembers and places special emphasis on supporting transitioning 
servicemembers, wounded warriors, and veterans in their search for 
employment. We continue our efforts to actively reach out to our 
veterans to assist them in their civilian employment search with 
aggressive outreach programs, transition assistance programs, career 
and job fairs, and benefits counseling and assistance.
    The Department continues this tradition in support of Executive 
Order 13518, the Veterans Employment Initiative. In January 2010, the 
Department stood up the DOD Veterans Employment Program Office to 
promote veterans recruitment, training and development throughout the 
Department. We are promoting the Veterans Initiative through DOD's 
Hiring Heroes Program, through which we conduct eight to ten Hiring 
Heroes Career Fairs throughout the U.S. for wounded, ill and injured 
servicemembers, transitioning military, veterans, and their families.
In-sourcing
    The Department is on track to reduce the level of contracted 
support service from the current 39 percent of our workforce to the 
pre-2001 level of 26 percent, and perform those services with full-time 
government employees. Over the next 5 years, DOD expects to hire up to 
33,400 new civil servants to fill positions established as a result of 
insourcing contracted services. This includes 5,000 acquisition 
personnel over fiscal year 2010/2011 and 10,000 through fiscal year 
2014. On January 4, 2010, the Department submitted to Congress a report 
on ``fiscal year 2010 Insourcing Initiative and Plans.'' DOD Components 
estimated they would establish nearly 17,000 new civilian 
authorizations in fiscal year 2010 to perform currently contracted 
work.
    There are no artificial limits placed on DOD Components' 
identification of in-sourcing candidates (i.e., contracted services 
that would more appropriately be performed by government employees). 
The Department considers insourcing as a well-reasoned part of Total 
Force management that:

         Rebalances the workforce and rebuilds organic 
        capabilities.
         Ensures that inherently governmental functions that 
        support the readiness/management needs of the Department are 
        performed by government employees.
         Implements Congressional direction on in-sourcing 
        (NDAA for Fiscal Year 2008).

    Contractors remain a vital part of the Department's Total Force. 
The Department is not ``replacing'' or ``converting'' contractors but 
rather in-sourcing contracted services--contractors remain a vital 
source of expertise to the Department and are an integral part of our 
Total Force.
                        other personnel concerns
Foreign Language, Regional, and Cultural Capabilities
    The Department is continuing its work to ensure our commissioned 
and noncommissioned officers are prepared for a full range of varying 
and complex missions that our current and future security environment 
requires which includes building expertise in foreign languages, 
regional and cultural skills. The fiscal year 2011 budget focuses on 
sustaining gains achieved in previous years and continuing to build a 
solid infrastructure in which to meet future demands. Baseline funding 
of $793 million in fiscal year 2011 supports redirected language and 
culture instruction to achieve higher proficiencies for the Total Force 
in these skills. During the most recent programming cycle, the 
Department committed an additional $29 million in fiscal year 2011 to 
establish Language Training Detachments to provide and sustain 
commanders' needs, support the Afghanistan/Pakistan Hands program, and 
expand the role of English language training for partner nation 
personnel. The Department's continuing efforts feature the following 
significant initiatives and accomplishments.
Military Leadership Diversity Commission
    As mandated by NDAA 2009, the Department established the Military 
Leadership Diversity Commission (MLDC) to conduct an independent review 
and comprehensive evaluation and assessment of policies that provide 
opportunities for the promotion and advancement of minority members of 
the Armed Forces, including minority members who are senior officers. 
Led by General Lester Lyles (ret.), the Commission consists of 26 
appointed members to include retired and active duty officers, 
enlisted, and civilian representation from all the Service components 
and the Coast Guard. The Commission will expand to 32 members.
    The Commission conducted its first meeting in Washington, DC in 
September 2009. Several monthly meetings are planned throughout the 
country during the independent review, culminating with a written 
report to the President and Congress no later than September 2010. The 
report shall include the Commission's findings and conclusions, 
recommendations for improving diversity within the Armed Forces, and 
other relevant information and proposals considered appropriate.
Sexual Assault Prevention and Response
    The Department's position on sexual assault is a simple one: Sexual 
assault is a crime that is incompatible with service in the U.S. Armed 
Forces. It undermines core values, degrades military readiness, 
subverts strategic goodwill, and forever changes the lives of victims 
and their families. To address this crime, the Department has put 
numerous broad-based programs in place to achieve our vision of 
enhancing military readiness by establishing a culture free from sexual 
violence.
    The Department's goal is to prevent sexual assault through 
institutionalized prevention efforts that influence the knowledge, 
skills, and behaviors of servicemembers to stop a sexual assault before 
it occurs. We have developed a comprehensive prevention strategy built 
around the concept of bystander intervention. Throughout the 
Department--from the newest recruits to the most senior leaders--
servicemembers are getting educated on the role they can play as 
individuals in preventing this crime.
    In conjunction with prevention, we are working to increase 
awareness so when a crime does occur, it is reported. We want any 
victims within the military to come forward, first and foremost, to get 
treatment, and if so desired, provide details of the crime so the 
perpetrator can be held accountable.
    The Department is committed to ensuring the sexual assault 
prevention and response program works as intended. This ``system 
accountability'' is achieved through data collection, analysis, and 
reporting of case outcomes. In order to improve data collection, 
analysis, and case management, the Department initiated the development 
of the Defense Sexual Assault Incident Database (DSAID). In January 
2010, a Request for Proposal was issued to identify a vendor for the 
database, with selection expected by the fall.
    The Department has participated in several external reviews in 
recent years, most recently by the Government Accountability Office 
(GAO) and the Defense Task Force on Sexual Assault in the Military 
Services (DTF-SAMS). DTF-SAMS released their report in December 2009 
and GAO released their report in February 2010. We are currently 
reviewing and responding to their recommendations.
Child Custody
    The Department believes the States are in the best position to 
balance the competing interests within the context of their own 
domestic relations laws. Approximately 30 States have passed 
legislation that addresses the special circumstances facing military 
parents who have custody of children but who are not married to the 
other parent.
    The American Bar Association, National Military Family Association, 
and the Senate support the Department's position. Although the Senate 
has continued to reject Federal child custody legislation, it did 
include language in the NDAA for Fiscal Year 2010 that requires a 
report to Congress on military child custody issues by March 31, 2010. 
Senate Armed Services Committee staff indicate this report will form 
the basis for hearings anticipated in April 2010.
    The Department has committed to several efforts to address the 
unique challenges facing military members who have custody of a child 
but are not married to the other parent. The Department is working with 
its State liaisons to encourage those 20 States who have not addressed 
military child custody issues in their domestic relations laws to do 
so. The Department is also looking for opportunities to increase 
participation in and support of the American Bar Association's Military 
Pro Bono project, which provides free in-court representation to 
military members for domestic relations cases (and other cases). 
Finally, the Department is updating and reissuing its Family Care Plan 
instruction, which can, if used properly, significantly reduce custody 
problems without the detrimental effects of the proposed Federal law.
Federal Voting
    The Department vigorously assists our men and women in uniform, 
their voting-age dependents and U.S. citizens residing overseas to 
successfully participate in the 2010 primary and general elections. 
Initial indications are that the Department's programs are having a 
significant impact: for the 2008 general election, the active duty 
military voter registration rate exceeded that of the general 
population's: 77 percent for the military as compared to 71 percent for 
the general population.
    Unfortunately, while more than 91 percent of absentee ballots were 
successfully returned by general electorate voters in the 2008 general 
election, only 67 percent of uniformed services and overseas voter 
absentee ballots were successfully returned. Unsuccessful return of 
ballots represents the single greatest point of failure for military 
and overseas voters, and is largely due to absentee ballots being sent 
out too close to the election, with insufficient time for the voter to 
successfully receive, vote and return the ballot by the States' 
mandated deadlines. In fact, more than 81 percent of all the voting 
failure suffered by military and overseas voters was because of ballots 
transmitted to them, but never returned.
    The Department is focusing its voting assistance programs to 
address the overwhelming point of failure by focusing on those programs 
that will expedite both the delivery and return of ballots from 
military and overseas voters. First, the Federal Voting Assistance 
Program is developing an online wizard that will allow military and 
overseas voters to receive and mark their complete Federal, State, and 
local ballot online, and then print it out for voter verification, 
signature of the voter's oath, and postal mail return of the paper 
ballot. Second, the Military Postal System is also preparing an 
expedited ballot return system which will return ballots by Express 
Mail, as well as provide the voter with an online tracking system all 
the way to delivery to the local election official. The Military Postal 
System's desired delivery time is no more than 7 days from receipt of 
the ballot from the voter to delivery to the local election official.
    The Department is also taking full advantage of the authority 
granted it under the Military and Overseas Voter Empowerment (MOVE) Act 
of 2009 to designate all military installation voting assistance 
offices as National Voter Registration Act voter registration agencies. 
This will allow the Department to also collect from and mail in for 
those voters (who desire the assistance), the FPCAs or other 
registration forms completed by those voters.
    The Department has been working closely with States to identify 
those changes in State law necessary to achieve the requirements of the 
MOVE Act, and to provide sufficient opportunity for military and 
overseas voters to successfully complete the absentee voting process.
                               conclusion
    We face two fundamental, and related, challenges. First, we must 
continue to attract and retain high quality, motivated individuals for 
Active and Reserve military service and we must maintain an 
enthusiastic and skilled civilian workforce. Second, we must weigh 
sufficiency against the risks of an uncertain future. As we invest in 
our human capital, we must do so judiciously. While our future 
challenges may often seem without bounds, our resources are not. We 
must make hard choices, as a Department and as a Nation, of allocating 
our resources the best we can to win the war at hand while taking care 
of our most valuable asset--our men and women in uniform. I look 
forward to working with this Congress in this effort.

    Senator Webb. Thank you very much, Secretary Stanley.
    Secretary Lamont.

STATEMENT OF HON. THOMAS R. LAMONT, ASSISTANT SECRETARY OF THE 
             ARMY FOR MANPOWER AND RESERVE AFFAIRS

    Mr. Lamont. Chairman Webb, Senator Graham, distinguished 
members of the committee, thank you for the opportunity to 
appear before you today.
    I appear before you on behalf of 1.1 million men and women 
serving here and abroad in peaceful, as well as hostile, 
environments. This combat-seasoned force is resilient and 
professional, yet strained and out of balance. More than 1 
million of this Nation's finest citizens have deployed, over 
the past 8 years, into harm's way. We realize, very well, that 
there are costs associated with this conflict, both visible and 
invisible.
    Our current programs to relieve stress on the force are 
critical to maintaining a healthy, balanced, and prepared 
force. These programs help us defend our country against some 
of the most persistent and wide-ranging threats in our Nation's 
history. The success of these programs is due, in large part, 
to the support Congress has given us since this Army went to 
war in 2001.
    First and foremost, you have enabled us, through 
appropriate resources, to meet a temporary end-strength 
increase for our agile Army. As a result, this will, in part, 
alleviate the stress and strain on the total Army. This is a 
step in the right direction to get our personnel structure back 
in balance.
    Congress has also given us the means to improve the quality 
of life for our soldiers and their families. Soldiers remain in 
the Army based on the established incentive programs, such as 
an excellent healthcare system, educational opportunities, 
financial stability with sufficient bonuses, general vacation 
time, soldier and family services, and frankly, out of a true 
sense of duty to our country. This Congress has embraced our 
needs, and for that, we are very grateful.
    The Army continues to face challenges, which we will 
encounter today and well into the future. Armed with lessons 
learned, it is our intent to stay in front of those challenges, 
anticipate them, develop strategies and programs to address 
them, and hopefully, keep them from becoming problems in the 
future.
    Specifically, one of the challenges that we are addressing 
is the concept of the Operational Reserve. The Army's Reserve 
component continues to transition from a strategic Reserve to 
an operational force. The Army will require recurrent, assured, 
and predictable access to the Reserve component to meet 
operational requirements. This transformation of the Reserve 
component into an operational force will provide an opportunity 
for the Army to provide the most cost-effective total force by 
investing resources in the most cost-efficient portion of the 
Army's total force.
    Our focus this year centers on restoring the balance, 
resilience, and sustainment of the force, growth in talent, and 
our ability to meet the Nation's needs with the highest-quality 
force available. The Army will continue to work hard to attract 
and retain the best, but we need your help in taking on this 
larger problem. The challenging environments that our soldier's 
serve in demand that we maintain the standards as set, and we 
must remain ever-vigilant that our force is manned with both 
physically and mentally qualified soldiers, as it is today.
    As you are well aware, we have some tough challenges ahead 
of us. I'm confident, however, that with the operational and 
institutional agility this Army has developed over the past 9 
years, we will meet all the challenges that will come our way. 
It is always easy to commit to a plan of action when we know 
that Congress supports us. Your leadership and your support 
have been unwavering.
    I appreciate this opportunity to come before the committee, 
both now and in the future, and I look forward to your 
questions.
    Senator Webb. Thank you very much, Secretary Lamont.
    [The prepared statement of Mr. Lamont follows:]
              Prepared Statement by Hon. Thomas R. Lamont
                              introduction
    Chairman Webb, Senator Graham, distinguished members of this 
subcommittee, thank you for the opportunity to appear before you on 
behalf of America's Army. Our greatest heroes are America's most 
precious resource--our soldiers. These soldiers and their families, 
backed by our civilian workforce, represent the very best of America's 
values and ideals and faithfully shoulder the load that our Nation asks 
of them. This fighting force of 1.1 million soldiers is continually 
tested at home and abroad. Repeatedly our Nation's men and women step 
forward and pledge to serve. They recognize the challenges facing our 
Nation, answer the call, and become part of something larger than 
themselves. Their dedicated service and sacrifice are deserving of the 
very best services, programs, equipment, training, benefits, lifestyle, 
and leadership available. Our focus this year centers on restoring the 
balance, resilience, and sustainment of the force, growth in talent, 
our ability to meet the national challenges, and the importance of 
maintaining this strength to meet the demands now and for the future. 
Thank you for your steadfast commitment to ensuring our soldiers, their 
families, and our civilian workforce by supporting our personnel 
initiatives to ensure growth, sustainment and well being of our All-
Volunteer Force.
                           strategic overview
    America's Army, strained by over 8 years of persistent conflict, 
remains a resilient force. Our Army, however, is also stretched and out 
of balance while demand has continued to grow. The Army has added 
nearly 100,000 more soldiers since 2004. More than one million of our 
country's finest men and women have deployed to combat, with over 5,000 
lives sacrificed in the line of duty. The Army appreciates your recent 
support in providing the Army with temporary end strength increase of 
22,000 to provide some relief to our stressed force. We will complete 
the initial ramp of 15,000 by the end of fiscal year 2010 and will 
evaluate the need to complete the remaining amount later this year. 
Even with this temporary increase, we face many challenges ahead, but 
must remain vigilant and supportive to the needs of our people. We must 
continue to address these needs and find a way to get our Army back to 
a balanced force.
                              end strength
    To alleviate the stress and strain on the force, the Department of 
Defense authorized the Army a Temporary End Strength Increase (TESI) of 
up to 22,000 Active Duty soldiers. Currently the plan is to use 15,000 
of the 22,000 with a decision on the remaining 7,000 expected at the 
end of the second quarter, fiscal year 2010. This temporary increase 
provides additional, primarily skill level one, soldiers within highly 
deployed Military Occupational Specialties (MOSs) to combatant 
commanders. TESI has already increased unit readiness and will provide 
increased manning and readiness until fiscal year 2013 when the Army 
returns to its base end strength level of 547,400 in the Active 
component. While the majority of these additional soldiers are 
enlisted, the officer ranks will also experience a slight increase.
    Another advantage of TESI is a reduction in the use of Stop Loss. 
The Army expects to achieve a 50 percent reduction in the number of 
soldiers affected by Stop Loss by June 2010. As of January 2010, 7,861 
soldiers were affected by Stop Loss, a 41 percent reduction from the 
January 2009 baseline of 13,217. By January 2011, the Army will have no 
soldiers deployed under Stop Loss. However, soldiers in post-deployment 
reintegration or demobilization may still be in Stop Loss until early 
spring 2011. TESI and the implementation of voluntary stabilization 
programs for each component have made significant contributions to the 
Army's ability to eliminate Stop Loss, while minimizing the potentially 
detrimental impact to unit readiness.
    We continue to make significant progress in our efforts to restore 
balance. Increasing time between deployments for our soldiers and 
building greater predictability for soldiers and families continues to 
be one of our key concerns. Despite the short term impact of the recent 
surge of troops to Afghanistan, we expect the ratio of Boots on Ground 
(BOG) time to dwell time at 1:2 for the Active Force and 1:4 for the 
Reserve component to improve as demand decreases. Eventually, increased 
dwell time will be achieved by lowering the demand on our forces while 
increasing the size of the active Army. This will ease the constant 
pressures on our forces as we move into the rotational cycle of the 
Army Forces Generation (ARFORGEN) model. The Army Senior Leadership 
remains committed to meet these deployment goals while eliminating Stop 
Loss, and without any increase in tour length for our soldiers.
            recruiting and retention (officer and enlisted)
    Our soldiers are the Army's most important resources, and our 
ability to meet the challenges of the current and future operational 
environments depends on our ability to sustain the All-Volunteer Force. 
The pace and demand of the operational environment over the last 
several years has caused us to dedicate our focus to reaching a high 
volume of recruits. The shift in the economy, however, has allowed us 
to demand even higher quality recruits. Despite the challenges of an 
Army engaged in two protracted conflicts, the Army exceeded its 
enlisted recruiting and retention missions for fiscal year 2009 and is 
confident it will meet its goals for fiscal year 2010. The Army met 104 
percent of its recruiting goals for fiscal year 2009, while at the same 
time, meeting its quality benchmarks for new recruits. Successfully 
meeting these critical benchmarks moves us closer to restoring balance. 
As we dedicate ourselves to the fiscal year 2010 recruiting mission, we 
will continue to monitor trends and make adjustments as required.
    In fiscal year 2009, with congressional support, the total Army 
spent $4.9 billion on recruiting and retention. In fiscal year 2010, 
these programs received $4.4 billion due to a more favorable recruiting 
and retention environment. Our $4.6 billion, fiscal year 2011 request 
is based on the need to continue funding for contracts written between 
fiscal year 2006 and fiscal year 2009 and to ensure the success of the 
total Army's recruiting and retention missions. The amount budgeted for 
contractual payments is anticipated to decrease in fiscal year 2012 and 
subsequent years.
    Because of this funding, the Army is now a higher quality All-
Volunteer Force. For example, the Army's percentage of ``high quality'' 
enlisted soldiers with a high school diploma have increased by 2.1 
percent since the end of fiscal year 2009. Additionally, recruits 
scoring in the upper range (50-99 percent) on the Armed Forces 
Qualification Test (AFQT) increased 2.0 percent; and recruits who 
scored poorly (30 percent and below) on the AFQT decreased 0.4 percent. 
The Army was able to decrease the amount of ineligibility waivers 
previously provided for enlistments and appointments. Also, the Army 
was able to repair mid-grade officer shortages in the Regular Army, 
which provided the opportunity to aggressively target mid-grade 
shortages in the Reserve components.
    Overall, the Army's programs are effective in recruiting and 
retaining both officers and enlisted soldiers with critical skills. For 
enlisted soldiers, the Enlistment Bonus (EB), the Selective 
Reenlistment Bonus (SRB), Critical Skills Retention Bonus (CSRB), Army 
College Fund (ACF), and the Student Loan Repayment Program (SLRP) 
remain as proven and effective tools for filling critical skills. The 
ACF and SLRP are especially effective in attracting quality recruits 
who have some college experience or plan to attend college after the 
Army.
    To assist in recruiting critical skills, the Army launched the 
``Military Accessions Vital to the National Interest'' (MAVNI) Pilot 
Program which the Secretary of Defense authorized on November 25, 2008 
and Army launched on February 23, 2009. The purpose was to attract high 
quality individuals with exceptional skills in health care professions 
or native speaking skills in at least 1 of 35 critical foreign 
languages. MAVNI recruits are non-U.S. citizens who have been legally 
present in the United States for 2 or more years and speak a critically 
needed foreign language or are U.S. licensed health care professionals 
who meet or exceed all requirements for military service but for U.S. 
citizenship. They do not have permanent residency (i.e. Green Cards). 
We recruited 788 MAVNI with language skills and 143 health care 
professionals during the 12 months since the program launched. Without 
spending a single dollar on marketing or advertising, Army received 
over 12,000 leads for the MAVNI program and positive media coverage. Of 
the foreign language speakers recruited, 66 percent have a bachelor's 
degree or higher, and 30 percent have at least a master's degree. Half 
the MAVNI recruits speak and comprehend the foreign language for which 
they were recruited at the 3/3 level or higher which is akin to a 
college graduate. Their loss from the Delayed Entry Program (DEP) is 
one-third that of non-MAVNI recruits and their attrition rate once in 
the Service is virtually nil. We reached the cap for this program 
established by the Secretary of Defense so until the program is 
extended we are unable to recruit the many applicants waiting to be 
processed.
    Through a separate program, the Army has recruited more than 1,600 
soldiers as military interpreters and translators under the MOS O9L 
Program. This MOS enlists native speakers of Arabic, Pashtu, Dari, 
Farsi, and Kurdish into all components of the Army to serve as 
interpreters in uniform. Combatant Commanders have found them to be 
force multipliers as they bring high levels of proficiency in these 
languages as well as firsthand cultural knowledge.
    In fiscal year 2009, all components exceeded the annual retention 
goal. The Active Army achieved 124 percent of the annual goal, the Army 
Reserve achieved 105 percent, of the annual goal, and the Army National 
Guard achieved 106 percent of the annual goal. During fiscal year 2009, 
retention bonuses were carefully monitored and adjusted to achieve the 
maximum result, ensuring the Army met its retention goals while 
remaining fiscally responsible. The economic environment allowed the 
Army to reduce incentive levels as well as the number of occupations 
offering bonuses, while focusing on our most critical skills. In 
addition, use of the Army's Critical Skills Retention Bonus greatly 
assisted in retaining very experienced senior enlisted soldiers with 
invaluable leadership and combat experience. Retention of combat 
experienced veterans remains critical to current and future readiness. 
In fact, 39 percent of all reenlistments occurred while soldiers were 
deployed. The Active Army also continued to support and encourage 
Active Duty soldiers who elected not to reenlist to transfer to the 
Reserve component upon completion of their Active Duty tour.
    The Army retention mission is also on track to meet the goals set 
for fiscal year 2010. The Active Army has reenlisted 41,262 soldiers 
for 68 percent of the annual goal, the Army Reserve has reenlisted 
4,291 for 42 percent of the annual goal, and the Army National Guard 
has reenlisted 10,771 soldiers for 35 percent of the annual goal. In 
all components, the Army expects to finish successfully in every 
category.
    The Post-September 11 GI Bill, which took effect August 1, 2009, 
provides a significantly enhanced level of educational benefits for 
Active Duty servicemembers. Additionally, it serves as a valuable 
incentive to attract and retain quality soldiers of all ranks. The Army 
expects the Post-September 11 GI Bill to serve as an inducement for 
college oriented teens to join the Army, while transferability should 
increase retention within our mid-career (6-10 years of service), 
category of soldiers. Although it is too early to fully determine the 
impact of the Post-September 11 GI Bill on both recruiting and 
retention, initial signs are positive. In particular, we've kept a 
watchful eye on the retention of our initial term soldiers who some 
feared might separate under expiration of their term of service in 
order to use their educational benefits. However, the Army exceeded its 
retention goals for first-term soldiers in fiscal year 2009 and 
continues to do so in fiscal year 2010.
    Shortages remain within our officer corps due to overall structural 
growth of the Army. To correct this, the Army initiated the Captains' 
Retention Incentive Menu in September 2007. The Army spent $443.6 
million from fiscal year 2007 to present on this incentive program. The 
goal of the program was to recruit, retain, and manage critical skills 
to increase the retention of lieutenants and captains for 3 years. The 
Captains' Retention Incentives Menu program included a cash option 
based on the officer's branch, resident graduate school attendance for 
up to 18 months, or attendance at the Defense Language Institute for 1 
year. As a result, the Army's retention rate for Captains increased in 
fiscal year 2008 to 89.1 percent and again in fiscal year 2009 to 89.9 
percent over the 10-year average of 88 percent. The program guaranteed 
retention through fiscal year 2011 for over 16,000 of the 23,000 
captains who were eligible to participate. The timing of our Captains' 
Retention Incentives Menu program, concurrent with the dramatic 
downturn of the economy and job market, helped support our retention 
goals. The cash and Defense Language Institute options ended in 
November 2008. The remaining retention incentive, the Expanded Graduate 
School Program, has been funded at $7.5 million in fiscal year 2010. 
Overall, the single most effective retention incentive for junior 
officers was the cash bonus. Over 94 percent of the more than 16,000 
officers who took incentives in fiscal year 2008 elected to take the 
cash bonus. Department of Defense survey data analysis showed that most 
officers who intended to separate or were undecided, took the incentive 
and committed to further obligated Army service.
    The U.S. Military Academy (USMA) and ROTC both continue to offer 
pre-commissioning incentives. These consist of offering new officers 
their Post or Branch of Choice or Graduate Schooling. In fiscal year 
2006 through fiscal year 2009 there were approximately 6,000 
participants. These incentives have increased longevity by 40 percent 
for newly-commissioned, high-performing USMA and ROTC officers.
    In spite of a dramatically changed recruiting climate, based on the 
economy, our message to our soldiers and their families must resound 
with assurance that they will be cared for in a manner commensurate 
with their service and sacrifice. Incentives, bonuses, and pay are only 
part of the equation in creating balance in our soldiers and families 
lives. In the event of a life changing injury or the loss of life, our 
soldiers are assured that their families will receive financial and 
programmatic support for their loss and sacrifice. This support 
includes full-earned benefits and disability compensation. The Army is 
working closely and aggressively with soldiers and their families to 
streamline access to assistance from other Federal agencies, such as 
the Social Security Administration, Department of Labor, and Department 
of Veterans Affairs.
    In direct support of President Obama's Veteran's Day Executive 
Order on employment of veterans in the Federal Government, we have 
begun a Veterans Employment Transition Initiative to streamline, 
synchronize, and integrate existing policies, programs, and initiatives 
to assist soldiers and their families as they transition out of the 
military. The intent is to ensure that they have timely visibility of 
every opportunity available to them as they transition to civilian 
life, whether as Federal workers or as contributing members of the 
private sector.
    The Army carefully manages its resources, reviewing and adjusting 
incentives at least quarterly to ensure we attract and retain quality 
individuals in needed occupations, while remaining fiscally responsible 
to avoid excessive payments. The economic environment has allowed us to 
reduce incentive amounts and the number of occupations offered bonuses 
or education incentives. Enlistment Bonuses are at the lowest levels 
since the 1990s drawdown. However, we must retain the flexibility to 
apply incentives as necessary to retain soldiers with critical or 
specialized skills. The continued authorities and funding of these 
programs by Congress remain critical to the sustainment of the Army.
                 individual ready reserve mobilization
    The Individual Ready Reserve (IRR) is a category of the Ready 
Reserve, and is composed of those members of the Ready Reserve who are 
not serving in Selected Reserve units or assignments, or in the 
Inactive National Guard. The availability of IRR soldiers is critical 
to the Army's mission of providing properly trained and equipped units 
of sufficient strength to meet contingency operation or mobilization 
requirements. As of February 28, 2010, there are 59,413 soldiers in the 
IRR. Since September 11, 2001, a total of 29,997 soldiers received 
mobilization orders and a total of 12,018 soldiers deployed to the 
CENTCOM Area of Responsibility. The Army applies specific screening 
criteria and a tiered systemic approach regarding involuntary 
mobilization of the IRR. These actions align with the January 2007 DOD 
policy on Utilization of the Total Force and take into account a 
soldier's dwell time, Military Service Obligation (MSO), and previous 
deployments in support of OCONUS Contingency Operations (OCO).
    An effective IRR program is based on several factors, including the 
soldiers' understanding of their obligations, access to benefits and 
support, and time to adjust personal affairs prior to mobilizations. In 
an ongoing effort to validate the readiness of the IRR, the Army 
continues to implement the IRR Muster program. Approximately 5 months 
after entering the IRR program, soldiers will be ordered to muster 
duty. Afterward, soldiers are required to muster each year they remain 
in the IRR. Through the muster program, the Army established a 
partnership with the Department of Veterans Affairs to use VA medical 
centers as muster sites for the added opportunity of connecting 
soldiers to VA services. During fiscal year 2009, the Army spent 
approximately $3.6 million to muster 13,500 soldiers, contributing to 
3,300 soldiers returning to Army Reserve formations. The Army plans to 
muster 14,000 IRR soldiers at an estimated cost of $4.2 million in 
fiscal year 2010 and expect to impact 3,500 soldiers returning to Army 
Reserve Formations.
                          operational reserve
    As the Army continues to institutionalize the Operational Reserve, 
our first and greatest challenge is to effectively and efficiently 
deliver ready and trained soldiers. Transforming the Reserve components 
(RC) into an operational force in the near-term (fiscal year 2012-2014) 
will provide a means for RC forces to provide proportional support to 
the Army's Force Supply model of a Corps Headquarters, 5 division 
headquarters (4 Active component (AC), 1 RC), 20 Brigade Combat Teams 
(15 AC, 5 RC), and 90,000 enablers (41,000 AC, 49,000 RC) to support 
combatant command requirements through 2014 time period. It is 
important to note that programming decisions are required in the near 
term to ensure RC forces are sufficiently ready to support the Army's 
force generation plans. Without sufficient resources in unit 
management, collective training and medical/dental readiness, the RC 
will not be ready to support the planned 1/5/20/90 force supply 
construct.
    The Army will require recurrent, assured and predictable access to 
the RC to meet operational requirements as requirements increase for 
Army forces to conduct overseas engagement activities over the 
remaining years of the program period (fiscal year 2015-2017). During 
this period, RC forces will be mobilized and employed in full spectrum 
operations at rates proportional to AC forces within force utilization 
goals of 1:3 (AC) and 1:5 (RC). Continued investments in RC unit 
management, collective training and medical/dental readiness are 
required to achieve required readiness levels in accordance with these 
ARFORGEN goals. Moreover, these investments are required within the 
base funding to ensure the RC achieves a level of institutional 
transformation that cannot be achieved through the year-by-year 
allocation of resources from overseas contingency operations funds.
    Finally, transforming the RC into an operational force provides an 
opportunity for the Army to provide the most cost-effective Total Force 
and mitigate any decline in resources by investing now in the most 
cost-efficient portion of the Army's Total Force. The Army National 
Guard (ARNG) and the U.S. Army Reserve account for 51 percent of the 
Army's military end strength for 16 percent of the base budget. When 
comparing the cost per soldier, the relative value of the RC is even 
greater. A 2008 comparison of AC/RC manpower by HQDA G-8 identified the 
approximate total costs per Regular Army soldier in manpower, training, 
equipping, organization costs and operating costs as $135,000, compared 
to $36,000 for ARNG soldiers and $35,000 for Army Reserve soldiers. 
Given the relative value is a reasoned investment for the Army's Total 
Force, this will make targeted investments improve RC readiness. 
Moreover, such investments in the near-term (POM 2012-2017) will 
position the Army to better manage the risks of declining resources for 
the Army, should such a reduction be required in the next 2 to 5 years. 
However, delays in these investment decisions reduce the Army's 
flexibility to consider strategic alternatives to a larger Active Force 
structure model in the long-term.
                            quality of life
    Recognizing that the strength of our Army comes from the strength 
of our Army families, the Secretary of the Army and Chief of Staff of 
the Army initiated the Army Family Covenant in October 2007 and 
reaffirmed this commitment by resigning the Covenant this past October. 
The Covenant institutionalizes the Army's commitment to provide 
soldiers and families a quality of life commensurate with the quality 
of service they provide our Nation. The Army Family Covenant 
incorporates programs designed to build strength and resilience in our 
families. These improved services and programs help to mitigate the 
stress from mutiple deployments and frequent military moves.
    The Covenant focuses on the following: standardizing soldier and 
family programs; increasing access and quality of health care; 
improving soldier and family housing; ensuring excellence in our 
schools, youth and child care services; expanding the education and 
employment opportunities for family members; improving soldier quality 
of life in recreation, travel, and the Better Opportunities for Single 
Soldiers program; and improving relationships with local communities 
and marketplaces.
    From fiscal year 2007 to fiscal year 2010, the Army more than 
doubled its investment in family programs. To ensure they remain 
enduring, these increases have been included in the fiscal year 2010 
base budget. Furthermore, this funding will increase from $1.7 billion 
in fiscal year 2010 to $1.9 billion in fiscal year 2015.
    We must never forget that we are one Army made up of Active Duty, 
National Guard, and Army Reserve components and must often reach 
``beyond the gates of the garrison'' to ensure we support our 
geographically dispersed families. We are thankful for all the citizens 
and community based organizations that have stepped up to support our 
soldiers and their families, regardless of their location.
              civilian personnel and workforce development
    Department of the Army civilian employees provide vital support to 
soldiers and families in this era of persistent conflict. They share 
responsibility for mission accomplishment by delivering combat support 
and combat service support--at home and abroad. More than ever, Army 
civilians are an absolutely essential component of readiness and a key 
element in restoring balance. Today, the Army Civilian Corps has nearly 
300,000 employees with 3,832 currently serving in harm's way in the 
U.S. Central Command area of operations.
    Since September 11, 2001, we increased the civilian workforce from 
222,000 to 263,169 (plus 24,357 Civil Works) due to overseas 
contingency operations, Defense Health Program increases, Family and 
Soldier Support initiatives, acquisition workforce growth, in-sourcing 
contracts associated with inherently governmental functions, military 
technician increases, and military-to-civilian conversions. Future 
Civilian employee growth is critical to supporting current plans to 
rebalance the Army to 73 brigade combat teams and associated combat 
support/combat service support units by fiscal year 2011.
    In fiscal year 2009, the Army saved significant resources by in-
souring more than 900 core governmental functions to Army civilians. We 
plan to in-source 7,162 positions in fiscal year 2010, and are 
programmed to in-source 11,084 positions during fiscal year 2011-2015, 
of which 3,988 are acquisition positions. These positions were 
identified in the Army's on-going contractor inventory review process.
    Current workforce development programs, such as the Army Intern 
Program; the Army Fellows Program; the Presidential Management Fellows 
Program; the Senior Fellows Program, and the Army Senior Leader 
Development Program, to name a few, are helping the Army to ``build a 
bench'', of future Army leaders. In an era of persistent conflict, 
however, the operational and budgetary realities of fighting terrorism 
on multiple fronts have simultaneously increased the requirements for 
development and decreased the available funding. Simply put, the Army's 
resources to develop our Civilians have not kept pace with the need. 
While current training and development programs provide highly 
competitive growth opportunities, better incentives for self-
development and professional development are needed to ensure the 
Civilian cohort is as prepared to meet future missions as their 
military counterparts. The Department of the Army also has several 
initiatives to focus and invigorate development of the civilian 
workforce, which complement the strategic workforce plan requirements 
outlined in the National Defense Authorization Act for Fiscal Year 
2010.
    The Army is developing a Civilian Human Capital Strategy to better 
focus on the full life-cycle needs of Civilian Workforce, from 
recruitment to replacement. Because of the increasing complexity of 
today's operational environment, the Army must invest more resources 
into recruiting, sustaining, and developing its Civilian workforce. The 
Initial emphasis of our Civilian Human Capital Strategy will be on 
identification of the competencies needed by employees in mission 
critical occupations, assessment of the current competency levels of 
the workforce, and strategies for closing the gaps. This focus will 
enable the Army to develop competency-based civilian recruiting and 
hiring strategies as well. This approach will help ease the transition 
from one generation to the next as we implement Base Realignment and 
Closure and begin to experience the next wave of baby boomer 
retirements.
                     army equal opportunity policy
    The Army leads the Nation in Equal Opportunity (EO) policy and 
practice. Commanders at all levels are responsible for sustaining 
positive EO climates within their organizations to enhance Army 
Readiness. Remaining applicable and relevant within the ever-changing 
environment in which we operate, the Army is transforming EO policy/
program by integrating and institutionalizing equal opportunity and 
diversity goals, objectives and training practices. This effort will 
strengthen the foundation of the Army's Human Capital Strategy. Since 
fiscal year 2008, the Army has invested $3.4 million and expects to 
invest another $0.9 million in fiscal year 2010 for EO personnel and 
services support, database and survey systems, outreach support, and 
training contracts.
                sexual assault and harassment prevention
    The Army's goal is to eliminate sexual assault and harassment by 
creating a climate that respects the dignity of every member of the 
esteemed band of brothers and sisters. The Secretary of the Army 
(SECARMY) and the Chief of Staff (CSA) remain personally involved in 
reinforcing to all soldiers and leaders the importance of preventing 
sexual assault and harassment. Under their guidance and leadership, the 
Army launched a comprehensive sexual assault prevention strategy that 
requires leaders to establish a positive command climate where sexual 
assault is clearly not acceptable. The strategy further encourages 
soldiers to execute peer-to-peer intervention personally, and to not 
tolerate behavior that could lead to sexual assault.
    The cornerstone of the Army's prevention strategy is the ``I. A.M. 
Strong'' campaign, where the letters I, A, and M stand for Intervene--
Act--Motivate. The ``I. A.M. Strong'' campaign features soldiers as 
influential role models and provides peer-to-peer messages outlining 
the Army's intent for all its members to personally take action in the 
effort to protect our communities. Leaders have embraced ``I. A.M. 
Strong'' initiatives and are motivating soldiers to engage proactively 
and prevent sexual assault.
    The Army's sexual assault prevention strategy consists of four 
integrated phases and extends through calendar year 2014 as we work to 
be the Nation's leader in sexual harassment and sexual assault 
prevention.
    The SECARMY introduced the ``I. A.M. Strong'' campaign at the 
Sexual Assault Prevention Summit in September 2008. The Summit served 
as a platform to launch Phase I (Committed Army Leadership) by 
providing training on best practices and allowing commands the 
opportunity to develop prevention plans to support the Army strategy.
    Phase II of the prevention strategy (Army-wide Conviction) includes 
educating soldiers to understand their moral responsibility to 
intervene and stop sexual assault and harassment. Phase II began at the 
2009 Sexual Assault Prevention Summit (6-10 Apr 09) during which the 
SECARMY, CSA, and Sergeant Major of the Army addressed attendees, which 
included over 100 sergeants major and 50 general officers.
    Phase III culminates the dedicated effort of leaders and soldiers 
under Phase I and Phase II by ``Achieving Cultural Change'' that truly 
reflects Army values and fosters an environment free from sexual 
harassment and sexual assault.
    The final phase is ``Sustainment, Refinement, and Sharing,'' during 
which the prevention program continues to grow while motivating 
national partners to support our efforts to change generally accepted 
negative social behaviors; thus eliminating the crime of sexual 
assault.
    With the implementation of the strategy, a likely near-term 
consequence will be an increase in the number of reported cases as 
soldiers' and other victims' propensity to report increases. This 
increase in cases will require more sexual assault responder support, 
specifically: victim advocates, healthcare personnel, investigators, 
and prosecutors.
                       suicide prevention program
    The loss of any soldier is a tragedy, particularly when it could 
have been prevented. There were 160 suicides by active-duty soldiers 
during 2009, continuing the 5-year trend of increased suicides within 
the Army. As a result, we have instituted a multi-level, holistic 
approach to health promotion, risk reduction and suicide prevention. 
Although the total number and rate of suicides in the Army remains of 
deep concern, we should remember each of these suicides represents an 
individual and a family that has suffered an irreparable loss---and, as 
a result, our suicide prevention efforts are focused on directly 
assisting soldiers, their families, and our Army civilians.
    On 16 April 2009, the Vice Chief of Staff of the Army (VCSA) signed 
the Army Campaign Plan for Health Promotion, Risk Reduction, and 
Suicide Prevention, a comprehensive plan setting in motion 
unprecedented changes in Army doctrine, policy, and resource 
allocation, as well as immediate guidance to commanders, in order to 
address the problem of suicides in the overall context of risk 
reduction and health promotion.
    The Army Suicide Prevention Task Force has addressed more than 240 
different tasks related to suicide prevention doctrine, organization, 
training, materiel, leadership, personnel, and facilities. Over 90 
percent of these tasks have been implemented.
    To build on the Army Campaign Plan's accomplishments during 
calendar year 2009, the Army Suicide Prevention Task Force is leading 
an effort to review and assess the effectiveness of Army Health 
Promotion, Risk Reduction and Suicide Prevention programs at all 
levels. Army has partnered with National Institute of Mental Health to 
conduct a long-term study (Army Study to Assess Risk and Resilience on 
Servicemembers) of risk and protective factors to inform health 
promotion and suicide prevention efforts. The VCSA Task Force is also 
reviewing all Army programs at all levels that are related to health 
promotion, risk reduction, suicide prevention, or were implemented to 
address soldier, family, or DA civilian stressors to ensure that the 
programs provide appropriate levels of support and address current 
problems, risk factors, and are relevant to today's soldiers' families' 
and DA civilians needs.
                 comprehensive soldier fitness program
    The Army's Comprehensive Soldier Fitness (CSF) program is a 
structured, long-term assessment and development program designed to 
build the resilience and enhance the performance of the Army's 
soldiers, families, and civilian personnel. The CSF program uses 
individual assessments, tailored virtual training, classroom training 
and embedded resilience experts to provide soldiers with the critical 
skills needed to take care of themselves, their families and their 
teammates in this era of persistent conflict. By developing the five 
dimensions of strength--physical, emotional, social, spiritual, and 
family--CSF equips soldiers with the skills to become more self-aware, 
fit, balanced, confident, and competent, and ultimately better prepared 
to face the physical and psychological challenges of sustained 
operations.
                      army substance abuse program
    The Nation's persistent conflict has created symptoms of stress for 
our soldiers, including an increase in alcohol and drug abuse. This 
commander's program uses prevention, education, deterrence, detection, 
and rehabilitation, to reduce and eliminate alcohol and drug abuse. It 
is based on the expectations of readiness and personal responsibility.
    A team recently returned from deployment to U.S. Army Forces, U.S. 
Central Command. To support our commanders, clear and effective 
procedures for random drug testing in theater are under development, 
such as the implementation of online tools to train unit prevention 
leaders and to quickly inform commanders of test results. Another area 
under development is the review of portable prevention education 
packages for deployed soldiers, soldiers at home, and soldiers in the 
RC. Additionally, the Army is conducting a pilot program that provides 
confidential education and treatment to soldiers who self-refer to the 
Army substance abuse program for assistance with alcohol issues. In 
addition to the pilot program, we are conducting a broader, more 
detailed study to determine the exact nature and extent of any stigma 
in the Army associated with substance abuse treatment. This study will 
run concurrently with the pilot program. The pilot program and detailed 
study were concluded on March 1, 2010 and we expect to report to 
Congress in April 2010. We want to ensure that all soldiers who may 
need assistance can get assistance without the barrier of stigma.
                        congressional assistance
    Recruiting, retention, and providing for the well-being of the best 
Army in the world requires a significant commitment by the American 
people. The Army is grateful for the continued support of Congress for 
competitive military benefits and compensation, along with incentives 
and bonuses for soldiers and their families and for the civilian 
workforce. These are critical in helping the Army be the employer of 
choice.
                               conclusion
    We must maintain an appropriate level of investment to ensure a 
robust and high-quality force. The well-being and balance of our force 
are absolutely dependent upon your tremendous support. The Army is 
growing and transforming in a period of persistent conflict. We will do 
so with men and women of the highest caliber whose willingness to 
serve, is a credit to this great Nation.

    Senator Webb. Secretary Garcia.

 STATEMENT OF HON. JUAN M. GARCIA III, ASSISTANT SECRETARY OF 
           THE NAVY FOR MANPOWER AND RESERVE AFFAIRS

    Mr. Garcia. Chairman Webb, Senator Graham, distinguished 
members of the committee, it's my pleasure to be here today to 
testify on behalf of our Navy and Marine Corps personnel.
    For the past 5 months as an Assistant Secretary of the 
Navy, I've had the honor of representing and advocating for the 
nearly 650,000 sailors and marines, both Active Duty and 
Reserve, and 180,000 civilian employees who, together, are 
globally engaged across a spectrum of operations ranging from 
major combat to humanitarian assistance.
    Across the Department of the Navy, we are asking our 
sailors, marines, and civilians to take on extraordinary tasks 
ranging from combat operations in Afghanistan to unplanned 
disaster relief in Haiti. The men and women who comprise the 
Navy and Marine Corps have invariably risen to meet the 
challenge presented.
    Our leadership team--Secretary Mabus, Under Secretary Work, 
Admiral Roughead, and General Conway--have set a course for the 
Department of the Navy that drives our human capital strategy, 
focusing on our greatest asset: our people. In order to achieve 
our best, we promote an environment in which every person can 
excel, where each person is treated with dignity and respect, 
and where all are recognized for the contributions they make.
    Both the Navy and Marine Corps are experiencing historic 
success in recruiting and retention of Active Duty 
servicemembers. I assess that both Services will continue 
meeting their recruiting and end-strength goals for the 
foreseeable future. It's a tribute to both the dedication of 
our military personnel communities and to the patriotism of our 
Nation's young men and women that we are able to maintain an 
All-Volunteer Force of unprecedented quality through more than 
8 years of active combat operations.
    Recruiting and retention in certain fields--healthcare, 
Special Forces, nuclear power--continue to pose challenges and 
will require the use of special pays and bonuses to ensure 
adequate numbers of qualified personnel are available in those 
critical specialties.
    Despite its high operational tempo, the Marine Corps was 
able to grow to 202,000 Active Duty end strength 2 years ahead 
of schedule. This focus on Active Duty recruiting and retention 
resulted in a slight shortfall of the Marine Reserve component 
end strength for 2009. For this same reason, 2010 Reserve 
strength may also be slightly below target.
    The health of the Reserve components is of particular 
concern because of our dependence on them to meet our global 
obligations. Since September 11, more than 142,000 mobilization 
requirements have been met by members of the Navy and Marine 
Corps Reserve.
    A high tempo, high stress environment appears to be the new 
normal for the Department of the Navy. One of the lessons to be 
learned from recent years is that our people step up and 
perform superbly in times of greatest need. But, the reality of 
continuing operations in Afghanistan, combined with our other 
deployment commitments, undeniably places great stress on our 
forces. The Department of the Navy is employing every measure 
available to help identify consequent risks, and we continue to 
assess and reevaluate these programs daily.
    As Secretary Gates has said, apart from the war itself, we 
have no higher priority than taking care of the wounded, ill, 
and injured. Through the Marine Corps Wounded Warrior Regiment 
and the Navy Safe Harbor Program, the sea Services strive to 
provide the best possible support for our personnel struck 
down, to include reintegration into society and a new emphasis 
on post-service employment.
    I'd like to thank the committee members for their 
continuous commitment to the support of our expeditionary 
fighting men and women, especially to those who have returned 
from the front line of battle with broken bodies but unbroken 
spirits, our wounded warriors.
    I look forward to your questions.
    [The prepared statement of Mr. Garcia follows:]
               Prepared Statement by Hon. Juan M. Garcia
    Chairman Webb, Senator Graham, and distinguished members of the 
subcommittee, it is my pleasure to be here today to testify on behalf 
of our Navy and Marine Corps personnel. For the past 5 months as an 
Assistant Secretary of the Navy, I have had the honor of representing 
and advocating for the nearly 650,000 sailors and marines, both Active 
Duty and Reserve, and 180,000 civilian employees who, together, are 
globally engaged across a spectrum of operations ranging from major 
combat to humanitarian assistance. Across the Department of the Navy, 
we are asking our sailors, marines, and civilians to take on 
extraordinary tasks ranging from combat operations in Afghanistan to 
unplanned disaster relief in Haiti. The men and women who comprise the 
Navy and Marine Corps have invariably risen to meet the challenges 
presented.
    Our leadership team, Secretary Mabus, Under Secretary Work, Admiral 
Roughead, and General Conway, have set a course for the Department of 
the Navy that drives our Human Capital Strategy--focusing on our 
greatest asset--our people. In order to achieve our best, we promote an 
environment in which every person can excel, where each person is 
treated with dignity and respect, and where all are recognized for the 
contributions they make.
    Let me address some particular areas of interest and concern 
related to the Department's manpower and personnel.
    In terms of military personnel, both the Navy and Marine Corps are 
experiencing historic success in recruiting and retention of active 
duty servicemembers. I assess that both Services will continue meeting 
their recruiting and end-strength goals for the foreseeable future. It 
is a tribute to both the dedication of our military personnel 
communities and to the patriotism of our Nation's young men and women 
that we are able to maintain an All-Volunteer Force, of unprecedented 
quality, through more than 8 years of active combat operations.
    Recruiting and retention in certain fields--including health care, 
Special Forces, and nuclear power--continue to pose challenges, and we 
still require the use of special pays and bonuses to ensure adequate 
numbers of qualified personnel are available in critical specialties 
such as these.
    The Navy expects to continue to need an additional 4,400 end-
strength for Overseas Contingency Operations. In considering that 
requirement, it is important to remember that the number of active duty 
sailors has been in gradual decline since the Vietnam war. As recently 
as 1993 the Navy had half-again as many sailors on active duty, and 
available for assignments, as it does today.
    Despite its high operational tempo, the Marine Corps was able to 
grow to 202,000 active duty end strength 2 years ahead of schedule. 
This focus on active duty recruiting and retention resulted in a slight 
shortfall of the Marine Reserve component end strength for 2009. For 
this same reason, 2010 Reserve strength may also be slightly below 
target. The health of the Reserve components is of particular concern 
because of our dependence on them to meet our global obligations. Since 
September 11, more than 142,000 mobilization requirements have been met 
by members of the Navy and Marine Corps Reserve.
    Another topic of particular interest is the introduction of female 
personnel on submarines. On February 19, 2010, the Secretary of Defense 
notified Congress of our intent to change the policy prohibiting the 
service of women in submarines. After the requisite notification period 
has expired, it is the Navy's intent to have the first cadre of female 
officers commence training on nuclear prototypes and begin a pipeline 
that will ultimately lead them to qualification as Naval Submariners, 
removing one of the last gender barriers in the U.S. Navy, and helping 
to insulate us from the anticipated surge in hiring by the civilian 
nuclear power industry in the decades to come. Because of the critical 
mission and demanding environment of the submarine force, we envision a 
gradual, and measured approach to this integration. Our initial efforts 
will focus on officers only and will concentrate on our large boats 
(SSGNs and SSBNs), where the existing infrastructure will accommodate 
these changes without material alteration. As a measure of extra 
caution, the Navy will not reduce the number of male officers trained 
and qualified for submarine duty until we have experience with 
successfully placing female officers in those roles.
    Some might argue that such initiatives should not be undertaken 
during a period of high operating tempo and stress on the force. But a 
high tempo, high stress environment appears to be the new normal for 
the Department of the Navy. One of the lessons to be learned from 
recent years is that our people step up and perform superbly in times 
of greatest need. Yet the reality of continuing operations in 
Afghanistan combined with our other deployment commitments undeniably 
places great stress on our forces.
    Stress on the force has many causes and manifests in many forms. 
The Secretary of Defense asked former Secretary West and Retired 
Admiral Clark to lead an independent review of the tragic events at 
Fort Hood. Their review produced 86 recommendations for changes in, or 
reviews of, procedures and policies. Currently, the Department of the 
Navy is working with the other Services and the Office of the Secretary 
of Defense to evaluate those recommendations and implement those that 
seem appropriate. Well before the shootings at Fort Hood, the 
Department of the Navy had in place its Caregiver Occupational Stress 
Control Program, which is designed to enhance the resilience of 
caregivers, including mental health professionals, chaplains, corpsmen, 
and other counselors and advisers. Additionally, for reservists and 
individual augmentees returning from mobilization, the Department 
created the Returning Warrior Workshops (which are a part of the Yellow 
Ribbon Reintegration Program) to help with the adjustment to life back 
home.
    Stress on our personnel has likely played a role in the 
heartbreaking increase in suicide rates among the active duty in recent 
years. The Department of the Navy has employed every measure available 
to help identify those at risk, encourage them to seek help, and 
prevent these tragedies. We continue to assess and re-evaluate our 
programs daily, and will not stop, believing that even a single suicide 
by those wearing our Nation's cloth is one too many.
    As Secretary Gates has said, apart from the war itself, we have no 
higher priority than taking care of the wounded, ill, and injured. 
Through the Marine Corps's Wounded Warrior Regiment and the Navy's Safe 
Harbor Program, the sea services strive to provide the best possible 
support for our personnel struck down, to include reintegration into 
society, and a new emphasis on post-Service employment.
    Thanks to advances in military medicine, many of our most seriously 
wounded, who even a few years of ago would have died of injuries, are 
recovering and, in many cases, able to resume their military jobs. 
Others will require special accommodations and support for the rest of 
their lives. We are working in close partnership with the Department of 
Veterans' Affairs to ensure the best and most dignified treatment 
possible for those sailors and marines.
    Members of our civilian workforce continue their crucial 
contributions to our mission while coping with two significant 
transitions of their own.
    Consistent with your direction in the National Defense 
Authorization Act for Fiscal Year 2010, we are currently in the process 
of moving all of our civilian employees out of the National Security 
Personnel System. Those who are returning to the General Schedule will 
be converted no later than the end of the fiscal year. Those who will 
move to one of the various alternative pay systems will be transitioned 
during 2011.
    While this is occurring, the DOD is also engaged in a significant 
in-sourcing initiative, expected to add more than 33,000 civilian 
positions over the next 5 years to perform currently contracted 
services--the Department of Navy expects to establish 10,000 new 
civilian positions as part of this effort. This initiative will 
rebalance our workforce; rebuild organic capabilities; reduce 
operational risk by ensuring that inherently governmental and functions 
that support the readiness/management needs of the Department are 
performed by government employees; and that services are delivered in 
the most cost effective manner. Nearly a third of these new positions 
are expected to be part of the crucial acquisition workforce. These 
insourcing initiatives are consistent with DOD's High Priority 
Performance Goals in the President's fiscal year 2011 Budget's Analytic 
Perspectives volume.
    Finally, I would like to thank the committee members for their 
continuous commitment to the support of our expeditionary fighting men 
and women, especially to those who have returned from the front line of 
battle with broken bodies but unbroken spirits--Our Wounded Warriors.
    I look forward to your questions.

    Senator Webb. Thank you, Secretary Garcia.
    Secretary Ginsberg.

 STATEMENT OF HON. DANIEL B. GINSBERG, ASSISTANT SECRETARY OF 
         THE AIR FORCE FOR MANPOWER AND RESERVE AFFAIRS

    Mr. Ginsberg. Thank you, Chairman Webb, Ranking Member 
Graham, and members of the subcommittee.
    It is my honor to testify before you today about our 
airmen. They are doing incredible work every day to serve our 
Nation and accomplish the missions that our Nation has asked of 
them. Our Air Force has been engaged in continuous operations 
for over 19 years. We have never been more engaged than today. 
We have over 38,000 airmen deployed around the world, and 
thousands more airmen providing direct support to the 
warfighter through our space systems, global mobility 
operations, and remotely-piloted operations, to name just a few 
of the critical capabilities that we provide.
    Overall, our force structure is healthy. We are working 
internal challenges to ensure we meet the increased demand for 
new and emerging missions, such as our remotely piloted 
aircraft, cyberoperations, and irregular warfare. We are 
meeting our total-force recruiting goals, except for a few 
hard-to-fill specialties in our officer medical specialties.
    To address this, we are aggressively pursuing a three-
pronged approach to, first, grow our own through expanded 
scholarship opportunities and commissioning opportunities for 
our enlisted force; second, increase compensation through 
special and incentive pays; and third, to improve quality of 
life.
    Although the Air National Guard will meet end strength, we 
are having challenges recruiting enough officers. That may be 
related to our high retention rates we are currently 
experiencing with our Active component. Historically, the Guard 
and Reserve rely heavily on recruiting prior-service trained 
airmen who separate from the Active side.
    An efficient and smooth transfer between each component and 
Civil Service allows the Air Force to access and retain 
important skill sets and balance our mission needs over time. 
To make this process work even better, we are focusing on our 
Continuum of Service Program. Through Continuum of Service, we 
are reviewing all Air Force, Office of the Secretary of Defense 
(OSD), and statutory requirements to identify areas where we 
can streamline the transfer between components. When statutory 
issues are identified, we will work with OSD and our 
counterparts in other Services to identify and support 
legislative proposals to you.
    Taking care of our airmen and their families is a top Air 
Force priority. In the spring of 2009, the Air Force renewed 
its longstanding commitment to our airmen and families by 
designating July 2009 through July 2010 as ``The Year of the 
Air Force Family.'' The observance serves two primary purposes. 
First, we examined our family support services and policies 
across the Air Force in order to expand or refine them as 
required to meet the emerging needs and expectations of our 
airmen, their families, and the larger Air Force family.
    Second, we set aside specific time to recognize the 
sacrifices and contributions of the members of our entire Air 
Force family--our Active, Guard, Reserve, civilian, spouses, 
and family members. We have focused our efforts to ensure we 
provide robust programs to meet the unique needs of our Guard 
and Reserve members and their families.
    In conjunction with the Year of the Air Force Family, we 
are also focused on reducing the stressors and mission 
detractors that impact our airmen and their families. We have 
taken a holistic approach to addressing airmen resiliency. We 
are strengthening our Exceptional Family Member Program to 
ensure we better meet their unique needs. We are dedicated to 
reducing incidence of sexual assault and suicide among our 
force. One is too many.
    Diversity is an integral part of our mission accomplishment 
and success in today's Air Force, and will remain in the 
forefront of that area, as we continue to exclusively attract, 
develop, and retain highly qualified professionals for the 
betterment of the total force.
    Across all of our programs, we continually strive to 
improve as we accomplish the Air Force's and the Nation's 
priorities. I am committed to ensuring we provide the best 
possible programs that increase our combat capability and take 
care of our most important asset: our airmen.
    I look forward to working with this committee, which has 
helped shape DOD into the world's premier defense organization. 
I thank you for the opportunity to appear before you today.
    [The prepared statement of Mr. Ginsberg follows:]
             Prepared Statement by Hon, Daniel B. Ginsberg
                              introduction
    Mr. Chairman, members of the subcommittee, thank you for this 
opportunity to discuss the Air Force's most important resource--our 
airmen. This diverse group of highly-skilled and dedicated men and 
women ensure our Air Force remains the most powerful in the world. Our 
airmen have been continuously deployed and globally engaged in combat 
missions for over 19 straight years. Approximately 38,800 airmen are 
currently deployed in support of joint operations across the globe. Of 
these, over 4,000 airmen are filling Joint Expeditionary Taskings in 
non-traditional roles in Iraq, Afghanistan and elsewhere. Thousands 
more are providing critical direct support to our combatant commanders 
from their home station. These critical capabilities include space 
systems such as GPS, rapid global mobility of people and supplies, as 
well as intelligence, surveillance, and reconnaissance from space and 
remotely piloted aircraft. Our airmen are committed to winning today's 
fight and prepared for tomorrow's challenges.
    As the Air Force's assistant Secretary for Manpower and Reserve 
Affairs, I am focused on accomplishing the Air Force's priorities by 
developing and implementing programs and policies to best leverage our 
total force--Active, Guard, Reserve, and civilians--to maximize our 
combat capability for the joint commanders. To that end, I have made 
Continuum of Service (CoS), which will allow for smooth transfer of 
skilled airmen between components, and increasing the diversity of our 
force high priorities. I am also attuned to the overall health of our 
force. We are working essential programs that support our wounded 
warriors, help airmen reintegrate after deployments, provide families 
with the support they need and minimize the incidents of sexual assault 
and suicide to name just a few.
                   end strength and force management
    With the National Defense Authorization Act for Fiscal Year 2010, 
our current approved total force end strength is 686,944. This includes 
331,700 Active component; 179,044 civilians; 69,500 Reserve; and 
106,700 Air National Guard. In the fiscal year 2011 budget request, our 
programmed total force end strength is 702,669. This includes 332,200 
Active component, 192,569 civilians, 71,200 Reserve, and Air National 
Guard end strength remaining at 106,700.
    The Air Force's fiscal year 2011 budget request preserved end 
strength in the face of fiscal constraints, realigned Active component 
and Reserve manpower within existing resources, and grew civilian end 
strength to meet Air Force priorities. Major manpower drivers include 
initial investment toward remotely piloted aircraft fleet operational 
capability to 65 combat air patrols; enhancing cyberspace/irregular 
warfare/command and control capabilities; and resourcing required Air 
Force priorities to include Acquisition Excellence, further 
enhancements to Nuclear Enterprise, and developing and caring for our 
airmen and their families while rebalancing our total force mix for 
agile combat support.
    Maintaining the optimum overall force size as well as balancing 
critical skill-sets is a routine part of the Air Force's force 
management efforts. The current downturn in the economy has had a 
direct impact on the Air Force's lower attrition rates projected in 
fiscal year 2010. As a result, the Air Force is expected to exceed end 
strength by about 3,700 airmen (2,100 officers and 1,600 enlisted) in 
fiscal year 2010. Although this increase would fall under the Secretary 
of the Air Force's purview of 2 percent over authorized end strength, 
the Air Force implemented a force management plan to bring this back in 
alignment. In fiscal year 2010, we made small adjustments in several 
areas including limited reductions of officer and enlisted accessions, 
increased service commitment waivers, waived enlisted time-in-grade 
requirements for retirement, and we are implementing an additional 
enlisted date-of-separation rollback. We are continually monitoring 
results from these actions and to date we have achieved about 50 
percent of our fiscal year 2010 force management goal. Even with these 
efforts, we do not expect these actions to fully achieve the reductions 
targeted for fiscal year 2010. As a result, we will likely continue 
many of these actions and consider other force management options for 
the remainder of fiscal year 2010 and in fiscal year 2011 as needed. 
Utilizing force management tools is a necessary and routine leadership 
obligation to ensure the Air Force remains within authorized strength 
levels and get the right balance of grades and skills to meet our 
evolving mission requirements. However, we strive to use these force 
management tools in a deliberate manner with the least disruption to 
the cohesion of the force.
                               recruiting
    Even in a time of higher retention and a struggling economy, 
recruiting the highest quality airmen is as important as ever. Our 
recruiting force continues to achieve the enlisted accession mission 
with integrity and excellence. In fiscal year 2009, we met mission 
requirements for enlisted recruiting in all components (Active, Guard, 
and Reserve). To date in fiscal year 2010 we have achieved 100 percent 
of our active-duty accession goals and 100 percent and 112 percent of 
our Reserve and Guard accession goals, respectively.
    Although we have achieved mission goals in our line officer 
accession programs, we continue to struggle with health professions 
officer recruitment and retention. In fiscal year 2009, we recruited 
approximately 70 percent of officer health professions requirements 
exceeding the fiscal year 2008 production of 62 percent. The ongoing 
high-demand for medical professionals in the lucrative civilian market 
makes it difficult for the Air Force to attract and retain fully 
qualified individuals. As a result, in 2006 the Air Force implemented a 
long-term ``grow our own'' strategy by offering more medical school 
scholarships in student-based markets. In fiscal year 2008, we filled 
431 of 437 available scholarships (98.6 percent) and for fiscal year 
2009, we accessed 376 of 371 scholarships (101 percent). In fiscal year 
2010, we are on track to achieve a 100 percent scholarship fill rate. 
Our main shortfall in recruiting is attracting fully-qualified medical 
professionals to come straight into the service particularly in the 
Biomedical Science Corps. Psychology, Pharmacy, Optometry and Public 
Health Officers continue to be challenging to recruit. Our continued 
challenges in the health professions are why we have submitted $85.7 
million in this year's budget request for officer bonuses to attract 
and retain more medical professionals on active duty. We are 
appreciative of and ask for your continued support in this area.
    Although recruitment is also strong in the Reserve and Air National 
Guard, they face challenges with fewer prior-servicemembers due to 
lower Active component attrition rates and increased requirements for 
new and emerging mission specialties. As a result, both the Air 
National Guard and the Air Force Reserve have had to increase their 
non-prior service recruitment efforts. In fact, the Reserve non-prior 
service recruiting requirement has nearly doubled since the end of 
fiscal year 2007. Increased recruitment of non-prior servicemembers for 
both Air National Guard and the Air Force Reserve has directly resulted 
in increased recruitment costs as well as increased training costs over 
that of already trained prior-servicemembers. The continued support of 
the Air Force, Department of Defense and Congress will undoubtedly 
shape the foundation of their success.
                               retention
    Although overall officer retention has remained strong, we have had 
challenges with retention of rated officers, some critical skills and 
some health profession specialties. To address our rated officer 
shortages, we implemented a rated recall program to bring back 500 
trained pilots to help fill our rated staff positions allowing more 
current pilots to return to the cockpit. The Air Force prudently 
employs Special and Incentive (S&I) pays to compensate for and 
incentivize the performance of hazardous and arduous duties, the 
acceptance of duty in hostile or remote and isolated locations, and the 
recruiting and retention of personnel with specific skills or in 
specific career fields. Fiscal year 2010 Active component recruiting 
and retention S&I pays total $465.9 million. For fiscal year 2011, we 
have requested this be increased to $480.1 million. This increase is 
due to changing eligible populations, anniversary payments, and the 
addition of retention bonuses for five stressed officer career fields. 
Our S&I pays are critical as we shape the force to meet new and 
emerging missions and support the combatant commanders in today's 
fight.
    The quality of Air National Guard recruits has not declined and 
their retention rate remains strong at 96.9 percent. The Air National 
Guard saves on average $62,000 in training costs for every qualified 
member retained or recruited. Our focus in this area allows us to 
retain critical skills lost from the Active component and save valuable 
training dollars. In 2009, through the use of our 14 In-Service Air 
National Guard recruiters strategically placed at active duty bases, 
the Air National Guard garnered approximately 896 confirmed accessions 
of a total of 5,309 accessions. The bonuses and incentive programs are 
a key component to that success.
    Retention for the Air Force Reserve remains solid with first-term 
airmen retention being the highest in recent history. Likewise, second-
term and career airmen retention has rebounded following a drop in 
recent years due in-part to force structure changes. Although we have 
not formally studied the causes, we attribute this increase in 
retention rates primarily to the recent legislative authorizations 
congress has approved that enhance incentives to remain in the service 
like inactive duty training (IDT) travel pay, streamlining of TRICARE 
Reserve Select premiums, enhanced bonuses and the Post-September 11 GI 
Bill. We anticipate this positive trend in retention will continue for 
the foreseeable future.
                           civilian personnel
    Management of the civilian workforce will continue to be a priority 
for the Air Force. We are working collaboratively with the Deputy Under 
Secretary of Defense for Civilian Personnel Policy on Strategic Human 
Capital Planning efforts, in particular, to address the provisions in 
NDAA for Fiscal Year 2010 which require reporting by the Military 
Departments. We support this effort that will result in the Air Force 
and the Department of Defense (DOD) having the skills and competencies 
necessary to meet our current and future mission requirements.
    In October, 2009, the President signed into law the NDAA 2010 that 
repeals the authority for NSPS and requires DOD to transition civilian 
employees from NSPS to the appropriate statutory non-NSPS personnel and 
pay system not later than January 1, 2012. The Air Force has 
approximately 44,000 employees in NSPS. We are aggressively planning 
and preparing to transition these Air Force employees in an orderly and 
timely manner. We have begun the process of reclassification of 
positions, where necessary. We will soon issue a conversion plan that 
will inform and assist our human resource practitioners, supervisors, 
managers and employees to understand the transition process and to 
facilitate the transition. The NDAA also provided additional personnel 
flexibilities which we will be pursuing in conjunction with DOD and the 
Office of Personnel Management.
                               diversity
    Diversity is an integral part of mission accomplishment and success 
in today's Air Force and will remain in the forefront as we continue to 
inclusively attract, develop, and retain highly qualified professionals 
for the betterment of the Total Force. The capacity to educate, manage, 
lead, and train a diverse force is a core competency of Air Force 
leadership. Currently, we are pursuing collaborative diversity outreach 
initiatives with Air University, Civil Air Patrol, Junior and Senior 
Reserve Officer Training Corps, Officer Training School and the United 
States Air Force Academy. Additionally, strategic plans are being 
formalized to utilize the Air Force Diversity Champions to promulgate 
the aims of diversity within the Air Force and the community. Areas of 
interests and emphasis to cultivate and develop future leaders of the 
Total Force will include reaching out to students enrolled in science, 
technology, engineering and mathematics programs in high schools, 
colleges and universities across the Nation.
    As the demographics of the Nation continue to change, the Air Force 
must position itself to optimize the true benefits of a diverse force 
and respectfully request appropriate Congressional funding for the 
sustainment of the aforementioned outreach initiatives. By 
incorporating diversity management leadership principles and strategies 
to leverage the unique qualities and talents of all citizens, the Air 
Force will achieve mission excellence and sustain dominance in air, 
space, and cyberspace.
                          continuum of service
    An important aspect of retention is our ability as a Service to 
allow skilled airmen to easily transfer from one component to another 
providing the Air Force flexibility while retaining valuable skills. 
CoS transforms the operating culture and paradigms to shape the future 
of personnel and manpower delivery throughout the Air Force to meet 
global mission requirements.
    CoS efforts have already positively impacted our Air Force members 
through a number of initiatives. Through our on-line CoS Tracking Tool 
(CoSTT), any airman can submit a proposal for a CoS initiative. Our 
tool was modified for use by the Army and is now being adapted for use 
throughout the Department of Defense. CoS initiatives have already 
improved our joint-spouse PCS process, interservice transfer of rated 
officers and helped facilitate the establishment of the Religious 
Professional Scholarship Program (RPSP) allowing members to attend 
seminary and later return to active duty. The RPSP is designed to help 
fill manning shortfalls within the chaplaincy for underrepresented 
faiths within the Air Force. This program is now being considered for 
utilization by my Navy and Army counterparts. In addition, CoS helped 
modify the chaplain accession age ceiling from 42 to 47.
    Some current Air Force CoS initiatives include: (1) aligning the 
Air Reserve Component pregnancy policy with that of the Army and Marine 
Corps to allow pregnant women to work until her orders expire; (2) 
changing Air Force policy on ``Lawful Permanent Resident'' accessions 
for critical specialties by utilizing current laws permitting the 
appointment of a Reserve Component officer who has been lawfully 
admitted to the United States; (3) evaluating the authority provided in 
the NDAA for Fiscal Year 2009 by considering a ``Career Intermission 
Pilot Program'' to determine whether a more flexible career path will 
prove to be an effective retention tool; and (4) examining the effects 
of changes to Air Force policy that would bring fully qualified 
personnel into stressed career fields faster than traditional methods 
by recognizing the value of nongovernmental experience.
    The Air Force CoS program is an important force multiplier as it 
not only helps our airmen transition between components, but also 
balances people and mission to ensure the right airman is in the fight. 
We greatly appreciate the outstanding support of the Senate Armed 
Services Committee Personnel Subcommittee on many of our CoS 
initiatives.
                           suicide prevention
    Preventing suicide among our airmen is extremely important to the 
well-being of our force. The Air Force developed the basis for its 
suicide prevention program in 1993 and it is one of ten suicide 
prevention programs listed on the Substance Abuse and Mental Health 
Services Administration's National Registry of Evidence-Based Programs 
and Practices. Although this program resulted in a reduction in the 
number of suicides among airmen, within the Air Force we have 
recognized the importance of a multi-faceted approach to meet the 
varied needs of our people. Since the initial program began, we have 
placed a strong emphasis on leadership involvement in preventing 
suicides. Training has been implemented in various professional 
military education curricula to create awareness among Air Force 
leaders and frontline supervisors of behaviors that may lead to suicide 
and to inform leadership of actions they can take to prevent suicide. 
We have identified specific career fields in which the requirements of 
the job place enormous stress on airmen and we are developing targeted 
programs to improve resiliency and encourage airmen to seek help early. 
To facilitate the seeking of mental health services, we have placed 
behavioral health specialists in our primary care clinics.
    Additionally, we emphasize community involvement in suicide 
prevention, combining the efforts of chaplains, family counselors, and 
other non-medical counselors to meet the psychological health needs of 
airmen. Finally, we collaborate with our sister Services, with the 
Defense Center of Excellence for Traumatic Brain Injury and 
Psychological Health, and with the Department of Veterans Affairs to 
identify best practices and continuously improve our existing suicide 
prevention program. Recently, the Air Force Surgeon General took the 
lead in implementing a two-tiered program to create and enhance 
psychological resiliency in deploying and returning airmen. This 
program includes a 2-day decompression program when the airmen return 
from theater. We believe one suicide is one too many and are strongly 
committed to preventing suicides and caring for our airmen.
                 sexual assault prevention and response
    Preventing sexual assault is also a top Air Force priority. Since 
program implementation in 2005, the Air Force has maintained a multi-
disciplinary approach to addressing sexual assault that supports home-
stationed and deployed airmen. A robust Air Force response to victims 
includes dedicated full-time civilian and military Sexual Assault 
Response Coordinators (SARCs) and more than 2,600 volunteer victim 
advocates who provide 24/7/365 support. Our robust Air Force Sexual 
Assault Prevention and Response program budget funds 80 civilian and 29 
military officer SARCs at the installation level, who work directly for 
the Vice Wing Commander. Our military SARCs provide a full-time 
deployed capability at seven primary deployment locations. The 
Secretary of the Air Force recently approved the addition of 24 Air 
Force Office of Special Investigations agents trained and dedicated to 
investigate sexual assault. Caring and professional response to victims 
has been a focus of the Air Force program but equally important is our 
focus to prevent the crime before it occurs.
    The primary challenge of addressing sexual assault in the military 
and society at large is to confront a culture where sexual assault is 
allowed to exist. It requires a positive, ongoing effort to educate our 
airmen and others, about the realities of sexual assault, debunking 
myths that continue to be propagated by media and entertainment, and 
maintained by peer pressure or other societal convention. The Air Force 
has developed a prevention-based approach that directly focuses on 
fostering positive behavior that is in concert with our core values. 
The approach includes leadership focus from the top down, risk 
reduction, and bystander intervention training. The later is a strategy 
that motivates and mobilizes people who may see, hear, or recognize 
signs of an inappropriate or unsafe situation, to act.
    We will be working with Dr. Stanley, OSD (P&R), and our sister 
Services, to address the recommendations in the report of the Defense 
Task Force on Sexual Assault in the Military Services. Sexual assault 
is a crime. The Air Force is dedicated to the elimination of this crime 
and we recognize the challenges dealing with this very complex issue.
                      year of the air force family
    In the spring of 2009, the Air Force renewed its longstanding 
commitment to taking care of our airmen and families by designating 
July 2009 through July 2010 as ``Year of the Air Force Family.'' The 
observance serves two primary purposes. Across the Air Force, we 
examined our support services and policies in order to expand or refine 
them as required to meet the emerging needs and expectations of our 
airmen, their families, and the larger Air Force Family. Second, we set 
aside specific time to recognize the sacrifices and contributions of 
all of the members of our Air Force family--our Active, Reserve, and 
Guard--civilians, spouses, and family members.
    We have focused our efforts to ensure we provide robust programs to 
meet the unique needs of our Guard and Reserve members and their 
families. The Yellow Ribbon Reintegration Program is one important way 
we are accomplishing this. The Air Force is working alongside other 
services in this DOD-wide effort to ensure the Air National Guard and 
Air Force Reserve airmen and their families are connected with all of 
the appropriate resources before, during and after deployments. We 
continue to focus on the reintegration phase after returning home and 
ensure that commanders are involved and aware throughout. We continue 
to improve our effectiveness and relationships with other associations 
such as the Department of Veterans Affairs and the Department of Labor 
in providing current and relevant information to members. The Air Force 
remains focused on airmen and their families and will ensure the 
oversight and success of the Yellow Ribbon Reintegration Program.
    Additionally, we are ensuring the Year of the Air Force Family does 
not overlook our ``extended Family'' our retirees, parents and the 
nongovernmental and community partners that support Air Force people 
every day across the Nation. We are using this year long period to 
launch our sharper focus on improving support to airmen and families. 
Under Secretary Donley's leadership, our concerted attention on 
providing the support that results in stronger, more resilient airmen 
and families will remain a priority in the years to come.
    In April 2010, we will hold a Caring for People Forum that will 
bring together helping professionals, airmen, and family members to 
develop an action plan to address the pressing and longer term concerns 
of airmen and families which will be briefed to senior leadership at 
the end of the forum.
    We are working to strengthen all of the partnerships that 
contribute to the quality of life for our members. These will include 
close rapport with local school districts (to enhance quality education 
and garner on-site support for children impacted by repeated 
deployments), housing privatization projects and agreements between our 
bases and city or county services.
                   wounded warrior and survivor care
    The Air Force Wounded Warrior program focuses on the needs of 
recovering airmen and their families, as well as families of the 
fallen. We now have 17 Recovery Care Coordinators (RCC) in 15 
locations, with an additional 10 RCCs being hired this year. Our RCCs 
are the primary point of contact for our wounded, ill, and injured 
airmen and ensure the health care, financial, informational, and 
personal needs of airmen and their families are available in a timely 
manner. Because of the range of questions airmen and families have 
after an injury or illness has incurred, it is critical to the healing 
process to have relevant and accurate information available to our 
airmen. Recovery Care Coordinators are in place to ensure those 
knowledgeable in medical and other areas of expertise are available to 
provide the requested information. This assistance is provided for as 
long as the airmen and families want assistance during recovery, 
rehabilitation, and reintegration. The Air Force also continues to work 
closely with the Office of Wounded Warrior Care and Transition Policy 
in the Office of the Secretary of Defense to ensure our programs 
continue to support all wounded, ill, and injured servicemembers. It is 
our solemn duty that these airmen receive the utmost support and care.
                               conclusion
    I am continually impressed, but not surprised, by the tremendous 
hard work and focus our airmen display daily as they accomplish their 
missions. I am dedicated to providing them the best programs and 
support, removing any policy barriers and pursuing innovative ways to 
streamline our processes to allow them to be even more effective. Our 
Air Force is a critical component to our Nation's defense as we are 
faced with uncertain and ever changing threats.
    We appreciate your unfailing support to the men and women of our 
Air Force, and I look forward to your questions.

    Senator Webb. Thank you very much.
    I thank all of you for your testimony.
    I think what I would like to do is--since I took a good bit 
of time in my opening statement, I think I would like to just 
start with an 8-minute round, and Senator Graham could begin, 
and then we could go to Senator Hagan and Senator Begich, and 
then I'll follow on after you.
    Senator Graham. Well, thank you, Mr. Chairman.
    Secretary Stanley, when it comes to the personnel part of 
the budget, we're going to grow the Army and Marine Corps. I 
think we need to. The healthcare component--how do we get a 
grip on this? What are some ideas that you all are talking 
about there?
    Dr. Stanley. Well, Senator, in my 3 weeks, we haven't 
really talked a lot about details on----
    Senator Graham. You mean, you haven't fixed this in 3 
weeks? [Laughter.]
    Dr. Stanley. What we have done--in fact, the very first 
thing I did--and I think we would--working with Congress even 
then--was to bring someone over with the skills and qualities 
to at least fill the position temporarily while we wait on the 
person, who is to be confirmed at some point in the future, to 
work with. And so, this has been an actual priority from day 
one, actually, because we recognize the healthcare costs.
    Senator Graham. Okay, well, that's fair--and 
congratulations, to all of you, by the way, for having your 
job. This time last year we were looking for people like you, 
and now we have them.
    The idea of the Guard and Reserve recruitment and 
retention--with the economy like it is, it's a good time for 
the military, but I think the economy's going to get better--I 
hope it will, and I'm sure it will eventually--TRICARE benefits 
for the Guard and Reserve--I'd just like to get your impression 
about how that program has worked, from each of the Services. 
Secretary Stanley, how is it being received by our Guard and 
Reserve Force, that they are now eligible for TRICARE? They 
have to pay a premium.
    The second issue, what effect do you believe it would have 
if we allowed people to retire at 55 if they would do more 
Active Duty service--earn their way from 60 to 55?
    Starting with Secretary Stanley.
    Dr. Stanley. Well, Senator, I know that, the TRICARE 
programs, all of those programs are under review right now 
because it's all a part of the gestalt of looking at all of 
healthcare. I don't have answers for you today.
    Senator Graham. Okay.
    Dr. Stanley. But, we look forward to working with Congress 
on that.
    Senator Graham. From the Services' point of view, what are 
you hearing from the Army, the Marines, and the Air Force?
    Mr. Lamont. From the Army's perspective, TRICARE Reserve 
has gone over very well. But, we're finding, among particularly 
our Reserve component, they don't fully appreciate or are 
educated enough to understand its availability to them. We 
think it's incumbent upon this to broaden that perspective so 
they avail themselves of what's out there.
    It's an excellent program, and it's a wonderful incentive. 
On the Reserve side, we may also, at some point in time, need 
to look at some potential other incentives, from the healthcare 
side, as we continue operationalizing the Reserve. But, it's a 
resource issue, of course, as well, for all of us.
    Senator Graham. Okay.
    Secretary Garcia?
    Mr. Garcia. Senator, I have the opportunity and the honor 
to continue to serve in the Reserves, and had a Reserve 
squadron, until coming to take this appointment. I will tell 
you the--among those circles, the program is--there's a lot of 
awareness of it, and it's very popular.
    The piece that many members have read about, and are very 
interested in, is what's been called the ``gray area'' piece; 
that is, for retired reservists, not yet 60, being able to 
access TRICARE Select and some of those programs before their 
retirement.
    As Secretary Lamont said, there's a price tag that comes 
with that. I look forward to wrestling with that, with you. 
But, I can tell you that, among my circles, on the Navy and 
Marine side, it's very popular and well thought of.
    Mr. Ginsberg. Senator, TRICARE Reserve Select is a very 
well-liked program. We have good participation rates, as I 
understand it, within the Air Guard and Air Reserve. It's not 
just a benefit, it provides a tool to our airmen to make sure 
that they're medically ready for deployment.
    One of the challenges we need to look at this 
systematically--is whether--the health of the provider network, 
and whether maybe a stand-alone Air Guard base, whether we have 
a sufficient network in place, or we're taking imbursements. 
It's something we want to look at to ensure that this program 
is moving along helpfully.
    Senator Graham. Well, one last question. The sexual 
harassment, sexual assault problem is being better identified, 
and the number of reported cases is growing, which I think is 
probably an indication, not that there are more activity, it's 
just getting easier to report it, and people feel more 
confident about reporting it. But, we're not nearly where we 
need to be.
    Just very quickly, from each Service's perspective, what 
are you doing in that regard to enhance the ability of a 
servicemember to report sexual harassment or assaults in a way 
they feel will not be detrimental to their career?
    Mr. Lamont. From the Army perspective, we're looking at it 
from a couple of different directions. First, we want to make 
it easier for them to report. We have initiated programs that 
allow for the confidentiality of the report. Plus, we're also, 
as I think we----
    Senator Graham. In that regard, do we need to look at 
changing our laws? Because there's a lot of privileges 
available maybe in the civilian side, not available to military 
members. I know you have a priest-penitent privilege and 
limited medical privilege, but just look at that and see if 
there are some changes we need to make on the Personnel 
Subcommittee to expand privileges to healthcare providers. I'd 
just----
    Mr. Lamont. All right.
    Senator Graham. Okay.
    Mr. Lamont. Otherwise, as we try to build resilience within 
the force, particularly on our Sexual Harassment/Assault 
Response Prevention situation, we have initiated a program 
called ``I. A.M. Strong''--``I'' being ``Intervene,'' ``A'' 
being ``Act,'' ``M'' being ``Motivate.'' Though it's a command-
oriented climate that we're trying to address, that would 
respect the dignity of all of our soldiers, we've looked for 
this ``I. A.M. Strong'' program to educate and train our 
soldiers, on a peer-to-peer basis, to remove any stigma of 
going forward to make those reports.
    We believe it's working, at least as we've seen the number 
of reports increase. We still believe, unfortunately, that only 
roughly a third of sexual assaults are being reported.
    Senator Graham. Thank you.
    Mr. Garcia. Senator, Secretary Mabus has stood up the 
Sexual Assault Prevention Response Office. The dedicated 
officer--civilian SES--reports directly to him for the first 
time and a network of Sexual Assault Response Coordinators 
(SARCs) implemented in each unit across the fleet. As you 
indicated, we are seeing a rise in reported incidents. The 
challenge is to discern whether that's availability to 
reporting or whether it's a true spike in incidents. It's 
something we wrestle with every day.
    Mr. Ginsberg. Senator, I think from the Air Force 
perspective, this is an issue of leadership, it's an issue of 
investment, and it's just a leader--an issue of communication. 
Leadershipwise, it's about showing from the highest levels on 
down, that sexual assault absolutely won't be tolerated and 
that from our perspective, goes against everything--all of 
those core values that we hold dear.
    It's about putting in money for a strong, baseline program, 
a good, strong, healthy organization, along with funding for 
investigations, and very active and aggressive investigations. 
It's also a matter of just making sure that those who are 
victims know that their resources and reporting channels are 
available to them. We have an ability for somebody who is a 
victim to come forward and provide limited information about 
what happened so they'll come forward. It's called restricted 
reporting, and that's provided a useful channel for victims.
    Senator Graham. Thank you, all, for your service. I'm going 
to have to run to another hearing, but I shall return.
    Senator Webb. Thank you very much, Senator Graham.
    Senator Hagan.
    Senator Hagan. Thank you very much, Mr. Chairman.
    I do, too, want to thank all of you for your service to our 
country. I really do appreciate it.
    Secretary Stanley, you mentioned, in your opening remarks, 
about the Military Spouse Career Advancement Account--as it's 
being referred to MyCAA--and about the stop in the 
implementation of it. I have a serious concern with that, 
because, one, neither Congress nor the people who were 
beneficiaries of this program were given any sort of upfront 
notification about any of the problems that were being seen in 
the program. This pause has certainly caused a lot of concern 
to many people in my State, in North Carolina, because it's an 
excellent program and a lot of people are taking advantage of 
it. I think the uncertainty that's been put forth right now has 
resulted in the Department's decision--has certainly negatively 
impacted and affected the morale of our servicemembers and 
their families. It certainly has had, I think, an adverse 
impact on family readiness.
    But, one of the questions I have in the President's fiscal 
year 2011 budget, which reflects increased funding for this 
enhanced career and educational opportunities, does it address 
the longer-term needs of the program?
    Dr. Stanley. First of all, we are addressing the concerns, 
short-term and long-term. The Secretary is now, at this time, 
making a decision, looking at options that have been presented 
to him. But I will say that there are still some unanswered 
questions on long-term, but I feel confident that they're going 
to be addressed. I certainly share your concern about what's 
happened, in terms of the program being stopped. I understand 
that.
    Senator Hagan. Well, the lack of notification was certainly 
alarming too, I think, Members of Congress and the people who 
were the beneficiaries.
    As far as improving the implementation of the program, do 
you need more specialists on staff to help with that? Or is 
that some of the things you're looking into?
    Dr. Stanley. Actually, in my arrival--just to be very 
blunt.
    Senator Hagan. Okay.
    Dr. Stanley. I was sworn in on the 16th, and I learned 
about it on the 16th.
    Senator Hagan. Wow.
    Dr. Stanley. So----
    Voice. Welcome aboard. [Laughter.]
    Dr. Stanley.--I'm going to----
    Senator Hagan. Wow.
    Dr. Stanley. So, we're addressing the issues dealing with 
MyCAA----
    Senator Hagan. Okay.
    Dr. Stanley.--as we move forward. I'm very optimistic about 
it working out okay.
    Senator Hagan. Okay.
    Another question, concerning the Census. I'm concerned that 
servicemembers that are deployed during the conduct of the 2010 
Census will be counted in a negative way that impacts the 
communities that host military installations. For the 1990 and 
2000 Census, the decision was made to count deployed 
servicemembers as overseas.
    North Carolina currently has approximately 41,200 
servicemembers deployed as a part of the overseas 
contingencies, and in the event that they are counted as 
prescribed by the Census Bureau, areas with large 
concentrations of military personnel, I believe, will be 
significantly undercounted and underfunded for the next 10 
years.
    What's preventing the Defense Manpower Data Center from 
providing the Census Bureau with information regarding the base 
of last assignment or permanent U.S. duty station as the 
primary response for our deployed servicemembers that are 
currently engaged in overseas contingencies?
    Dr. Stanley. Senator, I'm going to ask to take that 
question for the record.
    Senator Hagan. Okay. That's fair.
    Dr. Stanley. Because I'd like to get back to you with a 
very specific----
    Senator Hagan. Okay.
    Dr. Stanley.--and correct answer.
    [The information referred to follows:]

    This issue falls under the purview of the Census Bureau, and we 
must follow its guidance on how to count our personnel. The Census 
Bureau, in turn, is following what it perceives to be existing 
Congressional guidance.
    We are aware of no law specifying how to count military members 
deployed overseas. The Census Bureau is using a bill passed in the 
House in 1990, H.R. 4903, as the methodology for counting overseas 
servicemembers and their accompanying dependents. This current 
methodology, used in 1990 and 2000, counts overseas military personnel 
in this order (where the data is available): State home of record, 
State of legal residence, and State of last duty station (i.e., base of 
last assignment).
    The Department recognizes the decision to use the current 
methodology will result in overseas military personnel being assigned 
to a home State without counting them toward the populations of towns 
or counties. We also understand counting ``last duty station'' first 
would have a beneficial effect on States with a large military 
population. We have discussed with the Census Bureau methodologies 
other than using ``home of record'' first, and these methodologies 
might provide a more accurate snapshot of the current residence of the 
military personnel and also the desired town and county specificity. 
However, the current methodology does have the benefit of consistency 
over time.
    The Department stands ready to discuss all possible methodologies 
with the Census Bureau. We also look forward to continuing to work with 
Congress on this important matter.

    Senator Hagan. Well, let me go to one other one. We were 
talking about suicide. One of you referred to that. So, 
Secretaries Lamont, Garcia, and Ginsberg, I think we have 
witnessed an unacceptable number of suicides within our 
military population, and some of these losses, hopefully, could 
have been prevented if servicemembers had the ability to access 
professional care during the early stages of emotional 
distress. I'm sure we all agree that we have to reduce those 
numbers. What measures are being taken within the Services to 
ensure that our military men and women receive and gain easier 
access to mental healthcare without being stigmatized--that's, 
obviously, sometimes associated with that--and with going 
through the chain of command?
    Secretary Lamont?
    Mr. Lamont. First, you're absolutely right, we take the 
loss of any soldier, through any means, very, very seriously. 
It truly is one of the very highest priorities that we have. We 
look at it from early identification of risk factors, as well 
as early intervention when we recognize those risk factors, to 
move in and encourage, as best we can, to have those 
individuals who may exhibit those risk factors to seek out 
help.
    We have instituted a program designed to reduce the stigma 
of reaching out for mental health care. Actually, what we're 
finding out with some of our younger soldiers, who, for 
whatever reasons, do not wish to meet personally with a 
healthcare provider, for instance--we have a software program, 
that they go online and they self-address----
    Senator Hagan. Right.
    Mr. Lamont.--their issues. It's become a very valuable tool 
for us. But, it's going to take a lot of effort.
    Also, we clearly have to address the resiliency side, and 
we're making our effort to do that through a program called 
Comprehensive Soldier Fitness, where we explore, not only just 
the physical health, but the mental, the emotional and the 
spiritual well-being of the soldier, as well, to build that 
mental health resiliency as best we can to address the issues 
going on in his or her life.
    Senator Hagan. Thank you.
    Mr. Garcia. Senator, I appreciate your question. For the 
first time, last year, our Marine rate approached that of the 
national rate; we normed for age and gender. It's an issue we 
brief daily and constantly look for a correlation that we can 
zero in on.
    We focused much of our training at the NCO level. We feel 
that they have the most insight and perspective to what our 
young sailors and marines are wrestling with, those issues. But 
every marine, every sailor receives training and is made aware 
that they have access to master's-level counseling. It is 
confidential unless, in the aftermath of that training, the 
counselor feels that the individual is suicidal, homicidal, or 
is unfit for duty. But, everyone is aware of it from boot-camp 
level on.
    Senator Hagan. Do you think these things are making a 
difference in the attitude and the health of our men and women?
    Mr. Garcia. I think there is a----
    Senator Hagan. Great.
    Mr. Garcia.--undeniably, a new level of awareness from E-1 
to O-10. I've seen the training that takes place at Marine Boot 
Camp, at Marine Corps Recruit Depot. It's the first time where 
a Marine drill instructor to--a new boot camp marine sees that 
drill instructor take his cover off and address him personally, 
in a way that he has not, yet. It speaks to the importance and 
the significance, I think, that the Corps and the Department 
are placing on this.
    Senator Hagan. Okay.
    Mr. Ginsberg. Well, Senator, obviously it's a tremendous 
tragedy even when one servicemember takes their life. We pride 
ourselves, in the Air Force, being a family, and when one feels 
so alienated that it becomes a major problem at the highest 
reaches.
    This is a matter--this goes to our staffing--our capacity 
levels, in terms of having enough psychiatrists and trained 
psychologists. We, in the Air Force, are doing well, but 
obviously there's tremendous competition with the private 
sector for trained psychiatrists and trained psychologists. The 
bonuses that you provide us are absolutely essential for us to 
grow our force and to bring in psychiatrists and trained 
psychologists.
    I'd also say that this is--and to address the stigma, one 
of the things that we're doing in the Air Force is to locate 
our mental health clinics within military treatment facilities, 
within regular divisions within the hospital, basically, where 
somebody who's going in to get treatment is not seen as going 
to some special clinic, but is just part of--accessing regular 
care. We want to normalize care.
    Senator Hagan. That's good.
    All right, thank you, Mr. Chairman.
    Senator Webb. Thank you, Senator Hagan.
    Just to follow on for a moment on that line of questioning, 
I believe you could show--and, in fact, the Chief of Staff of 
the Army recently brought me a chart to this effect--that there 
is a direct correlation between dwell time--the amount of time 
that people have between deployments--and the percentage of 
emotional difficulties that are in these units. That's why I 
introduced this dwell-time amendment in 2007. When the Chief of 
Staff of the Army called me and said they were going to 15-
month deployments, with only 12 months dwell time back in the 
United States before they redeployed--having spent 4 years as a 
committee counsel over in the House Veterans' Affairs 
Committee, when we first started examining the difficulties of 
people who had served in Vietnam, first of all, I said, ``I 
can't believe you're going to do that. I don't think there's 
any operational requirement that should cause you, at this 
point in our history, to put that kind of pressure on our 
people. You're going to have challenges on the other end of 
doing this.'' Quite frankly, we're seeing that.
    All of your responses basically go to the means--and I 
salute these means--of addressing the situation once it occurs, 
but I don't think there's anything more valuable than putting 
the right kind of dwell time on our units. Particularly, when 
you look at the young age of the people who are doing these 
multiple deployments, and where they are in terms of addressing 
issues of adulthood.
    Mr. Lamont. If I may----
    Senator Webb. Mr. Lamont, do you want to----
    Mr. Lamont.--just add a comment to that. We have any number 
of programs that are well intentioned, well resourced, it 
doesn't matter. There is nothing more important than exactly 
what you say--is the dwell time of our soldiers, with their 
families and others, that will help them decompress and serve 
them so much better in this kind of situation. It is dwell 
time.
    Senator Webb. I totally agree. Thank you for saying that.
    Senator Begich.
    Senator Begich. Thank you very much, Mr. Chairman.
    I want to talk about TRICARE for a second, but then I 
actually want to get back to the SARC. In Anchorage, in 
municipal government, we call it SART, a very similar program, 
I think, but I want--that's what I want to ask you.
    But, Secretary Stanley, let me--I represent Alaska. It's 
very unique when it comes to TRICARE. It's the one that is not 
managed by a contractor, out of the whole system. We have some 
very unique situations. Alaska's population, in total, is--
about two-thirds has Federal healthcare in some form or 
another: Medicaid, Medicare, Indian Health Services, VA, 
Federal employed. So, it's probably the highest percentage, I 
would bet, or per capita, in the country. So, it has some 
unique challenges. Then, geographically, the geography of 
Alaska is very vast, and so we have some great challenges.
    I have introduced a piece of legislation to set up a task 
force for Alaska to bring all the different agencies that deal 
with healthcare and TRICARE as part of that--and DOD would be 
at that table--to try to figure out what's the best way to 
deliver services. I don't know if you've had any chance to see 
that legislation, have any comment on it. If you haven't seen 
it yet, I'd be anxious to get your comment for the record, at 
some point, if you think the task force will be of help for 
something very unique, I think, in Alaska. I don't know if you 
have any comment on that.
    Dr. Stanley. Yes, Senator. I haven't seen the legislation, 
but I've seen what I can best describe now are anecdotal pieces 
of information that tell me, in Alaska, we have some unique 
issues that deal with healthcare, as you've already described. 
So, I look forward to not only looking at the legislation, but 
working very closely with you to address some very significant 
issues.
    Senator Begich. Great, I would love to get your response 
for the record, I appreciate that.
    [The information referred to follows:]

    Since two-thirds of Alaskans use a Federal health care program, 
creating an interagency task force \1\ would be helpful in working 
together to assess and plan improvements to health care access for our 
Alaskan beneficiaries in a coordinated manner. TRICARE has tested 
alternate means of reimbursement and other Alaska-unique initiatives to 
improve access to care, and we are happy to discuss our findings with 
the task force and learn the successes other Federal agencies have 
experienced as they face the unique challenges Alaska presents.
---------------------------------------------------------------------------
    \1\ Note: The creation of the Interagency Access to Health Care in 
Alaska Task Force was mandated by section 5104 of H.R. 3590, the 
Patient Protection and Affordable Care Act (P.L. 111-148 (124 Stat. 
119)).
---------------------------------------------------------------------------
    Our TRICARE Regional Office-West team has already begun engaging 
other Federal partners in Alaska in anticipation of establishment of 
the interagency task force. We look forward to discussing a potential 
rate schedule that recognizes the uniqueness of the health care system 
in Alaska.

    Senator Begich. The other thing I want to say--and the 
folks from the Federal Government that have been working on the 
TRICARE, that have been managing it for us, have done a great 
job. But, I'm also very pleased to see that there is kind of a 
reexamination. How would a contractor work? Would there be a 
benefit? Is there some advantage, or maybe not advantage, 
depending on how it's all looked at? So, I am pleased with 
that, and that perspective, and I want you to know that. But, 
do you have, from your view, working with TRICARE contractors, 
what would you consider some of the advantages that you have 
seen in the value of delivering that healthcare? From a 
contractor delivering it, versus the way it's done in Alaska?
    Dr. Stanley. I'm afraid my answer would probably be 
personal, only because----
    Senator Begich. Personal is sometimes better.
    Dr. Stanley.--I'm a recipient----
    Senator Begich. Very good.
    Dr. Stanley.--of TRICARE benefits and the contractor, and 
from what I've benefited from. It's been pretty transparent to 
me, in being able to use a system that works very well. But, I 
don't think that's going to address some of the macro issues 
we're talking about. I'm also aware of the fact that there are 
some, already, challenges that exist with the TRICARE system as 
it's presently presented, with our contractors as we address 
contracting issues. So, I'm looking into those issues now, but 
I will tell you that there are some pluses--some significant 
pluses--but, there are also some--probably some negatives 
that--as we look at that. But, I don't know what all of those 
are right now.
    Senator Begich. As you develop that, will you share it with 
the committee?
    Dr. Stanley. Absolutely.
    [The information referred to follows:]

    TRICARE-eligible beneficiaries make up almost 14 percent of the 
overall population in Alaska. In recognition of the challenges placed 
on military treatment facilities, we are working with TriWest, the 
TRICARE West Regional Contractor, to develop a preferred provider 
listing which would aid in providing more access to civilian providers. 
Our regional contractors are experienced in the identification and 
credentialing of qualified providers who are willing to provide care to 
our beneficiaries. In the future, we plan to identify primary care 
managers in the civilian community in the Fairbanks area to support 
beneficiaries assigned to Fort Wainwright and Eielson Air Force Base.

    Senator Begich. At least my side would be very interested 
in that.
    Dr. Stanley. I'll look forward to it.
    Senator Begich. Then, again, as we examine the role of 
TRICARE, the contractor who delivers TRICARE, as a potential 
option or augmentation to what we do in Alaska, I'm going to be 
very interested as we move through this over the next several 
months.
    Two other things. One more on TRICARE, and that is, one of 
the situations--and I use Alaska, obviously, because I 
represent Alaska--one of the things we do, if you take 
Medicare, Medicaid, TRICARE, Indian Health Services, VA, we're 
always chasing the highest rate, the reimbursement rate. Now, 
the problem we have in Alaska is, we have very high rates, no 
matter what. I mean, it's just delivery of care, that cost of 
care. We don't have a teaching hospital, for example. We lack a 
lot of things that other communities can tap into and, 
therefore, keep their costs more competitive. Ours, we've been 
very high-cost in. But, we've also been very fortunate, 
because, under the rules, you've been able to--DOD and--or, the 
Federal Government has been able to utilize, under a 
demonstration ability, to have a higher-rate reimbursement in 
Alaska. It's only been in a demonstration capacity they've been 
able to do it. Obviously, we're very interested. I know there's 
a study going on, or at least a potential study, that will talk 
about how those rates are different; and if they are, how do we 
make them more permanent? Because, obviously, doctors--and I 
think some of the comments made here is getting those doctors 
to perform those services under TRICARE. The reimbursement rate 
is critical.
    In Anchorage, for example, which is the largest provider, 
or largest city--about 43 percent of the State's population--I 
think we're down to--on Medicare, for new Medicare patients, I 
think we're down to less than three or four docs that will 
accept them. That's it. So, we are the tip of the iceberg of 
what's going to happen in this country, very rapidly, because 
our cost differential is now getting to a point where primary-
care doctors can't afford to do it; and second, there are less 
and less of them being produced, in the sense of the system.
    So, I would like, if you have any comment on, one, the 
demonstration project. Again, if you're not familiar, I'd be 
very interested. Then, how we go about getting some permanency 
to this, because when docs see a pointer that's not permanent, 
then they just say, ``We're just done waiting, we have to move 
on to others,'' honestly, business has to continue for what 
they do. So, do you have any comment on that? The demonstration 
project, how do we move it to permanency, and is that a 
realistic viewpoint?
    Dr. Stanley. Well, thank you, Senator.
    Let me just say that I've been briefed on the project, in 
general.
    Senator Begich. Good.
    Dr. Stanley. My commitment is to work closely with you, not 
to study the problem to death----
    Senator Begich. Now you're talking. [Laughter.]
    Dr. Stanley.--but to move forward with a solution.
    Senator Begich. Good.
    Dr. Stanley. So, I'm aware of it. Now the issue is, okay, 
addressing this on the degree of permanency, which is why I put 
in place someone to help--with expertise, immediately--that's a 
physician--until we get somebody confirmed. I can't wait that 
long.
    Senator Begich. Right.
    Dr. Stanley. Which is the reason we're moving, kind of, 
like at flank speed, for lack of a better word----
    Senator Begich. Good.
    Dr. Stanley.--to put things in place and address these 
issues. There are other issues, too.
    Senator Begich. Absolutely. We would love to see 
confirmations happen very rapidly, but don't wait for that. 
Move forward on progress, and I appreciate your comments.
    I will end, Mr. Chairman, just on one--and this is more of 
a comment to the--as a former mayor, we worked on a project 
called SART, which is Sexual Assault Response Team, which is a 
combination public service, police--and they all are 
centralized into one location. They work with the community 
hospitals. It's good for investigation purposes. It has a kids' 
unit. It has a variety of things that--one of the pieces to 
this equation--and I haven't asked the--and I'm not asking for 
a response, at this point. I just want you to become aware, if 
you can, with what we're doing in Anchorage, which is the SART 
team.
    Why I say that, there's a very important component of how 
the person who has been the victim works through the process, 
and how that's handled, which is critical to your 
investigations, conviction rates, as well as to the care that's 
necessary. Then, if there are family members engaged in this, 
in the sense of a child who's also been assaulted, there's a 
whole process that is much different than the adult process.
    The SART program has been recognized around the Nation as a 
very cohesive and--like you, we saw rates go up, in the sense 
of reporting, but we also saw conviction rates go up, education 
capacity increasing--and young people, children especially, 
which is probably the hardest to deal with, with sexual assault 
or violence in a household or in a home.
    I'd just ask you--and we'd be happy to supply you some 
information--it's very unique and has been very, very 
successful. In Anchorage, we have two large military bases, 
literally as far as that door is from our facilities and our 
population. We have a great relationship with the military 
that--we know this program has had some impact.
    So, I'd just encourage you, as you work through this very 
troubling issue, to be very frank with you, but one we have to 
deal with, not only from a sexual assault on the officer, but 
also so many families are now part of the military family that, 
30 years ago, was not the case, but today, it's 70 or 75 
percent of the families. So the kids of this population, also, 
we need to make sure they're getting the services they need, 
and education they need. So, I would just encourage you to----
    Dr. Stanley. Will do, sir.
    Senator Begich. Okay, and we'll get you some information 
from staff.
    Dr. Stanley. Great. Thank you.
    Senator Webb. Thank you very much, Senator Begich.
    Senator Chambliss.
    Senator Chambliss. Thank you very much, Mr. Chairman.
    Gentlemen, first of all, let me just say that I want to 
thank all of you for what you do. You're charged with managing 
the most important aspect of our military, and that's the 
people and the programs that support them.
    I know much of what you do deals with numbers, but I also 
know you have an appreciation for what those numbers represent, 
in terms of the individual and his or her family, and what it 
means to our Nation.
    You all, along with our second panel, will help give us a 
sense of how we're doing, and how we can best continue to 
support the men and women of the Armed Forces and their 
families. So, I thank you for being here.
    Secretary Ginsberg, it's always great to see a Georgian on 
a panel like this--
    Mr. Ginsberg. It's my honor to be here. Thank you, Senator.
    Senator Chambliss.--so thanks for your service.
    Secretary Stanley, let me just ask you if you are familiar 
with the situation of the commissary at Dobbins and the one 
that we're transferring from Gillem to Dobbins. Does that ring 
a bell at all with you?
    Dr. Stanley. Vaguely. If you keep talking, Senator, I think 
I might pull something up, here. [Laughter.]
    Senator Chambliss. I'm not surprised that you don't, but--
    Dr. Stanley. Okay.
    Senator Chambliss.--basically, a BRAC decision was made to 
close Fort Gillem, in Atlanta, and that's the commissary that 
has served our retired population for decades. A decision was 
made, by your predecessor, to construct a new commissary at 
Dobbins that obviously will continue to operate, and it's going 
to serve our retired population. And it's in the hands of DeCA 
right now. That's why I'm not surprised you're not familiar 
with it. But, I wish you would familiarize yourself with it. At 
some point, you're going to have some significant input into 
it, and it may just be an issue of DeCA trying to find the 
funding for it. But, in any event, it is obviously a critical 
issue for the retired population, as well as for our active 
duty folks in the area.
    Dr. Stanley. Yes, sir.
    Senator Chambliss. Secretary Lamont, in light of the Fort 
Hood incident last November, can you elaborate on specific 
steps that the Army is taking to better recognize the presence 
of soldiers who may have become radicalized, as Major Hasan 
was?
    Mr. Lamont. I can tell you this. We are going through a 
very extensive internal review to look at all components of 
extremism that may have crept into society and, of course, may 
touch more and more into our Military Services, and what we can 
do to address those. We're aware of some apparent shortcomings 
in our officer evaluation forms and in our enlisted 
evaluations, and how some of the right questions may just not 
get asked. Some of the identifying risk factors may not just be 
exposed, as well.
    There is a Defense-wide Fort Hood review in progress right 
now. As I understand it--and perhaps Dr. Stanley knows more 
than I--that perhaps sometime this summer there will be a full 
report, as all of the Services, I believe, are involved in that 
report. But, certainly the Army is drilling down very deeply to 
see, what in the world did we miss here?
    Senator Chambliss. Let me just mention to all of you--I 
think Senator Graham may have mentioned this in his opening 
comments--the Guard and Reserve retirement initiative, early 
retirement initiative, that we have been successful at having 
put in place, that we're now looking to extend the retirement 
date back to service beginning on September 11, 2001. If there 
are any stumbling blocks out there, I would appreciate hearing 
from you now, if you're aware of anything. Obviously, funding 
is an issue. We're going to continue to work that until we, 
ultimately, have that retirement date, or that service date to 
qualify for retirement, go back to September 11, 2001, when so 
many of our men and women began being called up. Any comments 
any of you have, relative to any issues that are outstanding, 
that might be in our way on that issue?
    Dr. Stanley. Senator, I hadn't heard anything, I'm not sure 
if my colleagues have.
    Mr. Lamont. I've heard very little.
    Senator Chambliss. Okay.
    Mr. Lamont. But, as you say, the number one thing that we 
always look on something like that, of course, is the resource 
concerns----
    Senator Chambliss. Yes.
    Mr. Lamont.--as you are well aware.
    Senator Chambliss. Yes. Well, we'll continue to work that 
from our end.
    One other question. Secretary Lamont, I understand that the 
Vice Chief of Staff of the Army is currently hosting an online 
virtual conference regarding the future of the U.S. Army 
Officer Corps. The central premise behind this virtual 
conference is the recruitment and employment of talent within 
the Army. This sounds like a great idea, and a great way to 
look at the caliber of the young men and women who are--who 
make up our officer corps, from flag officers on down--could 
you give us any comment on that? Are any of the other Services 
doing something similar to this, or have plans for it?
    Mr. Lamont. Well, I understand the goal of what the Vice 
Chief is after, here. Our officer structure is not where we 
need it to be, given some of the demands that we've had over 
the past 8 or 9 years, and as we've moved to our modular 
rotational model in ARFORGEN, it has caused some fairly serious 
changes in how our officer structure is handled.
    I think there is an effort out there, particularly in the 
grades of major, for instance, or that--there are serious 
shortcomings there, in the numbers that we have available. I 
think these--through--what he is trying to do is look for any 
acceptable options and alternatives to how we identify our 
officer corps, and where we can move them within the structure 
that's available now, our other grade challenges, grade-plate 
challenges, that we have.
    Mr. Ginsberg. I'm not familiar with the program, but we 
work very closely with the Army. I'd love to reach out with my 
colleague, here, and learn more about it. Certainly provide 
some formal views to you.
    Senator Chambliss. Okay.
    Secretary Garcia, Secretary Stanley, anything going on in 
your branch, similar to this?
    Dr. Stanley. I'm not familiar with the program. I'm, in 
fact, learning about it as he's talking, Senator.
    Senator Chambliss. Yeah. Well, it does sound like a good 
idea, because everybody has the same issues, relative to the 
makeup of our officer corps. The Army and the Marine Corps, I 
guess, have a little bit different situation, just because 
you've been taxed more than anybody else, but it is an issue 
that sounds to me like it has a lot of merit to it, and I would 
encourage every branch to follow suit, there.
    Thank you, Mr. Chairman.
    Senator Webb. Thank you, Senator Chambliss.
    I'm going to ask a couple of service-specific questions, 
and then, Secretary Stanley, I'd like to ask you a series of 
questions.
    Let me say, I was a boxer for 8 years. You've been bobbing 
and weaving for an hour and 15 minutes, here. [Laughter.]
    So, I'm going to ask you a series of questions to sort of 
get us all looking forward, since you just came to this job and 
I just assumed the chairmanship. But, first, I want to put 
something in front of the Service Assistant Secretaries.
    There was an article in Military Times last week on 
prescription drug use in the military. I don't know if you all 
saw that article, or not. But, it pointed out that one in six 
servicemembers is on some form of psychiatric drug; 17 percent 
of the Active-Duty Force, and as much as 6 percent of the 
deployed troops are on antidepressants; and the use of 
psychiatric medications has increased about 76 percent since 
the start of these current wars.
    First, I would like to express my appreciation to Senator 
Cardin for having brought this issue to the attention of people 
here in the Senate. But, these statistics, quite frankly, are 
astounding to me. I'd like to know if--how familiar the three 
Assistant Secretaries are with this issue inside your 
departments, and what your thoughts are. Is this an indication 
of the overall fatigue of the force, with these constant 
deployments, or is it an indication of a different approach to 
medical treatment? Are we on top of this?
    I know that last year there was a provision in the Defense 
bill to require the Department to report on the administration 
and prescription of these drugs.
    But, Secretary Lamont, let me start with you. What are your 
thoughts on this?
    Mr. Lamont. Well, I'm not specifically aware of the article 
you're speaking about. I was TDY last week. However, I am well 
aware of the concerns we have with our pain management program. 
Those are the prescription drugs that we have found to have 
really crept into our system in much wider usage than we were 
ever aware of before.
    I'll also suggest to you, drugs like Oxycontin, I 
understand is used both in pain management and as an 
antidepressant. That's caused a number of concerns, because--
the fear that they may be prescribed by separate healthcare 
providers.
    What we have done to try to address the pain management 
side, what we found was, depending on where you went for 
treatment, there could be an entirely different model, if you 
would, of how pain is treated and how pain drugs are 
prescribed. There was no consistency there. So, with the 
various Services, we began a joint task force, this last fall, 
which is due to report, at any date now, on how we can come 
together with some kind of consistency in how we handle our 
pain management problem--pain management equals the drugs--and 
how we administer the proliferation of drugs in our military 
system.
    Our soldiers are coming back wounded, sore, injured, in 
need of rehab, and that's--perhaps the easy answer, early on, 
was pain-managed prescription. But, there are other means. We 
hope this joint task force report will come to grips with how 
we can provide some consistency, not just throughout the Army--
I mean, we found that every Army Medical Center was dealing 
with pain in altogether different ways, all individual to their 
situation. But, not an Army-wide program at all. I think, with 
this task force, we'll have the Services all together, and 
hopefully all in sync, of how we can address this growing 
problem.
    [Additional information supplied by Secretary Lamont 
follows:]

    Pain management has a significant behavioral health component, and 
drugs like Oxycontin and antidepressants may be simultaneously 
prescribed by different health care providers for better symptom 
management. While drugs like Oxycontin are used for pain management, 
what we have found is that pain has a strong behavioral health 
component requiring the addition of drugs like antidepressants for 
better symptom management. These prescription combinations are often 
managed by different health care providers. The issue of multiple-
prescribers exists in our health system and others. It concerns me that 
patients can receive different agents like narcotics and psychiatric 
drugs from different sources.

    Senator Webb. Secretary Garcia?
    Mr. Garcia. Senator, I'm familiar with the piece, and, as I 
understood it, it also posited, or suggested, that there were--
elicit drug use, to include in theater. We continue to drug 
test randomly across the fleet, forward-deployed and at home.
    On the prescription side, our Special Assistant for Health 
Affairs has initiated a working group, generated by the piece, 
to research this apparent spike, especially on the Marine side. 
That's where we are. All I can do is continue to keep you 
posted on the results.
    Senator Webb. Secretary Ginsberg.
    Mr. Ginsberg. Senator, I'm not familiar with the article, 
but I think you raise, obviously, a very important question 
about the extent of prescription drug use and whether this is 
an indicator of stress, or is this a new push to medicine? I'd 
very much like to get some concrete data from our surgeon-
general community, and would be more than happy to provide that 
to you.
    [The information referred to follows:]

    Thank you for the opportunity to address this concern regarding the 
health and well-being of our Air Force members and their use of 
psychotropic medications. Based upon this inquiry we made two distinct 
efforts to review psychopharmacology utilization data for our active 
duty servicemembers. The first data set we reviewed was provided by 
LCDR Joseph B. Lawrence, USN, MSC as the Deputy Director, Department of 
Defense (DOD) Pharmacoeconomic Center COR, DOD Pharmacy Operation 
Center. LCDR Lawrence's data pull from the Military Health System (MHS) 
Pharmacy Data Transaction Service (PDTS) demonstrated that in the U.S. 
Air Force active duty psychotropic drug prescriptions increased from 
58,102 annually in 2005 to 113,010 annually in 2009. The most notable 
increases related to use of stimulant and sleep medications. Stimulants 
prescriptions increased from 6,886 in 2005 to 11,522 in 2009. The 
number of prescriptions for sleep medication went from 33,175 in 2005 
to 64,166 in 2009. These two classes of psychotropic medications 
accounted for approximately 65 percent of the total prescription 
increase over this time period. While prescription sleep medications do 
carry a low risk of abuse, they are also highly effective and 
beneficial when used appropriately for short-term use to address the 
maintenance of health sleep patterns with international travel and 
fluctuating operational work schedules.
    The second data pull was provided by Air Force Medical Operations 
Agency, Michael Squires. Mr. Squires extracted data from the PDTS table 
in the M2 which resulted in all Air Force active duty servicemembers 
who had received a psychotropic prescription (including 
antidepressants) between October 2009 and March 2010. The number of 
unique Air Force servicemembers who had one or more prescriptions for 
any psychotropic medication, including controlled prescription pain 
medications during this 6 month period was 81,253 or 22 percent of the 
Active Force. When controlled prescription pain medications are 
removed, the number of unique servicemembers on a psychotropic 
medication changes to 48, 233. This reflects a calculated user 
prevalence rate during a 6 month period of 1 in 8, or 13 percent , of 
the Active-Duty Force for psychotropic medications. This figure is a 6-
month period prevalence; point prevalence on a specific day would be 
lower. Additionally, this data pull illustrated a utilization rate over 
a 6 month period of controlled pain medications as 51 for every 400 
servicemembers (12.75 percent), an antidepressant utilization rate of 
23 for every 500 servicemembers (4.6 percent), a sleep medication 
utilization rate of approximately 19 of every 421 servicemembers (4.4 
percent), a stimulant utilization rate of approximately 4 out of every 
425 servicemembers (0.94 percent), and an antipsychotic utilization 
rate of approximately 2 for every 1,000 servicemembers (0.2 percent).

    Senator Webb. I'd just say as an observation, one, we do 
have a really stressed, young force, because of these 
deployments. This is an indicator I think we really should be 
tracking very closely, with repeated deployments and these 
sorts of things.
    The other is, just purely as an observation, from looking 
at where they are deployed and the restriction of the use of 
alcohol, I would say it's--having been a journalist in 
Afghanistan before I started doing this, it is always rather 
ironic to me that, for reasons of comity with these other 
countries, we didn't allow our troops to use alcohol, but, I'll 
tell you, I was in a lot of villages in Afghanistan where 
everybody had their marijuana patch and their opium patch.
    The relief of stress on individuals is handled differently 
in different cultures, and that may be something you want to 
look into. It's a very troubling statistic, to me. I hope we 
can look at it, not simply medically, but in these other ways, 
as well.
    Secretary Ginsberg, can you give this subcommittee, some 
insight on this decision to provide aviation pay to nonrated 
pilots in the Remotely-Piloted Aircraft Program, what the 
justification is and--how does that fit into traditional 
definitions of flight pay, and those sorts of things?
    Mr. Ginsberg. Absolutely. Senator, the Air Force is meeting 
a very high demand to provide remotely-piloted aircraft--combat 
air patrols (CAPs) to our combatant command commander in 
Afghanistan and Iraq. We are currently providing 41 CAPs to the 
theater. We're working, by the end of fiscal year 2013, to 
provide 65 CAPs. What we're trying to do is develop a career 
field, where our airmen, who are providing this critical 
support to our forces on the ground, our brothers in the Marine 
Corps and the Army, as well as many are Air Force officers and 
enlisted on the ground, providing them this direct support. We 
want to make sure they can grow and develop.
    The incentive pays are a critical part of maintaining a 
robust pipeline of airmen who are operating these systems.
    Senator Webb. Under what category are they paid now?
    Mr. Ginsberg. I'm sorry?
    Senator Webb. Under what category are they being paid?
    Mr. Ginsberg. Well, this is an OSD-approved--under a--of 
course, the broad authority that Congress provides, under the--
it's the--it's aviation continuation-paylike pay, and it----
    Senator Webb. It's not called ``flight pay''?
    Mr. Ginsberg. It's not called ``flight pay,'' but it's a--
it's a different authority that we're providing under. This 
about just making--this--these officers and enlisted members 
are providing absolutely critical direct support to our forces 
on the ground, and we are putting tremendous stresses on them. 
Our crew ratios are not sufficient, at this point. They have a 
hard time getting leave, regular leave. We need to provide 
them--we're not giving them the opportunity to move to new 
assignments as flexibly as other career areas. We need to 
provide them pay and bonuses that will help make sure that this 
career field remains attractive.
    I went to Creech early in my tenure, to Creech Airfield, 
where we have a lot of our operators. It is absolutely 
astounding, what those airmen are doing to provide day-in and 
day-out support, truly lifesaving work.
    Senator Webb. Okay, thank you.
    Mr. Ginsberg. So, again, it's about making sure that they 
get the right pay--
    Senator Webb. I think that----
    Mr. Ginsberg.--and benefits that they deserve.
    Senator Webb. Secretary Stanley, I believe that this is a 
good time, with your coming in, to get a strong analytical look 
at how all of the special incentive pays, bonus pays, 
reenlistment pays, enlistment--how all of these fit together in 
a way that is beneficial to the people who are serving, and 
also to the efficiency of our programs.
    What I would like to do in a--rather than taking a great 
deal of time this morning, what I would like to do is to work 
with you and your staff to develop a matrix, so that we can 
fully understand what we're doing in these programs. I believe 
that the best way to address issues is, first, to assemble, 
clearly, the facts. So we are going to come to you with some 
questions about the incentive pays, the special pays, the 
reenlistment bonuses, the whole panorama, to get an 
understanding of how they are used, how many people are used, 
what the criteria are, how many of these are directed by 
Congress, how many of them are subject to the discretion of the 
implementers--your staff and the other----
    Dr. Stanley. Yes.
    Senator Webb.--Service departments--so that we can have a 
clear picture, as we move forward in these programs. I'm not 
sure of the last time that that's been done. I don't want to go 
through every one of these and ask for your justifications, but 
we're going to be having some questions. I don't want these to 
be considered questions for the record that are going to be 
answered----
    Dr. Stanley. Yes, sir.
    Senator Webb.--a month or 2 months. I really want to work 
on this so we can aggressively address it.
    There's a couple of other areas that I would like to get 
some feedback from you on. One of them, I'm sure you're 
familiar with, this mentor program that there were numerous 
articles, particularly USA Today, about where retired flag 
officers are getting up to $2,600 a day to come in and 
basically give advice. You know the situation, you're a retired 
flag. A retired four-star can be making in excess of $200,000 a 
year and then be working for a defense company, and then come 
in and be getting this sort of pay to give advice that, quite 
frankly, traditionally, has been a part of having worn the 
uniform, a sort of a continuing stewardship.
    So, there's a lot of questions, here in Congress, about how 
that reflects upon the dignity of Service, quite frankly. We 
want to get to the bottom of how that program is run.
    Then there's another area which relates to military 
fellowships, to think tanks. I would like to get some data on 
this with respect to the numbers of people who are involved in 
this and how taxpayer dollars are being spent, beyond regular 
military compensation, on areas that are called ``tuition'' for 
Active Duty military officers to go over and work on a think 
tank and not only be paid by the taxpayers for their regular 
military compensation, but actually being paid tens of 
thousands of dollars into these think tanks for this office 
space, et cetera. I don't think I have a full understanding of 
how this works, and we'd like to get specific data from you. 
Each Service may be doing it differently, but we'd like to 
assemble that data.
    With that, I thank all of you for your testimony, and look 
forward to working with you on a very close basis. Our door is 
open for any issues that you want to bring to the subcommittee, 
or to my office, personally.
    Thank you very much.
    Dr. Stanley. I appreciate that.
    Mr. Lamont. Thank you.
    Mr. Garcia. Thank you very much. [Pause.]
    Senator Webb. Our second panel will have members of the 
military coalition, a consortium of nationally prominent 
uniformed service and veteran organizations: Master Chief 
(Retired) Joseph Barnes, National Executive Director of the 
Fleet Reserve Association; Ms. Kathleen Moakler is the 
Government Relations Director of the National Military Family 
Association; Master Sergeant Michael Cline (Retired) is the 
Executive Director of the Enlisted Association of the National 
Guard of the United States; Ms. Deirdre Parke Holleman is the 
Executive Director of The Retired Enlisted Association; and 
Colonel Steven Strobridge (Retired) is the Director of 
Government Relations for the Military Officers Association of 
America.
    I mentioned earlier that we had two statements that would 
be put in the record. Probably more appropriate, they would be 
put in at this point rather than at the beginning of the 
hearing.
    [The joint prepared statement of the Reserve Officers 
Association and Reserve Enlisted Association follows:]
  Joint Prepared Statement by the Reserve Officers Association of the 
               United States Reserve Enlisted Association
                              introduction
    On behalf of our members, the Reserve Officers Association (ROA) 
and the Reserve Enlisted Association (REA) thank the committee for the 
opportunity to submit testimony on military personnel issues. ROA and 
REA applaud the ongoing efforts by Congress to address readiness, 
recruiting and retention as evidenced by incentives in several 
provisions included in the National Defense Authorization Act (NDAA) 
for Fiscal Year 2010.
                           executive summary
    The Reserve Officers Association Calendar Year 2010 Legislative 
Priorities are:

         Reset the whole force to include fully funding 
        equipment and training for the National Guard and Reserves.
         Assure that the Reserve and National Guard continue in 
        a key national defense role, both at home and abroad. Support 
        citizen warriors, families and survivors.
         Provide adequate resources and authorities to support 
        the current recruiting and retention requirements of the 
        Reserves and National Guard.
         Support warriors, families, and survivors.

    Issues supported by the Reserve Officers and Reserve Enlisted 
Associations are to:
Changes to retention policies:
         Permit service beyond the current Reserve Officers 
        Personnel Management Act (ROPMA) limitations.
         Support incentives for affiliation, reenlistment 
        retention and continuation in the Reserve component.
Education:
         Increase MGIB-Selected Reserve (MGIB-SR) to 47 percent 
        of MGIB-Active.
         Include 4-year reenlistment contracts to qualify for 
        MGIB-SR.
Mobilization:
         Provide differential pay for deployed Federal 
        employees permanently.
         Permit reservists the option of accumulating leave 
        between active duty orders, as well as selling it back.
Pay and Compensation:
         Reimburse a Reserve component member for expenses 
        incurred in connection with round-trip travel in excess of 100 
        miles to an inactive training location, including mileage 
        traveled, lodging and subsistence.
         Obtain professional pay for Reserve component medical 
        professionals, consistent with the Active component.
         Eliminate the 1l/30th rule for Aviation Career 
        Incentive Pay. Career Enlisted Flyers Incentive Pay. Diving 
        Special Duty Pay. and Hazardous Duty Incentive Pay.
         Simplify the Reserve duty order system without 
        compromising drill compensation.
Spouse Support:
         Expand eligibility of surviving spouses to receive 
        Survivor Benefit Plan (SBP)-Dependency Indemnity Clause (DIC) 
        payments with no offset.
Health Care:
         Improve continuity of health care for all drilling 
        reservists and their families by:

                 Monitoring the implementation of the 
                Department of Defense (DOD) paying a stipend toward 
                employers health care for dependents.
                 Allowing gray-area retirees to buy-in to 
                TRICARE by mid-2010.
                 Providing Continuing Health Benefit Plan to 
                traditional drilling reservists who are beneficiaries 
                of TRICARE Reserve Select but are separated from the 
                Selected Reserve to provide COBRA protections,
                 Permitting active members in the Individual 
                Ready Reserve (IRR) who qualify for a 20-year 
                retirement to buy-into TRICARE.
                 Allowing demobilized retirees and reservists 
                involuntarily returning to IRR to qualify for 
                subsidized TRS coverage,
                 Providing TRS coverage to mobilization ready 
                IRR members; levels of subsidy would vary for different 
                levels of readiness.
                 Improve post-deployment medical and mental 
                health evaluations of returning Reserve component 
                members.

         Fund restorative dental care prior to mobilization.
         Extend military coverage for restorative dental care 
        following deployment to 90 days.
         Evaluate the Post-Deployment Medical Evaluation 
        process.
         Encourage a discussion on health care costs between 
        Congress, DOD, and nonprofits.
         Protect military and veteran's health care from 
        inclusion in national health legislation.
Voting:
         Ensure that every deployed servicemember has an 
        opportunity to vote by:

                 Working with the Federal Voting Assistance 
                Program
                 Supporting electronic voting

         Ensure that every military absentee ballot is counted.

    Only issues needing additional explanation are included below. 
Self-explanatory or issues covered by other testimony will not be 
elaborated upon, but ROA and REA can provide further information if 
requested.
                          readiness discussion
Operational versus strategic missions for the Reserve component:
    The Reserve Forces are no longer just a part-time strategic force 
but are an integral contributor to our Nation's operational ability to 
defend our soil, assist other countries in maintaining global peace, 
and fight in overseas contingency operations.
    National security demands both a Strategic and an Operational 
Reserve. The Operational Reserve requires a more significant investment 
of training and equipment resources, and places greater demands on its 
personnel as compared to the Strategic Reserve. Those serving in 
Operational Reserve units must be fully aware of the commitment 
required to maintain the expected level of readiness. A similar 
awareness and commitment is necessary for those responsible for 
providing resources to the Operational Reserve.
    Planners also must recognize that few individuals can remain in the 
operational Reserve for an entire career. There will be times when 
family, education, civilian career, and the other demands competing for 
their time and talents take priority. Such an approach requires the 
ability to move freely and without penalty between the operational and 
strategic elements of the Reserve component as a continuum of service.
    Each Service has its own force generation models and the Services 
organize, train, and equip their Reserve components to a prescribed 
level of readiness prior to mobilization to limit post-mobilization 
training and to maximize operational deployment time. ROA and REA urge 
Congress to continue to support and fund each Service's authority to 
manage the readiness of its own Reserve Forces as one model does not 
fit all.
    Congress can play an important role by requiring reports from 
Service leaders to ensure they have a plan for systematic augmentation, 
that the plan is adequately resourced, and that Reserve training and 
equipment will permit interoperability with the units they augment and 
reinforce. In an era of constrained budgets, a capable and sustainable 
Reserve and National Guard is a cost-effective element of national 
security.
Junior Officer and Enlisted Drain:
    As an initial obligated period draws to the end, many junior 
officers and enlisted choose to leave, creating a critical shortage of 
young people in the leadership conduit. This challenge has yet to be 
solved. ROA and the National Guard Education Foundation published a 
report suggesting solutions to the problem. Copies can be provided to 
the committee, or be found at http://www.roa.org/JO-shortage.
End Strength and Preparedness:
    It is noted that the only active service component to suffer cuts 
in the fiscal year 2011 proposed budget was the Coast Guard which will 
have a reduction of 1,100 personnel.
    The other Active components appear to maintain their end strengths 
with inclusion of temporary increases for the Army and the Navy. It 
should be remembered that individuals cannot be brought quickly on to 
active duly on a temporary basis, but it is an accumulation of 
experience and training that is acquired over years that becomes an 
asset for the military. Before cuts to the U.S. Coast Guard are made, 
ROA and REA hope that Congress requests a report from the U.S. Coast 
Guard, Department of Homeland Security, on the effect in the short and 
long term.
    Traditionally, it has been the Reserve component that has provided 
the temporary surge to fill-in the active duty numbers. The end 
strengths included in the President's budget appear to maintain current 
numbers. ROA and REA are concerned that the ongoing cuts to the Navy's 
Reserve will continue and this is a trend that needs to be reversed. A 
new manpower study needs to be done and published by the Navy Reserve 
to calculate the actual manning level: this study should be driven by 
readiness and not budgetary requirements.
    With pending withdrawals from Iraq and Afghanistan, there is 
already talk within the beltway about future cuts to military end 
strength to help offset rising deficits. Many blame the global war on 
terrorism for our current national debt, but part of high cost of the 
military is unpreparedness, and the bills borne by trying to create a 
force to match the need.
    Following World War I, Lieutenant General James Guthrie Harbord, 
USA, General John J. Pershing's chief of staff, was quoted in a 1922 
New York Times as saying. ``The size of our debt, incurred through 
unpreparedness, brings a demand for economy, and we continue 
unprepared. Thus unpreparedness brings the debt, and the debt continues 
unpreparedness.''
    Without external threats, the USA has traditionally reduced the 
size of its Armed Forces. But since the 1990s the Pentagon has 
recommended proportional cuts be taken in the Reserve component when 
taken in the Active Force. This reasoning fails in many ways. It 
results in a hollowing out of the force and preparedness, undermines 
morale, and undercuts retention. national security is put at risk. 
There is a need to maintain a national position of readiness, and the 
Reserve component is a cost-effective solution of being prepared. 
Should cuts be taken in the Active component, the Reserve component 
should grow in size to allow a place for readiness capability.
                          proposed legislation
Retirement
    ROA and REA again thank the committee for passing the early 
retirement benefit in the National Defense Authorization Act for Fiscal 
Year 2008, as a good first step toward changing the retirement 
compensation for serving Guard and Reserve members, but. . .
    Guard and Reserve members feel that with the change in the roles 
and missions of the Reserve component, their contracts have changed. 
Informal surveys keep indicating that earlier retirement remains a top 
issue asked for by guardsmen and reservists. They ask why so many Guard 
and Reserve members who have served in the global war on terrorism were 
excluded from the new benefit; they also ask why even earlier duty is 
not included: and if faced with the same risks as active duty, why 
there is a 20 year difference in access to retirement pay?
    1. ``ROA and REA'' endorse S.831. National Guard and Reserve 
Retired Pay Equity Act of 2009, which is a corrective measure to the 
National Defense Authorization Act for Fiscal Year 2008 including those 
Guard and Reserve members who have been mobilized since September 11, 
2001. Over 600,000 were unfairly excluded. We realize the expense of 
this corrective measure scored by CBO is $2.1 billion over 10 years, 
but hope that offset dollars can be found.
    2. ROA and REA don't view this congressional solution as the final 
retirement plan. The Commission on the National Guard and Reserve 
recommends that Congress should amend laws to place the Active and 
Reserve components into the same retirement system. Secretary of 
Defense Robert Gates refers to the Tenth Quadrennial Review of Military 
Compensation's comprehensive review of the military retirement systems 
for suggested reform. The latter report suggests a retirement pay equal 
to 2.5 percent of basic pay multiplied by the number of years of 
service.
    ROA and REA agree that a retirement plan, at least for the Reserve 
component, should be based on accruement of active and inactive duty. 
Early retirement should not be based on the type of service, but on the 
aggregate of duty. It shouldn't matter if a member's contributions were 
paid or non-paid; inactive duty, active duty for training, special 
works or for mobilization. Under a continuum of service, this approach 
would provide both the Active or Reserve component members with an 
element of personal control to determine when they retire and will 
encourage increased frequency of service beyond 20 years within the 
Reserve.
    3. An additional problem arises for O-4 officers who, after a break 
in service, have returned to the Reserve component. After being 
encouraged to return a number of officers find they are not eligible 
for nonregular retirement. When reaching 20 years of commissioned 
service they find they may have only 15 good Federal years. Current 
policy allows these individuals to have only 24 years of commissioned 
time to earn 20 good Federal years.
    4. With an ongoing shortage of mid-grade officers (O-2 to O-3), 
Congress should reexamine the DOPMA and ROPMA laws to permit O-3s 
without prior enlisted service to be able to retire at 20 years of 
service. Many of badly needed skills that the Services would like to 
retain, yet must be discharged if passed over for promotion to often.
    ROA urges Congress to make changes in U.S. Code to allow O-3s and 
O-4s with 14 to 15 good Federal years to remain on Active Duty or in 
the Reserve until they qualify for regular or non-regular retirement.
Education
    1. Montgomery ``GI'' Bill-Selected Reserve (MGJB-SR): To assist in 
recruiting efforts for the Marine Corps Reserve and the other uniformed 
services, ROA and REA urge Congress to reduce the obligation period to 
qualify for MGJB-SR (Section 1606) from 6 years in the Selected Reserve 
to 4 years in the Selected Reserve plus 4 years in the Individual Ready 
Reserve, thereby remaining a mobilization asset for 8 years.
    2. Extending MGIB-SR eligibility beyond Selected Reserve Status: 
Because of funding constraints, no Reserve component member will be 
guaranteed a full career without some period in a non-pay status. BRAC 
realignments are also restructuring the RC force and reducing available 
paid billets. Whether attached to a volunteer unit or as an individual 
mobilization augmentee, this status represents periods of drilling 
without pay. MGIB-SR eligibility should extend for 10 years beyond 
separation or transfer from a paid billet.
Leadership
    Both the Army and Air Force Reserve Chiefs may only be selected 
from general officers from that component's reserve, yet the Navy and 
the Marine Corps can select its Reserve leadership from either Active 
or Reserve flag officers. (U.S.C., title 10. section 3038 states that 
``The President, by and with the advice and consent of the Senate, 
shall appoint the Chief of Army Reserve from general officers of the 
Army Reserve . . .'' and section 8038 uses similar language for the 
appointment of the Chief of the Air Force Reserve, while U.S.C., title 
10, section 5143, only requires the President to appoint the Chief of 
Navy Reserve from flag officers of the Navy, and section 5144 only 
requires the President to appoint the Commander. Marine Forces Reserve, 
from general officers of the Marine Corps.) The Reserve Chief of a 
Service's Reserve should have an understanding of both the citizen 
warriors who are reporting to him or her, and the system through which 
the report. ROA urges Congress to change sections 5143 and 5144 of 
U.S.C., title 10 to only permit appointments from the Service's Reserve 
component.
Military Voting
    ROA thanks Congress for the improvements made to absentee voting in 
the fiscal year 2010 Defense Authorization. Military personnel, 
overseas citizens, and their families residing outside their election 
districts deserve every reasonable opportunity to participate in the 
electoral process. Yet, studies by Congressional Research Service show 
that 25 percent of military member and family votes were not counted in 
the 2008 election.
    ROA and REA urge Congress to direct the Government Accountability 
Office to report further on the effectiveness of absentee voting 
assistance to Military and Overseas Citizens for the 2010 General 
Election and determine how Federal Voting Assistance Program's efforts 
to facilitate absentee voting by military personnel and overseas 
citizens differed between the 2008 and 2010 national elections. ROA and 
REA also hopes Congress encourages the Secretary of Defense, in 
conjunction with States and local jurisdictions, to gather and publish 
national data about the 2010 election by voting jurisdiction on 
disqualified military and overseas absentee ballots and reasons for 
disqualification.
                         health care discussion
    1. ROA and REA hold concerns over the implementation of TRICARE for 
gray area retirees. Rear Admiral Christine S. Hunter has shared that 
enrollment could be as early as July or as late as November 2010, and 
that it might be regionally rolled out. DOD wants to treat Reserve gray 
area retirees as a separate health care risk group which will likely 
drive up the cost of health care premiums as well. ROA and REA hope 
that the committee will ask hard questions at a future hearing about 
the process, as individuals in the health care industry question the 
length of time and the approach being taken.
    2. Sustaining Reserve Health care. ROA and REA was disappointed to 
learn that Continued Health Care Benefit Plan is only allowed to 
members of the Selected Reserve if they have had a tour of active duty 
within the previous 18 months by DOD. This is denying COBRA protections 
for traditional reservists who haven't been activated, and even 
overlooks the Secretary of Defense's directive to mobilize National 
Guard and Reserve members 1 year out of 6, which would be a dwell time 
of 60 months between call-ups. There is little cost as the beneficiary 
pays a premium of 102 percent of TRICARE Cost.
    A continuity of health care is needed if a continuum of service is 
to be seriously considered. Just as an Active Force needs to be 
provided military health, the Reserve component needs to have a 
seamless health protection during different duty statuses. As even 
discharged active servicemembers have the benefit of the Continuing 
Health Care Benefit Plan, those Guard and Reserve members who have 
signed up for TRICARE Reserve Select need to have protections when they 
leave the Selected Reserve.
    ROA and REA encourage Congress to work with the Pentagon to open up 
Reserve component member access to the Continued Health Care Benefit 
Plan to any TRICARE Reserve Select beneficiary separating from the 
Selected Reserve under conditions that are not punitive in nature.
    3. Employer health care option: The ROA and REA continues to 
support an option for individual reservists where DOD pays a stipend to 
employers of deployed Guard and Reserve members to continue employer 
health care during deployment. Because TRICARE Prime or Standard is not 
available in all regions that are some distance from military bases it 
is an advantage to provide a continuity of health care by continuing an 
employer's health plan for the family members. This stipend would be 
equal to DOD's contribution to Active Duty TRICARE.
    4. Dental Readiness. Currently, dental readiness has one of the 
largest impacts on mobilization. The action by Congress in the NDAA for 
Fiscal Year 2010 was a good step forward, but still more needs to be 
done.
    In the first quarter of fiscal year 2009, the Army Reserve was 48.8 
percent dental class 1 or 2 Navy Reserve was 92.8 percent, Air Force 
Reserve 86.6 percent, Marine Corps Reserve 77 percent. Air Guard 91 
percent Army Guard 48.2 percent, and Coast Guard Reserve 83.2 percent.
    While there has been slight improvement since fiscal year 2007, the 
Army Reserve and Marine Corps Reserve have actually decreased their 
dental readiness which is due to large numbers of Class 4 
servicemembers. Regardless none of the Services have met the 95 percent 
dental readiness goal.
    The Services require a minimum of Class 2 (where treatment is 
needed, however no dental emergency is likely within 6 months) for 
deployment. Current policy relies on voluntary dental care by the Guard 
or Reserve member. Once alerted, dental treatment can be done by the 
military, but often times there isn't adequate time for proper 
restorative remedy.
    ROA and REA continues to suggest that the Services are responsible 
to restore a demobilized Guard or Reserve member to a Class 2 status to 
ensure the member maintains deployment eligibility.
    Because there are inadequate dental assets at Military Treatment 
Facilities for active members, active families, and reservists, ROA and 
REA further recommend that dental restoration be included as part of 
the 6 months Transitional Assistance Management Program (TAMP) period 
following demobilization. DOD should cover full costs for restoration, 
but it could be tied into the TRICARE Dental program for cost and 
quality assurance.
    5. TRICARE Health costs: ROA and REA applaud the efforts by 
Congress to address the issue of increasing Department of Defense 
health care costs and its interest to initiate dialogue and work with 
both the Pentagon and the beneficiary associations to find the best 
solution. The time has come to examine the cost of TRICARE and the 
level of beneficiary contribution.
    ROA and REA are committed to our membership to sustain this health 
care benefit. We fear that we will be unable to continue to sustain 
prohibitions on health care fees into the future. We need to work 
together to find a fair and equitable solution that protects our 
beneficiaries and ensures the financial viability of the military 
health care system for the future. Some associations seek to continue 
to a freeze on premium fees permanently; others are joining ROA and REA 
by admitting that some increases are necessary.
    ROA and REA endorse a tiered enrollment fee and congratulate the 
Task Force for developing one based on annual income. As most Guard and 
Reserve members retire at 25 to 30 percent of active duty retirement 
pay, it makes sense that G-R enrollment fees should be lower. ROA and 
REA do suggest that if enrollment fees are based on income that it be 
based just on military retirement income of Active and Reserve 
retirees.
    The ROA and REA do not endorse annual enrollment fees for 
individuals who don't use the TRICARE Standard plan. Eligibility should 
remain universal; a one-time administrative enrollment fee might be 
implemented with first use of the program.
    If TRICARE Standard enrollment fees are increased, Congress needs 
to review the recommended deductibles and current copayment levels. 
While TRICARE Prime is in the top 90 percent for cost generosity. 
TRICARE Standard is at a lower level of the spectrum of plan 
generosity.
    6. National Health Care Plan. ROA and REA are concerned that the 
national health care legislation does not include specific language 
that preserves military and veteran health care programs under separate 
authorities. While there have been verbal guarantees from congressional 
members and the President, getting the pledge in writing would curtail 
concerns.
                               conclusion
    ROA and REA reiterate our profound gratitude for the progress 
achieved by this committee by providing parity on pay and compensation 
between the Active and Reserve components, with the subcommittee also 
understanding the difference in service between the two components.
    ROA and REA look forward to working with the personnel subcommittee 
where we can present solutions to these and other issues, and offers 
our support in anyway.

    Senator Webb. Welcome, to all of you.
    I suppose we can start with Mr. Barnes and move to Mr. 
Strobridge.
    Welcome, sir.

    STATEMENT OF MASTER CHIEF JOSEPH L. BARNES, USN (RET.), 
    NATIONAL EXECUTIVE DIRECTOR, FLEET RESERVSE ASSOCIATION

    Mr. Barnes. Good morning, Mr. Chairman, Senator Graham, 
distinguished members of the subcommittee. Thank you for the 
opportunity to appear before you today.
    The Military Coalition's statement reflects the consensus 
of coalition organizations on a broad range of important 
personnel issues and extensive work by eight legislative 
committees, each comprised of representatives from the 
coalition's 34 military and veterans organizations.
    The five of us will address key issues important to the 
Active, Guard, and Reserve, retiree, and survivor communities, 
and military families, and will conclude healthcare concerns 
which impact everyone within these groups, including our 
magnificent wounded warriors.
    Before proceeding, I wish to thank you and the entire 
subcommittee and your outstanding staff for effective 
leadership and strong support of essential pay and benefit 
program enhancements, and particularly for programs to 
adequately care for our wounded warriors and their families.
    Adequate service end strengths are absolutely essential to 
success in Iraq and Afghanistan, and to sustaining other 
operations vital to our national security. The coalition 
strongly supports proposed Army and Navy end strength levels in 
2011. A recent Navy Times story titled ``Sailor Shortage'' 
cites too much work to do in the Navy and not enough people to 
do it, and lists the associated effects, which include little 
time for rest, fewer people to maintain and repair shipboard 
equipment, crew members with valuable skills being pulled for 
other jobs and not replaced, and lower material ship readiness.
    As referenced by the first panel, the strain of repeated 
deployments continues, and is also related to the adequacy of 
end strengths. Now we're tracking disturbing indicators of the 
effects, which include increasing drug and alcohol use, more 
mental healthcare appointments, alarming suicide rates, plus 
more military divorces. The unrelenting stress on 
servicemembers and their families is a serious and continuing 
concern that can lead to very serious morale, readiness, and 
retention challenges.
    Pay comparability remains a top priority, and the Coalition 
strongly supports the authorization of a 1.9-percent 2011 
Active Duty pay hike. We appreciate your past support for 
higher-than-ECI pay increases, which have collectively reduced 
the pay gap to 2.4 percent.
    Adequate funding for military recruiting efforts is 
important. During high retention periods, it's natural to look 
at reducing these accounts. However, sufficient resources are 
essential to ensuring continuing recruiting success. It's 
noteworthy that nearly three-quarters of the optimum 
recruiting-aged young people do not qualify for Military 
Service, and the Services must maximize efforts through our 
military recruiters to recruit optimum-quality personnel across 
the Armed Services.
    The coalition strongly supports the authorization to ship 
two personal vehicles in conjunction with PCS moves, along with 
long overdue increases in PCS mileage rates. We appreciate the 
distinguished Chairman's leadership on the enactment and 
implementation of the post-September 11 GI Bill and DOD 
policies on transferability options for personnel nearing 
retirement. However, technical corrections are still needed to 
ensure eligibility for members of the U.S. Public Health 
Service and NOAA Corps.
    Adequate programs, facilities, and support services for 
personnel impacted by BRAC actions, rebasing, and global 
repositioning is very important, particularly during wartime, 
which alone, results in significant stress on servicemembers 
and their families. The coalition notes with concern the 19-
plus-percent reductions in military construction and family 
housing accounts in the proposed 2011 budget request.
    Finally, the coalition remains committed to adequate 
funding to ensure access to the commissary benefit for all 
beneficiaries. This is an essential benefit, and the Defense 
Commissary Agency is to be commended for highly cost-effective 
management of 255 stores in 13 countries.
    Thank you again for the opportunity to present our 
recommendations.
    [The prepared statement of Mr. Barnes follows:]
    Prepared Statement by Master Chief Joseph L. Barnes, USN (Ret.)
                     the fleet reserve association
    The Fleet Reserve Association (FRA) is the oldest and largest 
enlisted organization serving active duty, Reserves, retired and 
veterans of the Navy, Marine Corps, and Coast Guard. It is 
Congressionally Chartered, recognized by the Department of Veterans 
Affairs (VA) as an accrediting Veteran Service Organization for claim 
representation and entrusted to serve all veterans who seek its help. 
In 2007, FRA was selected for full membership on the National Veterans' 
Day Committee.
    FRA was established in 1924 and its name is derived from the Navy's 
program for personnel transferring to the Fleet Reserve or Fleet Marine 
Corps Reserve after 20 or more years of active duty, but less than 30 
years for retirement purposes. During the required period of service in 
the Fleet Reserve, assigned personnel earn retainer pay and are subject 
to recall by the Secretary of the Navy.
    FRA's mission is to act as the premier ``watch dog'' organization 
in maintaining and improving the quality of life for Sea Service 
personnel and their families. FRA is a leading advocate on Capitol Hill 
for enlisted Active Duty, Reserve, retired and veterans of the Sea 
Services. The Association also sponsors a National Americanism Essay 
Program and other recognition and relief programs. In addition, the 
newly established FRA Education Foundation oversees the Association's 
scholarship program that presents awards totaling nearly $100,000 to 
deserving students each year.
    The Association is also a founding member of The Military Coalition 
(TMC), a 34-member consortium of military and veteran's organizations. 
FRA hosts most TMC meetings and members of its staff serve in a number 
of TMC leadership roles.
    FRA celebrated 85 years of service in November 2009. For over eight 
decades, dedication to its members has resulted in legislation 
enhancing quality of life programs for Sea Services personnel, other 
members of the uniformed services plus their families and survivors, 
while protecting their rights and privileges. CHAMPUS, now TRICARE, was 
an initiative of FRA, as was the Uniformed Services Survivor Benefit 
Plan. More recently, FRA led the way in reforming the REDUX Retirement 
Plan, obtaining targeted pay increases for mid-level enlisted 
personnel, and sea pay for junior enlisted sailors. FRA also played a 
leading role in advocating recently enacted predatory lending 
protections and absentee voting reform for servicemembers and their 
dependents.
    FRA's motto is: ``Loyalty, Protection, and Service.''
             certification of non-receipt of federal funds
    Pursuant to the requirements of House Rule XI, the FRA has not 
received any Federal grant or contract during the current fiscal year 
or either of the 2 previous fiscal years.
                                synopsis
    The FRA is an active participant and leading organization in The 
Military Coalition (TMC) and strongly supports the recommendations 
addressed in the more extensive TMC testimony prepared for this 
hearing. The intent of this statement is to address other issues of 
particular importance to FRA's membership and the Sea Services enlisted 
communities.
                              introduction
    Mr. Chairman, the FRA salutes you, members of the subcommittee, and 
your staff for the strong and unwavering support of programs essential 
to Active Duty, Reserve component, and retired members of the uniformed 
services, their families, and survivors. The subcommittee's work has 
greatly enhanced care and support for our wounded warriors and 
significantly improved military pay, and other benefits and enhanced 
other personnel, retirement and survivor programs. This support is 
critical in maintaining readiness and is invaluable to our uniformed 
services engaged throughout the world fighting the global war on 
terror, sustaining other operational commitments and fulfilling 
commitments to those who've served in the past.
                              health care
    Health care is exceptionally significant to all FRA shipmates 
regardless of their status and protecting and/or enhancing this benefit 
is the Association's top legislative priority. A recently released FRA 
survey indicates that nearly 90 percent of all Active Duty, Reserve, 
retired, and veteran respondents cited health care access as a 
critically important quality-of-life benefit associated with their 
military service. From 2006-2008 retirees under age 65 were targeted by 
DOD to pay significantly higher health care fees. Many of these 
retirees served before the recent pay and benefit enhancements were 
enacted and receive significantly less retired pay than those serving 
and retiring in the same pay grade with the same years of service 
today. Promises were made to them about health care for life in return 
for a career in the military with low pay and challenging duty 
assignments and many believe they are entitled to free health care for 
life.
    Efforts to enact a national health care reform coupled with 
inaccurate and widespread information on the associated impact on 
retiree health care benefits has created unease and a sense of 
uncertainty for our members. FRA opposes any effort to integrate 
TRICARE and VA health care into any national health care program and 
appreciates the exclusion of TRICARE and VA health care in the House 
version of the national health care proposal. Military and VA health 
care services are fundamental to military readiness and serve the 
unique needs of current and former servicemembers, their families and 
survivors. Merging these programs into a colossal bureaucracy designed 
to provide health care to all Americans would broaden their focus and 
reduce their effectiveness. That said, the Association is concerned 
about proposed Medicare spending cuts associated with reform 
initiatives which may negatively impact physician reimbursement rates 
and access to care for Medicare and TRICARE beneficiaries.
    FRA strongly supports Representatives Chet Edwards (TX) and Walter 
Jones (NC) legislation, ``The Military Retirees' Health Care Protection 
Act'' (H.R. 816) that would prohibit DOD from increasing TRICARE fees, 
specifying that the authority to increase TRICARE fees exists only in 
Congress.
    FRA thanks this subcommittee for resisting past efforts to shift 
increasing health care cost to beneficiaries and ensuring adequate 
funding for the Defense Health Program in order to meet readiness 
needs, fully fund TRICARE, and improve access for all beneficiaries 
regardless of age, status or location. Adequately funding health care 
benefits for all beneficiaries is part of the cost of defending our 
Nation.
                           concurrent receipt
    The Association appreciates President Obama's support for 
authorizing Chapter 61 retirees to receive their full military retired 
pay and veterans disability compensation and continues to seek timely 
and comprehensive implementation of legislation that authorizes the 
full concurrent receipt for all disabled retirees. The above referenced 
FRA survey indicates that more than 70 percent of military retirees 
cite concurrent receipt among their top priorities. The Association 
strongly supports the fiscal year 2011 budget request of $408 million 
to cover the first phase of the 5-year cost for concurrent receipt for 
Chapter 61 beneficiaries that are 90 percent or more disabled.
                            wounded warriors
    FRA appreciates the substantial Wounded Warriors legislation in the 
National Defense Authorization Act (NDAA) for Fiscal Year 2008. Despite 
jurisdictional challenges, considerable progress has been made in this 
area. However, the enactment of legislation is only the first step in 
helping wounded warriors. Effective oversight and sustained funding are 
also critical for successful implementation and FRA supports the 
following substantive changes:

         Establish a permanent and independent office for the 
        DOD/VA Interagency program and expand it's authority to include 
        oversight of all components of achieving a true seamless 
        transition;
         Authorizing full active duty TRICARE benefits, 
        regardless of accessibility of VA care, for 3 years after 
        medical retirement to help ease transition from DOD to VA;
         Extend and make permanent the charter of the ``Special 
        Oversight Committee'' to ensure improved coordination with DOD 
        and VA initiatives to help wounded warriors;
         Exempt severely wounded medically retired Medicare 
        part B premiums until age 65;
         Providing up to 1 year of continuous habitation in 
        onbase housing facilities for medically retired, severely 
        wounded and their families;
         Eliminate the servicemember's premium for the 
        Traumatic Servicemember Group Life Insurance;
         Ensure the creation and full implementation of a joint 
        electronic health record that will help ensure a seamless 
        transition from DOD to VA for wounded warriors; and
         Establishment of the Wounded Warriors Resource Center 
        as a single point of contact for servicemembers, their family 
        members, and primary care givers.

    Achieving an effective delivery system between DOD and VA to 
guarantee seamless transition and quality services for wounded 
personnel, particularly those suffering from Post Traumatic Stress 
Disorder and Traumatic Brain Injuries is very important to our 
membership. DOD should also make every effort to destigmatize mental 
health conditions that should include outreach, counseling, and mental 
health assessment for all servicemembers returning from the combat 
zone. Family support is also critical for success, and should include 
compensation, training, and certification, and respite care for family 
members functioning as full-time caregivers for wounded warriors. FRA 
supports ``The Caregivers and Veterans Omnibus Health Services Act''(S. 
1963), and parallel legislation to improve compensation, training and 
assistance for caregivers of severally disabled active-duty 
servicemembers.
                             suicide rates
    FRA is deeply concerned that more servicemembers have taken their 
own lives by November 2009 than have been killed in either the 
Afghanistan or Iraq wars. Congressional Quarterly reports that as of 
November 24, 334 servicemembers have committed suicide in 2009, 
compared with 297 killed in Afghanistan and 144 who died in Iraq. In 
response to this, Congress has significantly increased funding for 
mental health in the DOD and VA budgets that established a suicide 
hotline. DOD and VA also sponsor annual conferences on this issue. 
Jurisdictional challenges notwithstanding, it is critically important 
that Congress further respond and enhanced coordination between the 
Veterans Affairs and Armed Services Committees is key to addressing 
this. As of the above date the Army has had 211 of the 334 suicides, 
while the Navy had 47, the Air Force had 34 and the Marine Corps 
(active duty only) had 42. Increases in the number of suicides are not 
limited to active duty members only, the Department of Veterans Affairs 
(VA) has indicated that veterans suicides have also been increasing at 
an alarming rate.
         uniform services former spouses protection act reform
    The Association believes that the increasing divorce rates among 
active duty personnel and reservists is related to stress caused by 
repeated deployments in conjunction with 8 years of fighting a two-
front war. According to the Los Angeles Times, ``The 3.6 percent rate 
is a full percentage point above the 2.6 percent reported in late 2001, 
when the U.S. began sending troops to Afghanistan in response to the 
terrorist attacks. As in previous years, women in uniform suffered much 
higher divorce rates than their male counterparts--7.7 percent in 2009. 
An Army 2009 battlefield survey indicated that 22 percent of married 
soldiers were considering divorce, compared to 12.4 percent in 2003.'' 
\1\ The divorce rate for women in uniform is especially troubling, and 
these numbers do not take into account divorce rates for veterans. The 
FRA has long advocated introduction of legislation addressing the 
inequities of the Uniform Services Former Spouses Protection Act 
(USFSPA) and associated hearings on this issue. The Association 
believes that this law should be more balanced in its protection for 
both the servicemember and the former spouse.
---------------------------------------------------------------------------
    \1\ Associated Press, November 28, 2009, Divorce Rate Rises in 
Military, Los Angeles Times.
---------------------------------------------------------------------------
    The recommendations in the Department of Defense's (DOD) September 
2001 report, which assessed USFSPA inequities and offered 
recommendations for improvement is a good starting point for 
considering badly needed reform of this onerous law.
    Few provisions of the USFSPA protect the rights of the 
servicemember and none are enforceable by the Department of Justice or 
DOD. If a State court violates the right of the servicemember under the 
provisions of USFSPA, the Solicitor General will make no move to 
reverse the error. Why? Because the act fails to have the enforceable 
language required for Justice or the Defense Department to react. The 
only recourse is for the servicemember to appeal to the court, which in 
many cases gives that court jurisdiction over the member. Another 
infraction is committed by some State courts awarding a percentage of 
veterans' compensation to ex-spouses, a clear violation of U.S. law; 
yet, the Federal Government does nothing to stop this transgression.
    FRA believes Congress needs to take a hard look at the USFSPA with 
the intent to amend it so that the Federal Government is required to 
protect its servicemembers against State courts that ignore provisions 
of the act. Other provisions also weigh heavily in favor of former 
spouses. For example, when a divorce is granted and the former spouse 
is awarded a percentage of the servicemember's retired pay, this should 
be based on the member's pay grade at the time of the divorce and not 
at a higher grade that may be held upon retirement. The former spouse 
has done nothing to assist or enhance the member's advancements 
subsequent to the divorce; therefore, the former spouse should not be 
entitled to a percentage of the retirement pay earned as a result of 
service after the decree is awarded. Additionally, Congress should 
review other provisions considered inequitable or inconsistent.
                    adequate personnel end strength
    Insufficient end strength levels and the rigors of supporting 
Operations Iraqi Freedom and Enduring Freedom are having a negative 
impact on the quality of life of servicemembers which will ultimately 
lead to retention and recruitment challenges. FRA urges this 
distinguished subcommittee to ensure funding for adequate end strengths 
and people programs consistent with the Association's DOD funding goal 
of at least 5 percent of the gross domestic product for fiscal year 
2011.
                      active duty pay improvements
    Our Nation is at war and there is no more critical morale issue for 
active duty warriors than adequate pay. This is reflected in the more 
than 96 percent of active duty respondents to FRA's recent survey 
indicating that pay is ``very important.'' The Employment Cost Index 
(ECI) for fiscal year 2011 is 1.4 percent and based on statistics from 
15 months before the effective date of the proposed active duty pay 
increase. The Association appreciates the strong support from this 
distinguished subcommittee in reducing the 13.5 percent pay gap to the 
current level during the past decade. In addition, FRA notes that even 
with a fiscal year 2011 pay increase that is 0.5 percent above the ECI, 
the result will be the smallest pay hike since 1958. FRA urges the 
subcommittee to continue the increases at least 0.5 percent above the 
ECI until the remaining 2.4 percent pay gap is eliminated.
                        reserve early retirement
    The effective date of a key provision in the NDAA for Fiscal Year 
2008, the Reserve retirement age provision that reduces the age 
requirement by 3 months for each cumulative 90-days ordered to active 
duty is effective upon the enactment of the legislation and NOT 
retroactive to October 7, 2001. Accordingly the Association supports 
``The National Guardsmen and Reservists Parity for Patriots Act'' (H.R. 
208) sponsored by the subcommittee's ranking member Representative Joe 
Wilson (SC), to authorize reservists mobilized since October 7, 2001, 
to receive credit in determining eligibility for receipt of early 
retired pay. Since September 11, 2001 the Reserve component has changed 
from a Strategic Reserve to an Operational Reserve that now plays a 
vital role in prosecuting the war efforts and other operational 
commitments. This has resulted in more frequent and longer deployments 
impacting individual reservist's careers. Changing the effective date 
of the Reserve early retirement would help partially offset lost salary 
increases, lost promotions, lost 401K and other benefit contributions. 
The Association urges the subcommittee to support this important 
legislation.
                   paid-up survivor benefit annuities
    Under current law, retirees are no longer required to pay survivor 
benefit annuities (SBP) premiums after they have paid for 30 years and 
reach age 70. This is an inequity for those who may have entered the 
service at age 17 or 18 and will be required to pay for 33 or 32 years 
respectively until attaining paid-up SBP status. Therefore, FRA 
supports changing the minimum age for paid-up SBP from age 70 to age 67 
to ensure that those who joined the military at age 17, 18, or 19 and 
serve 20 years will only have to pay SBP premiums for 30 years.
              retention of final full month's retired pay
    FRA urges the subcommittee to authorize the retention of the full 
final month's retired pay by the surviving spouse (or other designated 
survivor) of a military retiree for the month in which the member was 
alive for at least 24 hours. FRA strongly supports ``The Military 
Retiree Survivor Comfort Act'' (H.R. 613), introduced by Rep. Walter 
Jones (NC) which addresses this issue.
    Current regulations require survivors of deceased military retirees 
to return any retirement payment received in the month the retiree 
passes away or any subsequent month thereafter if there is a processing 
delay. Upon the demise of a retiree, the surviving spouse is required 
to notify the Defense Finance and Accounting Service (DFAS) of the 
death. DFAS then stops payment on the retirement account, recalculates 
the final payment to cover only the days in the month the retiree was 
alive, forwards a check for those days to the surviving spouse or 
beneficiary. If not reported in a timely manner, DFAS recoups any 
payment(s) made covering periods subsequent to the retiree's death.
    The measure is related to a similar Department of Veterans Affairs 
policy. Congress passed a law in 1996 that allows a surviving spouse to 
retain the veteran's disability and VA pension payments issued for the 
month of the veteran's death. FRA believes military retired pay should 
be no different. This proposal is also in response to complaints from 
surviving spouses who were unaware of the notification requirement and 
those with joint bank accounts, in which retirement payments were made 
electronically, who gave little if any thought that DFAS could access 
the joint account and recoup overpayments of retirement pay. This 
action could easily clear the account of any funds remaining whether 
they were retirement payments or money from other sources.
    To offset some of the costs, if the spouse is entitled to SBP on 
the retiree's death, there will be no payment of the annuity for the 
month the retirement payment is provided the surviving spouse.
                   mandate travel cost reimbursement
    FRA appreciates the NDAA for Fiscal Year 2008 provision (section 
631) that permits travel reimbursement for reservist's weekend drills, 
not to exceed $300, if the commute is outside the normal commuting 
distance. The Association urges the subcommittee to make this a 
mandatory provision. This is a priority issue with many enlisted 
reservists who are forced to travel lengthy distances to participate in 
weekend drills without reimbursement for travel costs. Providing this 
travel reimbursement would assist with retention and recruitment for 
the Reserves--something particularly important to increased reliance on 
these personnel in order to sustain our war and other operational 
commitments.
                            family readiness
    Military deployments create unique stresses on families due to 
separation, uncertainties of each assignment and associated dangers of 
injury or death for the deployed servicemember. Further, adapting to 
new living arrangements and routines adds to the stress, particularly 
for children.
    Fortunately men and women in uniform continue to answer the calls 
to support repeated deployments--but only at a cost of ever-greater 
sacrifices for them and their families. Now more than ever before the 
support of their families is essential to enduring the mounting 
stresses of the war effort and other operational commitments. This 
stress has resulted in doubling the number of outpatient mental health 
visits (1 million in 2003 to 2 million in 2008) for children with an 
active duty parent.\2\ It's most important that DOD and the military 
services concentrate on providing programs for the families of our 
servicemembers. DOD should improve programs to assist military families 
with deployment readiness, responsiveness, and reintegration. There are 
a number of existing spousal and family programs that have been fine 
tuned and are successfully contributing to the well-being of this 
community. The Navy's Fleet and Family Centers and the Marines' Marine 
Corps Community Services and Family Services programs are providing 
comprehensive, 24/7 information and referral services to the 
servicemember and family through its OneSource links. OneSource is 
particularly beneficial to mobilized reservists and families who are 
unfamiliar with varied benefits and services available to them.
---------------------------------------------------------------------------
    \2\ Military.Com More Troops' Kids Seeking Counseling Associated 
Press, July 8, 2009
---------------------------------------------------------------------------
    It's true that ``the servicemember enlists in the military 
service--but it's the family that reenlists.'' To ensure the family 
opts for a uniformed career, the family must be satisfied with life in 
the military.
                               conclusion
    FRA is grateful for the opportunity to present these 
recommendations to this distinguished subcommittee. The Association 
reiterates its profound gratitude for the extraordinary progress this 
subcommittee has made in advancing a wide range of military personnel 
and retiree benefits and quality-of-life programs for all uniformed 
services personnel and their families and survivors. Thank you again 
for the opportunity to present the FRA's views on these critically 
important topics.

    Senator Webb. Thank you very much, Mr. Barnes.
    Ms. Moakler, welcome.

    STATEMENT OF KATHLEEN B. MOAKLER, GOVERNMENT RELATIONS 
         DIRECTOR, NATIONAL MILITARY FAMILY ASSOCIATION

    Ms. Moakler. Thank you. Chairman Webb, Senator Graham, 
thank you for the opportunity to speak today on behalf of 
military families, our Nation's military families.
    Many families are facing their ninth year of deployment, 
many have dealt with multiple deployments. We have second-
graders who have only known a lifestyle with a parent absent 
from their lives for months at a time, over and over again. We 
appreciate the many initiatives and programs supported by this 
subcommittee in the past. Military OneSource, increased 
benefits and support for surviving families, and the Yellow 
Ribbon Program are just a few. We have expanded access to 
mental health counseling across components, although the need 
continues to grow.
    Now military families expect these programs. They have 
become part of the overall fabric of family readiness. The 
challenge that now faces us is making sure that our family 
readiness programs receive sustained funding and continue to be 
included in the annual budget process. As the war has 
progressed, family readiness requirements have evolved. Some 
new programs have been initiated without evaluating already 
existing programs to see how they might have been adapted.
    The congressionally-mandated Military Family Readiness 
Council has begun an evaluation process. We endorse this 
process and hope that it will result in the elimination of 
repetitive or redundant programs. Existing programs can be 
improved, such as adding provisions for travel for family 
members participating in the Reserve-component Yellow Ribbon 
Program.
    With budget cuts and shortfalls looming, we should not 
randomly reduce funding to family programs, across the board. 
As redundant programs are identified, their elimination can add 
to efficiencies. Servicemembers and their families cite MWR 
programs, like gyms, libraries, and other installation-provided 
services, as important to their well-being during deployments. 
Substantial cuts to these programs make them wonder why 
Services talk about support, yet often cut or reduce the same 
programs that are identified as the most important by our 
families.
    One of the ways to evaluate the efficacy of programs is 
research. Our Association has spoken, for several years, 
concerning research into the effects of continuing deployments 
on our most vulnerable population: our military children. We 
appreciate the inclusion of a provision calling for a study in 
last year's NDAA. In May 2008, we commissioned the RAND 
Corporation to do a longitudinal study on the experience of 
1,500 families. Over the course of a year, RAND interviewed 
both the nondeployed caregiver parent and one child per family 
between the ages of 11 and 17. We addressed two key questions: 
How are school-aged children faring? What types of issues do 
military children face, related to deployment?
    The baseline findings were published in the January issue 
of the Journal of Pediatrics. The study found, as the months of 
parental deployment increased, so did the child's challenges. 
The total number of months away mattered more than the number 
of deployments. Older children experienced more difficulties 
during deployment, and there is a direct correlation between 
the mental health of the caregiver and the well-being of the 
child. It was interesting to note that in the initial findings, 
there were no differences in results between Service or 
components.
    What are the implications? Families facing longer 
deployments need targeted support, especially for older teens 
and girls. Supports need to be in place across the entire 
deployment cycle, including reintegration, and some nondeployed 
parents may need targeted mental health support.
    We still hear about needs for childcare. While most 
traditional childcare needs are being met, innovative 
strategies for after-hours care and respite care should be 
explored. These strategies need to be implemented across the 
Services, as well. Drop-in care for medical appointments, 
either at the Center for Disease Control or at the military 
treatment facility itself, can go a long way in improving 
access to care and eliminating missed appointments.
    I, too, must bring up the MyCAA Program, with an underline 
and an exclamation point. Several years ago, Congress mandated 
DOD create a program to promote portable careers for military 
spouses. The result was a very popular MyCAA program. Recent 
numbers indicate that 98,000 spouses already are enrolled in 
the program, an additional 38,000 have applied but have not yet 
completed the process. Unfortunately, DOD, as we have heard 
today, has recently had to suspend the program. We have heard, 
from many concerned military spouses using the MyCAA program, 
about the loss of funding for courses in which they were 
enrolled, and how they are scrambling to come up with the funds 
to continue, be it for an individual course that they are 
taking online or a semester.
    But, I think what bothered them the most was the way the 
notification was handled. There was no advance notification, 
information was sent via a press release. This, when the 
program was in possession of everyone's email address. Many 
view this as one more frustration in 8 long years of 
frustrations.
    The program may be a victim of its own success. We are 
unsure as to whether it was the lack of funds or an application 
overload, or both, that caused the suspension. We ask that the 
program be resumed as soon as possible, and that it be properly 
funded.
    We thank you for your support of our servicemembers and 
their families. We urge you to remember their service as you 
work to resolve the many issues facing our country. Working 
together, we can improve the quality of life for all these 
families.
    Thank you, and I await your questions.
    [The prepared statement of Ms. Moakler follows:]
               Prepared Statement by Kathleen B. Moakler
    Chairman Webb and distinguished members of the subcommittee, the 
National Military Family Association would like to thank you for the 
opportunity to present testimony on the quality of life of military 
families--the Nation's families. As the war has continued, the quality 
of life of our servicemembers and their families has been severely 
impacted. Your recognition of the sacrifices of these families and your 
response through legislation to the increased need for support have 
resulted in programs and policies that have helped sustain our families 
through these difficult times.
    We endorse the recommendations contained in the statement submitted 
by The Military Coalition. In this statement, our Association will 
expand on several issues of importance to military families:

          I. Family Readiness
          II. Family Health
          III. Family Transitions
                          i. family readiness
    The National Military Family Association believes policies and 
programs should provide a firm foundation for families buffeted by the 
uncertainties of deployment and transformation. It is imperative full 
funding for these programs be included in the regular budget process 
and not merely added on as part of supplemental funding. We promote 
programs that expand and grow to adapt to the changing needs of 
servicemembers and families as they cope with multiple deployments and 
react to separations, reintegration, and the situation of those 
returning with both visible and invisible wounds. Standardization in 
delivery, accessibility, and funding are essential. Programs should 
provide for families in all stages of deployment and reach out to them 
in all geographic locations. Families should be given the tools to take 
greater responsibility for their own readiness.
    We appreciate provisions in the National Defense Authorization Acts 
and Appropriations legislation in the past several years that 
recognized many of these important issues. Excellent programs exist 
across the Department of Defense (DOD) and the Services to support our 
military families. There are redundancies in some areas, and times when 
a new program was initiated before looking to see if an existing 
program could be adapted to answer an evolving need. Servicemembers and 
their families are continuously in the deployment cycle, anticipating 
the next separation, in the throes of deployment, or trying to 
reintegrate after the servicemember returns. Dwell times seem shorter 
and shorter as training, schools, and relocation impede on time that is 
spent in the family setting.
    ``My husband will have 3 months at home with us between deployment 
and being sent to school in January for 2 months and we will be PCSing 
soon afterwards. . . . This does not leave much time for reintegration 
and reconnection.''--Army Spouse
    We feel that now is the time to look at best practices and at those 
programs that are truly meeting the needs of families. In this section 
we will talk about existing programs, highlight best practices, and 
identify needs.
Child Care
    At every military family conference we attended last year, child 
care was in the top five issues affecting families--drop-in care being 
the most requested need. Some installations are responding to these 
needs in innovative ways. For instance, in a recent visit to Kodiak, 
Alaska, we noted the gym facility provided watch care for its patrons. 
Mom worked out on the treadmill or elliptical while her child played in 
a safe carpeted and fenced-in area right across from her. Another area 
of the gym, previously an aerobics room, had been transformed into a 
large play area for ``Mom and me'' groups to play in the frequently 
inclement weather. These solutions aren't expensive but do require 
thinking outside the box.
    Innovative strategies are needed to address the non-availability of 
after-hours child care (before 6 a.m. and after 6 p.m.) and respite 
care. We applaud the partnership between the Services and the National 
Association of Child Care Resource and Referral Agencies that provides 
subsidized child care to families who cannot access installation based 
child development centers. We also appreciate the new SitterCity.com 
contract that will help military families find caregivers and military 
subsidized child care providers.
    Still, families often find it difficult to obtain affordable, 
quality care especially during hard-to-fill hours and on weekends. Both 
the Navy and the Air Force have programs that provide 24/7 care. These 
innovative programs must be expanded to provide care to more families 
at the same high standard as the Services' traditional child 
development programs. The Army, as part of the funding attached to its 
Army Family Covenant, has rolled out more space for respite care for 
families of deployed soldiers. Respite care is needed across the board 
for the families of the deployed and the wounded, ill, and injured. We 
are pleased the Services have rolled out more respite care for special 
needs families, but since the programs are new we are unsure of the 
impact it will have on families. We are concerned, however, when we 
hear of some installations already experiencing shortfalls of funding 
for respite care early in the year.
    At our Operation Purple* Healing Adventures camp for families of 
the wounded, ill, and injured, families told us there is a tremendous 
need for access to adequate child care on or near military treatment 
facilities. Families need the availability of child care in order to 
attend medical appointments, especially mental health appointments. Our 
Association encourages the creation of drop-in child care for medical 
appointments on the DOD or VA premises or partnerships with other 
organizations to provide this valuable service.
    We appreciate the requirement in the National Defense Authorization 
Act for Fiscal Year 2010 calling for a report on financial assistance 
provided for child care costs across the Services and components to 
support the families of those servicemembers deployed in support of a 
contingency operation and we look forward to the results.
    Our Association urges Congress to ensure resources are available to 
meet the child care needs of military families to include hourly, drop-
in, and increased respite care across all Services for families of 
deployed servicemembers and the wounded, ill, and injured, as well as 
those with special needs family members.
Working with Youth
    Older children and teens must not be overlooked. School personnel 
need to be educated on issues affecting military students and must be 
sensitive to their needs. To achieve this goal, schools need tools. 
Parents need tools, too. Military parents constantly seek more 
resources to assist their children in coping with military life, 
especially the challenges and stress of frequent deployments. Parents 
tell us repeatedly they want resources to ``help them help their 
children.'' Support for parents in their efforts to help children of 
all ages is increasing, but continues to be fragmented. New Federal, 
public-private initiatives, increased awareness, and support by DOD and 
civilian schools educating military children have been developed. 
However, many military parents are either not aware such programs exist 
or find the programs do not always meet their needs.
    Our Association is working to meet this pressing need through our 
Operation Purple* Summer Camps. Unique in its ability to reach out and 
gather military children of different age groups, Services, and 
components, our Operation Purple program provides a safe and fun 
environment in which military children feel immediately supported and 
understood. Now in our seventh year, we have sent more than 30,000 
children to camp for free with the support of private donors. This 
year, we expect to send another 10,000 children to camp at 67 locations 
in 34 States and Guam, and Germany. We also provided the camp 
experience to families of the wounded. In 2009, we introduced a new 
program under our Operation Purple umbrella, offering family 
reintegration retreats in the national parks. They have been well 
received by our families and more apply than can attend. We are 
offering 10 retreats this year.
    Through our Operation Purple camps, our Association has begun to 
identify the cumulative effects multiple deployments are having on the 
emotional growth and well being of military children and the challenges 
posed to the relationship between deployed parent, caregiver, and 
children in this stressful environment. Understanding a need for 
qualitative analysis of this information, we commissioned the RAND 
Corporation to conduct a pilot study in 2007 aimed at the current 
functioning and wellness of military children attending Operation 
Purple camps and assessing the potential benefits of the Operation 
Purple program in this environment of multiple and extended 
deployments.
    In May 2008, we embarked on phase two of the project--a 
longitudinal study on the experience of 1,507 families, which is a much 
larger and more diverse sample than included in our pilot study. RAND 
followed these families for 1 year, and interviewed the nondeployed 
caregiver/parent and one child per family between 11 and 17 years of 
age at three time points over the year. Recruitment of participants was 
extremely successful because families were eager to share their 
experiences. The research addressed two key questions:

          How are school-age military children faring?
          What types of issues do military children face related to 
        deployment?

    In December, the baseline findings of the research were published 
in the journal Pediatrics. Findings showed:

         As the months of parental deployment increased, so did 
        the child's challenges.
         The total number of months away mattered more than the 
        number of deployments.
         Older children experienced more difficulties during 
        deployment.
         There is a direct correlation between the mental 
        health of the caregiver and the well-being of the child.
         Girls experienced more difficulty during 
        reintegration, the period of months readjusting after the 
        servicemember's homecoming.
         About one-third of the children reported symptoms of 
        anxiety, which is somewhat higher than the percentage reported 
        in other national studies of children.
         In these initial findings, there were no differences 
        in results between Services or components.

    What are the implications? Families facing longer deployments need 
targeted support--especially for older teens and girls. Supports need 
to be in place across the entire deployment cycle, including 
reintegration, and some nondeployed parents may need targeted mental 
health support. One way to address these needs would be to create a 
safe, supportive environment for older youth and teens. Dedicated Youth 
Centers with activities for our older youth would go a long way to help 
with this. Our Association, as an outgrowth of the study results, will 
be holding a summit in early May, where we will be engaging with 
experts to isolate action items that address the issues surfaced in the 
study. We will be happy to share these action items with you.
    Our Association feels that more dedicated resources, such as youth 
or teen centers, would be a first step toward addressing the needs of 
our older youth and teens during deployment.
Families Overseas
    Families stationed overseas face increased challenges when their 
servicemember is deployed into theater. One such challenge we have 
heard from families stationed in EUCOM concerns care for a family 
member, usually the spouse, who may be injured or confined to bed for 
an extended illness during deployment. Instead of pulling the 
servicemember back from theater, why not provide transportation for an 
extended family member or friend to come from the States to care for 
the injured or ill family member? This was a recommendation from the 
EUCOM Quality of Life conference for several years.
    Our Association asks that transportation be provided for a 
designated caregiver to an overseas duty station to care for an 
incapacitated spouse when a servicemember is deployed.
Military Housing
    In the recent RAND study of military children on the home front 
commissioned by our Association, researchers found that living in 
military housing was related to fewer caregiver reported deployment-
related challenges. For instance, fewer caregivers who lived in 
military housing reported that their children had difficulties 
adjusting to parent absence (e.g., missing school activities, feeling 
sad, not having peers who understand what their life is like) as 
compared to caregivers who needed to rent their homes. In a subsequent 
survey, the study team explored the factors that determine a military 
family's housing situation in more detail. Among the list of potential 
reasons provided for the question, ``Why did you choose to rent?'' 
researchers found that the top three reasons parents/caregivers cited 
for renting included: military housing was not available (31 percent); 
renting was most affordable (28 percent), and preference to not invest 
in the purchase of a home (26 percent).
    Privatized housing expands the opportunity for families to live on 
the installation and is a welcome change for military families. We are 
pleased with the annual report that addresses the best practices for 
executing privatized housing contracts. As privatized housing evolves 
the Services are responsible for executing contracts and overseeing the 
contractors on their installations. With more joint basing, more than 
one Service often occupies an installation. The Services must work 
together to create consistent policies not only within their Service 
but across the Services as well. Pet policies, deposit requirements, 
and utility polices are some examples of differences across 
installations and across Services. How will Commanders address these 
variances as we move to joint basing? Our families face many 
transitions when they move, and navigating the various policies and 
requirements of each contractor is frustrating and confusing. It's time 
for the Services to increase their oversight and work on creating 
seamless transitions by creating consistent policies across the 
Services.
    We are pleased the NDAA for Fiscal Year 2010 calls for a report on 
housing standards and housing surveys used to determine the Basic 
Allowance for Housing (BAH) and hope Congress will work to address BAH 
inequities.
    Privatized housing is working! We ask Congress to consider the 
importance of family well-being as a reason for expanding the amount of 
privatized housing for our military families.
Commissaries and Exchanges
    The commissary is a vital part of the compensation package for 
servicemembers and retirees, and is valued by them, their families, and 
survivors. Our surveys indicate that military families consider the 
commissary one of their most important benefits. In addition to 
providing average savings of more than 30 percent over local 
supermarkets, commissaries provide a sense of community. Commissary 
shoppers gain an opportunity to connect with other military families, 
and are provided with information on installation programs and 
activities through bulletin boards and publications. Commissary 
shoppers also receive nutritional information through commissary 
promotions and campaigns, as well as the opportunity for educational 
scholarships.
    Our Reserve component families have benefited greatly from the 
addition of case lot sales. We thank Congress again for the provision 
allowing the use of proceeds from surcharges collected at these sales 
to help defray their costs. Not only have these case lot sales been 
extremely well received and attended by family members not located near 
an installation, they have extended this important benefit to our 
entire military community.
    Our Association continues to be concerned that there will not be 
enough commissaries to serve areas experiencing substantial growth, 
including those locations with servicemembers and families relocated by 
BRAC. The surcharge was never intended to pay for DOD and Service 
transformation. Additional funding is needed to ensure commissaries are 
built or expanded in areas that are gaining personnel as a result of 
these programs.
    Our Association believes that additional funding is needed to 
ensure commissaries are built or expanded in areas that are gaining 
personnel due to BRAC and transformation.
    The military exchange system, like the commissary, provides 
valuable cost savings to members of the military community, while 
reinvesting their profits in essential Morale, Welfare and Recreation 
(MWR) programs. Our Association strongly believes that every effort 
must be made to ensure that this important benefit and the MWR revenue 
is preserved, especially as facilities are down-sized or closed 
overseas. In addition, exchanges must continue to be responsive to the 
needs of deployed servicemembers in combat zones and have the right mix 
of goods at the right prices for the full range of beneficiaries.
    As a member of the Defense Commissary Patron Council and a strong 
proponent of the military exchange system, our Association remains 
committed to protecting commissary and exchange benefits which are 
essential to the quality of life of our servicemembers, retirees, 
families and survivors.
Flexible Spending Accounts
    We would like to thank Members of Congress for the Sense of 
Congress on the establishment of Flexible Spending Accounts for 
uniformed servicemembers. We hope this subcommittee will press each of 
the seven Service Secretaries to establish these important pre-tax 
savings accounts in a consistent manner. Flexible Spending Accounts 
would be especially helpful for families with out-of-pocket dependent 
care and health care expenses. We ask that the flexibility of a 
rollover or transfer of funds to the next year be considered.
Financial Readiness
    Financial readiness is a critical component of family readiness. 
Our Association applauds DOD for tackling financial literacy head-on 
with their Financial Readiness Campaign. Financial literacy and 
education must continue to be on the forefront. We are strong 
supporters of the Military Lending Act (MLA) and hope Congress will 
press States to enforce MLA regulations within their State borders. 
With the depressed economy, many families may turn to payday lenders. 
DOD must continue to monitor the MLA and its effectiveness of derailing 
payday lenders.
    Military families are not immune from the housing crisis. We 
applaud Congress for expanding the Homeowners' Assistance Program to 
wounded, ill, and injured servicemembers, survivors, and servicemembers 
with Permanent Change of Station orders meeting certain parameters. We 
have heard countless stories from families across the Nation who have 
orders to move and cannot sell their home. Due to the mobility of 
military life, military homeowners must be prepared to be a landlord. 
We encourage DOD to continue to provide financial education to military 
servicemembers and their families to help families make sound financial 
decisions. We also encourage DOD to continue to track the impact of the 
housing crisis on our military families.
    We appreciate the increase to the Family Separation Allowance (FSA) 
that was made at the beginning of the war. In more than 8 years, 
however, there has not been another increase. We ask that the FSA be 
indexed to the Cost of Living Allowance (COLA) to better reflect rising 
costs for services.
    Increase the Family Separation Allowance by indexing it to COLA.
                           ii. family health
    Family readiness calls for access to quality health care and mental 
health services. Families need to know the various elements of their 
military health system are coordinated and working as a synergistic 
system. Our Association is concerned the DOD military health care 
system may not have all the resources it needs to meet both the 
military medical readiness mission and provide access to health care 
for all beneficiaries. It must be funded sufficiently, so the direct 
care system of Military Treatment Facilities (MTFs) and the purchased 
care segment of civilian providers can work in tandem to meet the 
responsibilities given under the TRICARE contracts, meet readiness 
needs, and ensure access for all military beneficiaries.
Military Health System
    Improving Access to Care
    In the question and answer period during a hearing of this 
subcommittee on June 3, 2009, Senator Lindsey Graham (R-SC) asked panel 
members to ``give a grade to TRICARE.'' Panel members rated TRICARE a 
``B'' or a ``C minus.'' Our Association's Director of Government 
Relations stated it was a two-part question and assigned a grade of 
``B'' for quality of care and ``C-'' for access to care. We welcomed 
this discussion focused on access issues in the direct care system--our 
military hospitals and clinics--reinforcing what our Association has 
observed for years. We have consistently heard from families that their 
greatest health care challenge has been getting timely care from their 
local military hospital or clinic.
    Our Association continues to examine military families' experiences 
with accessing the Military Health System (MHS). Families' main issues 
are: access to their Primary Care Managers (PCM); getting someone to 
answer the phone at central appointments; having appointments available 
when they finally got through to central appointments; after hours 
care; getting a referral for specialty care; being able to see the same 
provider or PCM; and having appointments available 60, 90, and 120 days 
out in our MTFs for follow-ups recommended by their providers. Families 
familiar with how the MHS referral system works seem better able to 
navigate the system. Those families who are unfamiliar report delays in 
receiving treatment or sometimes decide to give up on the referral 
process and never obtain a specialty appointment. Continuity of care is 
important to maintain quality of care. The MTFs are stressed from 8 
years of provider deployments, directly affecting the quality of care 
and contributing to increased costs. Our Association thanks Congress 
for requiring, in the NDAA for Fiscal Year 2009, a report on access to 
care and we look forward to the findings. This report must distinguish 
between access issues in the MTFs, as opposed to access in the civilian 
TRICARE networks.
    Our most seriously wounded, ill, and injured servicemembers, 
veterans, and their families are assigned case managers. In fact, there 
are many different case managers: Federal Recovery Coordinators (FRC), 
Recovery Care Coordinators, coordinators from each branch of Service, 
TBI care coordinators, VA liaisons, et cetera. The goal is for a 
seamless transition of care between and within the two governmental 
agencies, DOD and the VA. However, with so many coordinators to choose 
from, families often wonder which one is the ``right'' case manager. We 
often hear from families, some whose servicemember has long been 
medically retired with a 100 percent disability rating or others with 
less than 1 year from date-of-injury, who have not yet been assigned a 
FRC. We need to look at whether the multiple, layered case managers 
have streamlined the process, or have only aggravated it. Our 
Association still finds families trying to navigate alone a variety of 
complex health care systems, trying to find the right combination of 
care. Individual Service wounded, ill, and injured program directors 
and case managers are often reluctant to inform families that FRCs 
exist or that the family qualifies for one. Many qualify for and use 
Medicare, VA, DOD's TRICARE direct and purchased care, private health 
insurance, and State agencies. Why can't the process be streamlined?
    Support for Special Needs Families
    Case management for military beneficiaries with special needs is 
not consistent because the coordination of the military family's care 
is being done by a non-synergistic health care system. Beneficiaries 
try to obtain an appointment and then find themselves getting partial 
health care within the MTF, while other health care is referred out 
into the purchased care network. Thus, military families end up 
managing their own care. Incongruence in the case management process 
becomes more apparent when military family members transfer from one 
TRICARE region to another and is further exacerbated when a special 
needs family member is involved. Families need a seamless transition 
and a warm handoff between TRICARE regions and a universal case 
management process across the MHS. Each TRICARE Managed Care Contractor 
has created different case management processes. The current case 
management system is under review by DOD and the TRICARE Management 
Activity.
    We applaud Congress and DOD's desire to create robust health care, 
educational, and family support services for special needs children. 
But, these robust services do not follow them when they retire. We 
encourage the Services to allow these military families the opportunity 
to have their final duty station be in an area of their choice. We 
suggest the Extended Care Health Option (ECHO) be extended for 1 year 
after retirement for those already enrolled in ECHO prior to 
retirement. If the ECHO program is extended, it must be for all who are 
eligible for the program. We should not create a different benefit 
simply based on diagnosis.
    There has been discussion over the past years by Congress and 
military families regarding the ECHO program. The NDAA for Fiscal Year 
2009 included a provision to increase the cap on certain benefits under 
the ECHO program and the NDAA for Fiscal Year 201O established the 
Office of Community Support for Military Families with Special Needs. 
The ECHO program was originally designed to allow military families 
with special needs to receive additional services to offset their lack 
of eligibility for State or federally provided services impacted by 
frequent moves. We suggest that before making any more adjustments to 
the ECHO program, Congress should direct DOD to certify if the ECHO 
program is working as it was originally designed and if it has been 
effective in addressing the needs of this population. We need to make 
the right fixes so we can be assured we apply the correct solutions. 
This new office will go a long way in identifying and addressing 
special needs. However, we must remember that our special needs 
families often require medical, educational and family support 
resources. This new office must address all these various needs in 
order to effectively implement change.
    National Guard and Reserve Member Family Health Care
    National Guard and Reserve families need increased education about 
their health care benefits. We also believe that paying a stipend to a 
mobilized National Guard or Reserve member for their family's coverage 
under their employer-sponsored insurance plan while the servicemember 
is deployed may work out better for many families in areas where the 
TRICARE network may not be robust.
    Grey Area Reservists
    Our Association would like to thank Congress for the new TRICARE 
benefit for Grey Area Reservists. We want to make sure this benefit is 
quickly implemented and they have access to a robust network.
    TRICARE Reimbursement
    Our Association is concerned that continuing pressure to lower 
Medicare reimbursement rates will create a hollow benefit for TRICARE 
beneficiaries. As the 111th Congress takes up Medicare legislation, we 
request consideration of how this legislation will impact military 
families' health care, especially our most vulnerable service, access 
to mental health.
    National provider shortages in the mental health field, especially 
in child and adolescent psychology, are exacerbated in many cases by 
low TRICARE reimbursement rates, TRICARE rules, or military-unique 
geographic challenges--for example large populations in rural or 
traditionally underserved areas. Many mental health providers are 
willing to see military beneficiaries on a voluntary status. However, 
these providers often tell us they will not participate in TRICARE 
because of what they believe are time-consuming requirements and low 
reimbursement rates. More must be done to persuade these providers to 
participate in TRICARE and become a resource for the entire system, 
even if that means DOD must raise reimbursement rates.
    Pharmacy
    We caution DOD about generalizing findings of certain beneficiary 
pharmacy behaviors and automatically applying them to our Nation's 
unique military population. We encourage Congress to require DOD to 
utilize peer-reviewed research involving beneficiaries and prescription 
drug benefit options, along with performing additional research 
involving military beneficiaries, before making any recommendations on 
prescription drug benefit changes, such as co-payment and tier 
structure changes for military servicemembers, retirees, their 
families, and survivors.
    We appreciate the inclusion of Federal pricing for the TRICARE 
retail pharmacies in the NDAA for Fiscal Year 2008. However, we still 
need to examine its effect on the cost of medications for both 
beneficiaries and DOD. Also, we will need to see how this potentially 
impacts Medicare, civilian private insurance, and the National Health 
Care Reform affecting drug pricing negotiations.
    We believe it is imperative that all medications available through 
TRICARE Retail Pharmacy (TRRx) should also be available through TRICARE 
Mail Order Pharmacy (TMOP). Medications treating chronic conditions, 
such as asthma, diabetes, and hypertension should be made available at 
the lowest level of co-payment regardless of brand or generic status. 
We agree with the recommendations of the Task Force on the Future of 
Military Health Care that over-the-counter (OTC) drugs be a covered 
pharmacy benefit and there be a zero co-pay for TMOP Tier 1 
medications.
    The new T3 TRICARE contract will provide TRICARE Managed Care 
Contractors and Express-Scripts, Inc. the ability to link pharmacy data 
with disease management. This will allow for better case management, 
increase compliance, and decrease cost, especially for our chronically 
ill beneficiaries. However, this valuable tool is currently unavailable 
because the T3 contract is still under protest and has not yet been 
awarded.
    National Health Care Proposal
    Our Association is cautious about current rhetoric by the 
administration and Congress regarding National Health Care Reform. We 
request consideration of how this legislation will also impact TRICARE.
    The perfect storm is brewing. TMA will hopefully be instituting the 
new T3 contract in 2011. Currently, there is the possibility that two 
out of three TRICARE Managed Care Contractors could change. This means 
that the contracts of 66 percent of our TRICARE providers would need to 
be renegotiated. Add the demands and uncertainties to providers in 
regards to health care reform and Medicare reimbursement rate changes. 
This leads to our concern regarding the impact on providers' 
willingness to remain in the TRICARE network and the recruitment of new 
providers. The unintended consequences maybe a decrease in access to 
care due the lack of available health care providers.
    DOD Must Look for Savings
    We ask Congress to establish better oversight for DOD's 
accountability in becoming more cost-efficient. We recommend:

         Requiring the Comptroller General to audit MTFs on a 
        random basis until all have been examined for their ability to 
        provide quality health care in a cost-effective manner;
         Creating an oversight committee, similar in nature to 
        the Medicare Payment Advisor Commission, which provides 
        oversight to the Medicare program and makes annual 
        recommendations to Congress. The Task Force on the Future of 
        Military Health Care often stated it was unable to address 
        certain issues not within their charter or the timeframe in 
        which they were commissioned to examine the issues. This 
        Commission would have the time to examine every issue in an 
        unbiased manner.
         Establishing a Unified ``Joint'' Medical Command 
        structure, which was recommended by the Defense Health Board in 
        2006 and 2009.

    Our Association believes optimizing the capabilities of the 
facilities of the direct care system through timely replacement of 
facilities, increased funding allocations, and innovative staffing 
would allow more beneficiaries to be cared for in the MTFs, which DOD 
asserts is the most cost effective. The Task Force made recommendations 
to make the DOD MHS more cost-efficient which we support. They conclude 
the MHS must be appropriately sized, resourced, and stabilized; and 
make changes in its business and health care practices.
    We suggest additional funding and flexibility in hiring practices 
to address MTF provider deployments.
    Our Association recommends a 1 year transitional active duty ECHO 
benefit for all eligible family members of servicemembers who retire.
    We believe that Reserve component families should be given the 
choice of a stipend to continue their employer provided care during 
deployment.
Behavioral Health Care
    Our Nation must help returning servicemembers and their families 
cope with the aftermath of war. DOD, VA, and State agencies must 
partner in order to address behavioral health issues early in the 
process and provide transitional mental health programs. Partnering 
will also capture the National Guard and Reserve member population, who 
often straddle these agencies' health care systems.
    Full Spectrum of Care
    As the war continues, families' need for a full spectrum of 
behavioral health services--from preventative care and stress reduction 
techniques, to counseling and medical mental health services--continues 
to grow. The military offers a variety of psychological health 
services, both preventative and treatment, across many agencies and 
programs. However, as servicemembers and families experience numerous 
lengthy and dangerous deployments, we believe the need for 
confidential, preventative psychological health services will continue 
to rise. It will remain high, even after military operations scale 
down. Our study on the impact of the war on caregivers and children 
found the mental health of the caregiver directly affects the overall 
well-being of the children. Therefore, we need to treat the family as a 
unit rather than as individuals because the caregiver's health 
determines the quality of life for the children.
    Access to Behavioral Health Care
    Our Association is concerned about the overall shortage of mental 
health providers in TRICARE's direct and purchased care network. DOD's 
Task Force on Mental Health stated timely access to the proper 
psychological health provider remains one of the greatest barriers to 
quality mental health services for servicemembers and their families. 
The Army Family Action Plan (AFAP) identified mental health issues as 
their number three issue for 2010. While families are pleased more 
mental health providers are available in theater to assist their 
servicemembers, they are disappointed with the resulting limited access 
to providers at home. Families are reporting increased difficulty in 
obtaining appointments with social workers, psychologists, and 
psychiatrists at their MTFs and clinics. The military fuels the 
shortage by deploying some of its child and adolescent psychology 
providers to combat zones. Providers remaining at home report they are 
overwhelmed by treating active duty members and are unable to fit 
family members into their schedules. This can lead to provider 
compassion fatigue, creating burnout and exacerbating the provider 
shortage problem.
    We have seen an increase in the number of mental health providers 
joining the purchased care side of the TRICARE network. However, the 
access standard is 7 days. We hear from military families after 
accessing the mental health provider lists on the contractors' web 
sites that the provider is full and no longer taking TRICARE patients. 
The list must be up-to-date in order to handle real time demands by 
families. We need to continue to recruit more mental health providers 
to join the TRICARE network and we need to make sure we specifically 
add those in specialty behavioral health care areas, such as child and 
adolescence psychology and psychiatrists.
    Families must be included in mental health counseling and treatment 
programs for servicemembers. Family members are a key component to a 
servicemember's psychological well-being. Families want to be able to 
access care with a mental health provider who understands or is 
sympathetic to the issues they face. We recommend an extended outreach 
program to servicemembers, veterans, and their families of available 
mental health resources, such as DOD, VA, and State agencies. We 
appreciate the VA piloting programs that incorporate active duty 
servicemembers and their families into their newly established OIF/OEF 
health care clinics. The family is accessed as a ``unit'' and educated 
about the VA's benefits and services. These initiatives need to be 
expanded throughout the VA and fully funded.
    Frequent and lengthy deployments create a sharp need in mental 
health services by family members and servicemembers as they get ready 
to deploy and after their return. There is also an increase in demand 
in the wake of natural disasters, such as hurricanes and fires. We need 
to maintain a flexible pool of mental health providers who can increase 
or decrease rapidly in numbers depending on demand on the MHS side. 
Currently, Military Family Life Consultants and Military OneSource 
counseling are providing this type of service for military families on 
the family support side. The recently introduced web-based TRICARE 
Assistance Program (TRIAP) offers another vehicle for nonmedical 
counseling, especially for those who live far from counselors. We need 
to make the Services, along with military family members, more aware of 
resources along the continuum. We need the flexibility of support in 
both the MHS and family support arenas, as well as coordination of 
support between these two entities. We must educate civilian network 
providers about our culture. Communities along with nongovernment 
organizations are beginning to fulfill this role, but more needs to be 
done.
    Availability of Treatment
    Do DOD, VA, and State agencies have adequate mental health 
providers, programs, outreach, and funding? Better yet, where will the 
veteran's spouse and children go for help? Many will be left alone to 
care for their loved one's invisible wounds resulting from frequent and 
long combat deployments. Who will care for them when they are no longer 
part of the DOD health care system?
    The Army's Mental Health Advisory Team (MHAT) IV report links 
reducing family issues to reducing stress on deployed servicemembers. 
The team found the top noncombat stressors were deployment length and 
family separation. They noted soldiers serving a repeat deployment 
reported higher acute stress than those on their first deployment and 
the level of combat was the major contribution for their psychological 
health status upon return. Our study on the impact of deployment on 
caregivers and children found it was the cumulative time deployed that 
caused increased stress. These reports demonstrate the amount of stress 
being placed on our troops and their families.
    Our Association is especially concerned with the scarcity of 
services available to the families as they leave the military following 
the end of their activation or enlistment. Due to the servicemember's 
separation, the families find themselves ineligible for TRICARE, 
Military OneSource, and are very rarely eligible for health care 
through the VA. Many will choose to locate in rural areas lacking 
available mental health providers. We need to address the distance 
issues families face in finding mental health resources and obtaining 
appropriate care. Isolated servicemembers, veterans, and their families 
do not have the benefit of the safety net of services and programs 
provided by MTFs, VA facilities, Community-Based Outpatient Centers and 
Vet Centers. We recommend:

         using alternative treatment methods, such as 
        telemental health;
         modifying licensing requirements in order to remove 
        geographic practice barriers that prevent psychological health 
        providers from participating in telemental health services 
        outside of a VA facility;
         educating civilian network psychological health 
        providers about our military culture as the VA incorporates 
        Project Hero; and
         encouraging DOD and VA to work together to provide a 
        seamless ``warm hand-off'' for families, as well as 
        servicemembers transitioning from active duty to veteran status 
        and funding additional transitional support programs if 
        necessary.
    National Guard and Reserve Members
    The National Military Family Association is especially concerned 
about fewer mental health care services available for the families of 
returning National Guard and Reserve members. Some are eligible for 
TRICARE Reserve Select but, as we know, National Guard and Reserve 
members are often located in rural areas where there may be fewer 
mental health providers available. Policymakers need to address the 
distance issues that families face in linking with military mental 
health resources and obtaining appropriate care. Isolated National 
Guard and Reserve families do not have the benefit of the safety net of 
services provided by MTFs and installation family support programs. 
Families want to be able to access care with a provider who understands 
or is sympathetic to the issues they face. We recommend the use of 
alternative treatment methods, such as telemental health; increasing 
mental health reimbursement rates for rural areas; modifying licensing 
requirements in order to remove geographic practice barriers that 
prevent mental health providers from participating in telemental health 
services; and educating civilian network mental health providers about 
our military culture. We urge DOD to expand information outreach about 
the new TRIAP program, which provides access to non-medical counseling 
via phone and web through the TRICARE managed care support contractors. 
We hear the National Guard Bureau's Psychological Health Services (PHs) 
is not working as designed to address members' mental health issues. 
This program needs to be evaluated to determine its effectiveness.
    Children
    Our Association is concerned about the impact deployment and/or the 
injury of the servicemember is having on our most vulnerable 
population, children of our military servicemember and veterans. Our 
study on the impact of the war on caregivers and children found 
deployments are creating layers of stressors, which families are 
experiencing at different stages. Teens especially carry a burden of 
care they are reluctant to share with the non-deployed parent in order 
to not ``rock the boat.'' They are often encumbered by the feeling of 
trying to keep the family going, along with anger over changes in their 
schedules, increased responsibility, and fear for their deployed 
parent. Children of the National Guard and Reserve members face unique 
challenges since there are no military installations for them to 
utilize. They find themselves ``suddenly military'' without resources 
to support them. School systems are generally unaware of this change in 
focus within these family units and are ill prepared to lookout for 
potential problems caused by these deployments or when an injury 
occurs. Also vulnerable are children who have disabilities that are 
further complicated by deployment and subsequent injury of the 
servicemembers. Their families find stress can be overwhelming, but are 
afraid to reach out for assistance for fear of retribution to the 
servicemember's career. They often choose not to seek care for 
themselves or their families. We appreciate the inclusion of a study on 
the mental health needs of our children in the NDAA for Fiscal Year 
201O.
    The impact of the wounded, ill, and injured on children is often 
overlooked and underestimated. Military children experience a 
metaphorical death of the parent they once knew and must make many 
adjustments as their parent recovers. Many families relocate to be near 
the treating MTF or the VA Polytrauma Center in order to make the 
rehabilitation process more successful. As the spouse focuses on the 
rehabilitation and recovery, older children take on new roles. They may 
become the caregivers for other siblings, as well as for the wounded 
parent. Many spouses send their children to stay with neighbors or 
extended family members, as they tend to their wounded, ill, and 
injured spouse. Children get shuffled from place to place until they 
can be reunited with their parents. Once reunited, they must adapt to 
the parent's new injury and living with the ``new normal.'' We 
appreciate the inclusion of a study to assess the impact on children of 
the severely wounded in the NDAA for Fiscal Year 2010.
    We encourage partnerships between government agencies, DOD, VA, and 
State agencies and recommend they reach out to those private and 
nongovernmental organizations who are experts on children and 
adolescents. They could identify and incorporate best practices in the 
prevention and treatment of mental health issues affecting our military 
children. We must remember to focus on preventative care upstream, 
while still in the active duty phase, in order to have a solid family 
unit as they head into the veteran phase of their lives. School systems 
must become more involved in establishing and providing supportive 
services for our Nation's children.
    Caregiver Burnout
    In the eighth year of war, care for the caregivers must become a 
priority. There are several levels of caregivers. Our Association hears 
from the senior officer and enlisted spouses who are so often called 
upon to be the strength for others. We hear from the health care 
providers, educators, rear detachment staff, chaplains, and counselors 
who are working long hours to assist servicemembers and their families. 
They tell us they are overburdened, burnt out, and need time to 
recharge so they can continue to serve these families. These caregivers 
must be afforded respite care, given emotional support through their 
command structure, and be provided effective family programs.
    Education
    The DOD, VA, and State agencies must educate their health care and 
mental health professionals of the effects of mild Traumatic Brain 
Injury (mTBI) in order to help accurately diagnose and treat the 
servicemember's condition. They must be able to deal with polytrauma-
Post-Traumatic Stress Disorder (PTSD) in combination with multiple 
physical injuries. We need more education for civilian health care 
providers on how to identify signs and symptoms of mild TBI and PTSD.
    The families of servicemembers and veterans must be educated about 
the effects of TBI, PTSD, and suicide in order to help accurately 
diagnose and treat the servicemember/veteran's condition. These 
families are on the ``sharp end of the spear'' and are more likely to 
pick up on changes attributed to either condition and relay this 
information to their health care providers. Programs are being 
developed by each Service. However, they are narrow in focus targeting 
line leaders and health care providers, but not broad enough to capture 
our military family members and the communities they live in. As 
Services roll out suicide prevention programs, we need to include our 
families, communities, and support personnel.
    Reintegration Programs
    Reintegration programs become a key ingredient in the family's 
success. Our Association believes we need to focus on treating the 
whole family with programs offering readjustment information; education 
on identifying mental health, substance abuse, suicide, and traumatic 
brain injury; and encouraging them to seek assistance when having 
financial, relationship, legal, and occupational difficulties. We 
appreciate the inclusion in the NDAA for Fiscal Year 2010 for education 
programs targeting pain management and substance abuse for our 
families.
    Successful return and reunion programs will require attention over 
the long term, as well as a strong partnership at all levels between 
the various mental health arms of DOD, VA, and State agencies. DOD and 
VA need to provide family and individual counseling to address these 
unique issues. Opportunities for the entire family and for the couple 
to reconnect and bond must also be provided. Our Association has 
recognized this need and successfully piloted family retreats in the 
national parks promoting family reintegration following deployment.
    We recommend an extended outreach program to servicemembers, 
veterans, and their families of available psychological health 
resources, such as DOD, VA, and State agencies.
    We encourage Congress to request DOD to include families in its 
Psychological Health Support survey; perform a pre- and post-deployment 
mental health screening on family members (similar to the PDHA and 
PDHRA currently being done for servicemembers).
    We recommend the use of alternative treatment methods, such as 
telemental health; increasing mental health reimbursement rates for 
rural areas; modifying licensing requirements in order to remove 
geographic practice barriers that prevent mental health providers from 
participating in telemental health services; and educating civilian 
network mental health providers about our military culture.
    Caregivers must be afforded respite care; given emotional support 
through their command structure; and, be provided effective family 
programs.
Wounded Servicemembers Have Wounded Families
    Our Association asserts that behind every wounded servicemember and 
veteran is a wounded family. It is our belief the government, 
especially the DOD and VA, must take a more inclusive view of military 
and veterans' families. Those who have the responsibility to care for 
the wounded, ill, and injured servicemember must also consider the 
needs of the spouse, children, parents of single servicemembers and 
their siblings, and the caregivers. DOD and VA need to think 
proactively as a team and one system, rather than separately; and 
addressing problems and implementing initiatives upstream while the 
servicemember is still on active duty status.
    Reintegration programs become a key ingredient in the family's 
success. For the past 2 years, we have piloted our Operation 
Purple"'HealingAdventures camp to help wounded servicemembers and their 
families learn to play again as a family. We hear from the families who 
participate in this camp, as well as others dealing with the recovery 
of their wounded servicemembers that, even with Congressional 
intervention and implementation of the Services' programs, many issues 
still create difficulties for them well into the recovery period. 
Families find themselves having to redefine their roles following the 
injury of the servicemember. They must learn how to parent and become a 
spouse/lover with an injury. Each member needs to understand the unique 
aspects the injury brings to the family unit. Parenting from a 
wheelchair brings a whole new challenge, especially when dealing with 
teenagers. Parents need opportunities to get together with other 
parents who are in similar situations and share their experiences and 
successful coping methods. Our Association believes we need to focus on 
treating the whole family with DOD and VA programs offering skill based 
training for coping, intervention, resiliency, and overcoming 
adversities. Injury interrupts the normal cycle of deployment and the 
reintegration process. We must provide opportunities for the entire 
family and for the couple to reconnect and bond, especially during the 
rehabilitation and recovery phases.
    Brooke Army Medical Center (BAMC) has recognized a need to support 
these families by expanding in terms of guesthouses colocated within 
the hospital grounds and a family reintegration program for their 
Warrior Transition Unit. The on-base school system is also sensitive to 
issues surrounding these children. A warm, welcoming family support 
center located in guest housing serves as a sanctuary for family 
members. The DOD and VA could benefit from looking at successful 
programs like BAMCs, which has found a way to embrace the family unit 
during this difficult time.
    The Vet Centers are an available resource for veterans' families 
providing adjustment, vocational, and family and marriage counseling. 
The VA health care facilities and the community-based outpatient 
clinics (CBOCs) have a ready supply of mental health providers, yet 
regulations have restricted their ability to provide mental health care 
to veterans' families unless they meet strict standards. Unfortunately, 
this provision hits the veteran's caregiver the hardest, especially if 
they are the parents. We recommend DOD partner with the VA to allow 
military families access to mental health services. We also believe 
Congress should require the VA, through its Vet Centers and health care 
facilities to develop a holistic approach to care by including families 
when providing mental health counseling and programs to the wounded, 
ill, and injured servicemember or veteran.
    The Defense Health Board has recommended DOD include military 
families in its mental health studies. We agree. We encourage Congress 
to direct DOD to include families in its Psychological Health Support 
survey; perform a pre- and post-deployment mental health screening on 
family members (similar to the PDHA and PDHRA currently being done for 
servicemembers). We appreciate the NDAA for Fiscal Year 2010 report on 
the impact of the war on families and the DOD's Millennium Cohort Study 
including families. Both will help us gain a better understanding of 
the long-term effects of war on our military families.
    Transitioning for the Wounded and Their Families
    Transitions can be especially problematic for wounded, ill, and 
injured servicemembers, veterans, and their families. The DOD and the 
VA health care systems, along with State agency involvement, should 
alleviate, not heighten these concerns. They should provide for 
coordination of care, starting when the family is notified that the 
servicemember has been wounded and ending with the DOD, VA, and State 
agencies working together, creating a seamless transition, as the 
wounded servicemember transfers between the two agencies' health care 
systems and, eventually, from active duty status to veteran status.
    Transition of health care coverage for our wounded, ill, and 
injured and their family members is a concern of our Association. These 
servicemembers and families desperately need a health care bridge as 
they deal with the after effects of the injury and possible reduction 
in their family income. We have created two proposals. servicemembers 
who are medically retired and their families should be treated as 
active duty for TRICARE fee and eligibility purposes for 3 years 
following medical retirement. This proposal will allow the family not 
to pay premiums and be eligible for greater access to care at certain 
MTFs and for certain benefits offered to active duty families for 3 
years. Following that period, they would pay TRICARE premiums at the 
rate for retirees. servicemembers medically discharged from service and 
their family members should be allowed to continue for 1 year as active 
duty for TRICARE benefits and then move into the Continued Health Care 
Benefit Program (CHCBP) if needed.
    Caregivers
    Caregivers need to be recognized for the important role they play 
in the care of their loved one. Without them, the quality of life of 
the wounded servicemembers and veterans, such as physical, psycho-
social, and mental health, would be significantly compromised. They are 
viewed as an invaluable resource to DOD and VA health care providers 
because they tend to the needs of the servicemembers and the veterans 
on a regular basis. Their daily involvement saves DOD, VA, and State 
agency health care dollars in the long run. Their long-term 
psychological care needs must be addressed. Caregivers of the severely 
wounded, ill, and injured servicemembers who are now veterans have a 
long road ahead of them. In order to perform their job well, they will 
require access to mental health services.
    The VA has made a strong effort in supporting veterans' caregivers. 
The DOD should follow suit and expand their definition. We appreciate 
the inclusion in NDAA for Fiscal Year 2010 of compensation for 
servicemembers with assistance in everyday living. However, our 
Association believes this provision does not go far enough. In order to 
perform their job well, caregivers must be taught the skills to be 
successful.
    Compensation of caregivers should be a priority for DOD and the 
Secretary of Homeland Security. Caregivers must be recognized for their 
sacrifices and the important role they play in maintaining the quality 
of life of our wounded servicemembers and veterans. Financial 
compensation must be established for caregivers of injured 
servicemembers and veterans that begin while the hospitalized 
servicemember is still on active duty and transitions seamlessly to a 
VA benefit. Current law creates a potential gap in compensation during 
transition from active duty to veteran status. Our Association proposes 
that compensation should reflect the types of medical and non-medical 
care services provided by the caregiver. The caregiver should be paid 
directly for their services. Non-medical care should be factored into a 
monthly stipend tied to severity of injury--cognitive and physical 
injury and illness-and care provided. In order to perform their job 
well, caregivers must be taught the skills to be successful. This will 
require the caregiver to be trained through a standardized, certified 
program. Compensation for medical care should be an hourly wage linked 
to training and certification of the caregiver paid for by the VA and 
transferrable to employment in the civilian sector if the care is no 
longer needed by the servicemember or veteran.
    Consideration should also be given to creating innovative ways to 
meet the health care and insurance needs of the caregiver, with an 
option to include their family. Current proposed legislation does not 
include a ``family'' option. Additional services caregivers need are: 
respite care, such as 24 hour in-home care, mental health services, and 
travel and lodging expenses when accompanying servicemembers and 
veterans for medical care.
    There must be a provision for transition benefits for the caregiver 
if the caregiver's services are no longer needed, chooses to no longer 
participate, or is asked by the veteran to no longer provide services. 
The caregiver should still be able to maintain health care coverage for 
1 year. Compensation would discontinue following the end of services/
care provided by the caregiver. Our Association looks forward to 
discussing details of implementing such a plan with members of this 
subcommittee.
    The VA currently has eight caregiver assistance pilot programs to 
expand and improve health care education and provide needed training 
and resources for caregivers who assist disabled and aging veterans in 
their homes. DOD should evaluate these pilot programs to determine 
whether to adopt them for caregivers of servicemembers still on active 
duty. Caregivers' responsibilities start while the servicemember is 
still on active duty.
    Relocation Allowance and Housing
    Active duty servicemembers and their spouses qualify through the 
DOD for military orders to move their household goods when they leave 
the military service. Medically retired servicemembers are given a 
final PCS move. Medically retired married servicemembers are allowed to 
move their family; however, medically retired single servicemembers 
only qualify for moving their own personal goods.
    Our Association suggests that legislation be passed to allow 
medically retired single servicemembers the opportunity to have their 
caregiver's household goods moved as a part of the medical retired 
single servicemember's PCS move. This should be allowed for the 
qualified caregiver of the wounded servicemember and the caregiver's 
family (if warranted), such as a sibling who is married with children 
or mom and dad. This would allow for the entire caregiver's family to 
move, not just the caregiver. The reason for the move is to allow the 
medically retired single servicemember the opportunity to relocate with 
their caregiver to an area offering the best medical care, rather than 
the current option that only allows for the medically retired single 
servicemember to move their belongings to where the caregiver currently 
resides. The current option may not be ideal because the area in which 
the caregiver lives may not be able to provide all the health care 
services required for treating and caring for the medically retired 
servicemember. Instead of trying to create the services in the area, a 
better solution may be to allow the medically retired servicemember, 
their caregiver, and the caregiver's family to relocate to an area 
where services already exist.
    The decision on where to relocate for optimum care should be made 
with the Federal Recovery Coordinator (case manager), the 
servicemember's medical physician, the servicemember, and the 
caregiver. All aspects of care for the medically retired servicemember 
and their caregiver shall be considered. These include a holistic 
examination of the medically retired servicemember, the caregiver, and 
the caregiver's family for, but not limited to, their needs and 
opportunities for health care, employment, transportation, and 
education. The priority for the relocation should be where the best 
quality of services is readily available for the medically retired 
servicemember and higher caregiver.
    The consideration for a temporary partial shipment of caregiver's 
household goods may also be allowed, if deemed necessary by the case 
management team.
    Medical Power of Attorney
    We have heard from caregivers of the difficult decisions they have 
to make over their loved one's bedside following an injury. We support 
the Traumatic Brain Injury Task Force recommendation for DOD to require 
each deploying servicemember to execute a Medical Power of Attorney and 
a Living Will.
    Provide medically-retired wounded, ill, and injured servicemembers 
and their families a bridge of extended active duty TRICARE e1igibility 
for 3 years, comparable to the benefit for surviving spouses.
    Servicemembers medically discharged from Service and their family 
members should be allowed to continue for 1 year as active duty for 
TRICARE and then start the Continued Health Care Benefit Program 
(CHCBP) if needed.
    Caregivers of the wounded, ill, and injured must be provided with 
opportunities for training, compensation and other support programs 
because of the important role they play in the successful 
rehabilitation and care of the servicemember.
    The National Military Family Association is requesting the ability 
for medically retired single servicemembers to be allowed the 
opportunity to have their caregiver's household goods moved as a part 
of the medically retired single servicemember's PCS move.
    DOD should require each deploying servicemember to execute a 
Medical Power of Attorney and a Living Will.
    Senior Oversiqht Committee
    Our Association is appreciative of the provision in the NDAA for 
Fiscal Year 2010 establishing a DOD Task Force on the Care, Management, 
and Transition of Recovery, Wounded, Ill, and Injured Members of the 
Armed Forces to access policies and programs. We understand the Office 
of Wounded Warrior Care and Transition Policy (WWCTP), a permanent 
structure for the Senior Oversight Committee, is in the process of 
being established and manned. This Task Force will be independent and 
in a position to monitor DOD and VA's partnership initiatives for our 
wounded, ill, and injured servicemembers and their families, while this 
organization is being created.
    The National Military Family Association encourages all committees 
with jurisdiction over military personnel and veterans matters to talk 
on these important issues. We can no longer continue to create policies 
in a vacuum and be content on focusing on each agency separately 
because this population moves too frequently between the two agencies, 
especially our wounded, ill, and injured servicemembers and their 
families.
    We would like to thank you again for the opportunity to provide 
information on the health care needs for the servicemembers, veterans, 
and their families. Military families support the Nation's military 
missions. The least their country can do is make sure servicemembers, 
veterans, and their families have consistent access to high quality 
mental health care in the DOD, VA, and within network civilian health 
care systems. Wounded servicemembers and veterans have wounded 
families. The caregiver must be supported by providing access to 
quality health care and mental health services, and assistance in 
navigating the health care systems. The system should provide 
coordination of care with DOD, VA, and State agencies working together 
to create a seamless transition. We ask Congress to assist in meeting 
that responsibility.
                        iii. family transitions
Survivors
    In the past year, the Services have increased their outreach to 
surviving families. In particular, the Army's Survivor Outreach 
Services (SOS) program makes an effort to remind these families that 
they are not forgotten. DOD and the VA must work together to ensure 
surviving spouses and their children can receive the mental health 
services they need, through all of VA's venues. New legislative 
language governing the TRICARE behavioral health benefit may also be 
needed to allow TRICARE coverage of bereavement or grief counseling. 
The goal is the right care at the right time for optimum treatment 
effect. DOD and the VA need to better coordinate their mental health 
services for survivors and their children.
    We thank Congress for extending the TRICARE active duty family 
dental insurance benefit to surviving children. The current TRICARE 
Management Activity policy directive allows for the surviving children 
of Reserve component servicemembers who had not previously been 
enrolled to be eligible for the expanded benefit. We ask that 
eligibility be expanded to those active duty family members who had not 
been enrolled in the active duty TRICARE dental insurance program prior 
to the servicemember's death.
    Our Association recommends that eligibility be expanded to active 
duty survivors who had not been enrolled in the TRICARE Dental Program 
prior to the servicemember's death. We also recommend that grief 
counseling be more readily available to survivors.
    Our Association still believes the benefit change that will provide 
the most significant long-term advantage to the financial security of 
all surviving families would be to end the Dependency and Indemnity 
Compensation (DIC) offset to the Survivor Benefit Plan (SBP). Ending 
this offset would correct an inequity that has existed for many years. 
Each payment serves a different purpose. The DIC is a special indemnity 
(compensation or insurance) payment paid by the VA to the survivor when 
the servicemember's service causes his or her death. The SBP annuity, 
paid by DOD, reflects the longevity of the service of the military 
member. It is ordinarily calculated at 55 percent of retired pay. 
Military retirees who elect SBP pay a portion of their retired pay to 
ensure that their family has a guaranteed income should the retiree 
die. If that retiree dies due to a service-connected disability, their 
survivor becomes eligible for DIC.
    Surviving active duty spouses can make several choices, dependent 
upon their circumstances and the ages of their children. Because SBP is 
offset by the DIC payment, the spouse may choose to waive this benefit 
and select the ``child only'' option. In this scenario, the spouse 
would receive the DIC payment and the children would receive the full 
SBP amount until each child turns 18 (23 if in college), as well as the 
individual child DIC until each child turns 18 (23 if in college). Once 
the children have left the house, this choice currently leaves the 
spouse with an annual income of $13,848, a significant drop in income 
from what the family had been earning while the servicemember was alive 
and on active duty. The percentage of loss is even greater for 
survivors whose servicemembers served longer. Those who give their 
lives for their country deserve more fair compensation for their 
surviving spouses.
    We believe several other adjustments could be made to the SBP. 
Allowing payment of the SBP benefits into a Special Needs Trust in 
cases of disabled beneficiaries will preserve their eligibility for 
income based support programs. The government should be able to switch 
SBP payments to children if a surviving spouse is convicted of 
complicity in the member's death.
    We believe there needs to be DIC equity with other Federal survivor 
benefits. Currently, DIC is set at $1,154 monthly (43 percent of the 
Disabled Retirees Compensation). Survivors of Federal workers have 
their annuity set at 55 percent of their Disabled Retirees 
Compensation. Military survivors should receive 55 percent of VA 
Disability Compensation. We are pleased that the requirement for a 
report to assess the adequacy of DIC payments was included in the NDAA 
for Fiscal Year 2009. We are awaiting the overdue report. We support 
raising DIC payments to 55 percent of VA Disability Compensation. When 
changes are made, ensure that DIC eligibles under the old system 
receive an equivalent increase.
    We ask the DIC offset to SBP be eliminated to recognize the length 
of commitment and service of the career servicemember and spouse. We 
also request that SBP benefits may be paid to a Special Needs Trust in 
cases of disabled family members.
    We ask that DIC be increased to 55 percent of VA Disability 
Compensation.
Education of Military Children
    The National Military Family Association would like to thank 
Congress for including a ``Sense of Congress'' in regards to the 
Interstate Compact on Educational Opportunity for Military Children in 
last year's National Defense Authorization Act. The Compact has now 
been adopted in 27 States and covers over 80 percent of our military 
children. The Interstate Commission, the governing body of the Compact, 
is working to educate military families, educators, and States on the 
appropriate usage of the Compact. The adoption of the Compact is a 
tremendous victory for military families who place a high value on 
education.
    However, military families define the quality of that education 
differently than most States or districts that look only at issues 
within their boundaries. For military families, it is not enough for 
children to be doing well in their current schools, they must also be 
prepared for the next location. The same is true for children in under 
performing school systems. Families are concerned that they will lag 
behind students in the next location. With many States cutting 
educational programs due to the economic downturn, this concern is 
growing. A prime example is Hawaii, which opted to furlough teachers on 
Fridays, cutting 17 days from the school calendar. With elementary 
schools already on a shortened schedule for Wednesday, these students 
are only getting 3\1/2\ days of instruction a week. In addition, the 
recent cuts have made it increasingly hard for schools to meet IEP 
requirements for special needs students. Furthermore, Hawaii is 
requiring parents to pay more for busing, and the cost of school meals 
have gone up 76 percent. Our Association believes that Hawaii's cuts 
are just the ``tip of the iceberg'' as we are beginning to see other 
States make tough choices as well. Although Hawaii's educational system 
has long been a concern for military families, many of whom opt for 
expensive private education, Hawaii is not the only place where parents 
have concerns. The National Military Family Association believes that 
our military children deserve to have a good quality education wherever 
they may live. However, our Association recognizes that how we provide 
that quality education may differ in each location.
    We urge Congress to encourage solutions for the current educational 
situation in Hawaii and recognize that servicemembers' lack of 
confidence that their children may receive a quality education in an 
assignment location can affect the readiness of the force in that 
location.
    While our Association remains appreciative for the additional 
funding Congress provides to civilian school districts educating 
military children, Impact Aid continues to be underfunded. We urge 
Congress to provide appropriate and timely funding of Impact Aid 
through the Department of Education. In addition, we urge Congress to 
increase DOD Impact Aid funding for schools educating large numbers of 
military children to $60 million for fiscal year 2011. We also ask 
Congress to include an additional $5 million in funding for special 
needs children. The DOD supplement to Impact Aid is critically 
important to ensure school districts provide quality education for our 
military children.
    As increased numbers of military families move into new communities 
due to Global Rebasing and BRAC, their housing needs are being met 
further and further away from the installation. Thus, military children 
may be attending school in districts whose familiarity with the 
military lifestyle may be limited. Educating large numbers of military 
children will put an added burden on schools already hard-pressed to 
meet the needs of their current populations. We urge Congress to 
authorize an increase in this level of funding until BRAC and Global 
Rebasing moves are completed.
    Once again, we thank Congress for passing the Higher Education 
Opportunity Act of 2008, which contained many new provisions affecting 
military families. Chief among them was a provision to expand in-State 
tuition eligibility for military servicemembers and their families, and 
provide continuity of in-State rates if the servicemember receives 
Permanent Change of Station (PCS) orders out of State. However, family 
members have to be currently enrolled in order to be eligible for 
continuity of in-State tuition. Our Association is concerned that this 
would preclude a senior in high school from receiving in-State tuition 
rates if his or her family PCS's prior to matriculation. We urge 
Congress to amend this provision.
    We ask Congress to increase the DOD supplement to Impact Aid to $60 
million to help districts better meet the additional demands caused by 
large numbers of military children, deployment-related issues, and the 
effects of military programs and policies. We also ask Congress provide 
$5 million for school districts with Special Needs children.
Support for Military Voters
    The National Military Family Association would like to thank 
Congress for passing the Military and Overseas Voter Empowerment (MOVE) 
Act which was included in the National Defense Authorization Act for 
Fiscal Year 2010. As a member of the Alliance for Military and Overseas 
Voting Rights (AMOVR), our Association worked hard to pass this 
important legislation which resolves many of the absentee voting issues 
for our military servicemembers and their families. The passage of the 
MOVE ACT was a tremendous victory for our military community whose very 
service helps protect the right to vote.
Spouse Education and Employment
    Our Association wishes to thank Congress for recent enhancement to 
spouse education opportunities. In-State tuition, Post-September 11 
G.I. bill transferability to spouses and children, and other 
initiatives have provided spouses with more educational opportunities 
than previous years.
    Since 2004, our Association has been fortunate to sponsor our 
Joanne Holbrook Patton Military Spouse Scholarship Program, with the 
generosity of donors who wish to help military families. Our 2010 
application period closed on January 31, 2010. We saw a 33 percent 
increase in applications from previous years with more than 8,000 
military spouses applying to our program. Military spouses remain 
committed to their education and need assistance from Congress to 
fulfill their educational pursuits.
    We have heard from many military spouses who are pleased with the 
expansion of the Military Spouse Career Advancement Accounts, now 
called MyCAA. Unfortunately the abrupt halt of the program on February 
16, 2010 has created a financial burden and undue stress for military 
spouses. Spouses who have established accounts and those who planned to 
set-up accounts in the future have been barred for accessing funds. The 
MyCAA system only permitted users to request financial assistance 30 
days prior to a class start date. Many, who had planned on the funding, 
will not receive it, if they didn't have a start date entered into the 
system by February 16. We ask Congress to push DOD to restart this 
critical program and find a way to assist spouses who have been 
abruptly cut-off from receiving funding. We also ask Congress to fully 
fund the MyCAA program, which is providing essential educational and 
career support to military spouses. The MyCAA program is not available 
to all military spouses. We ask Congress to work with the appropriate 
Service Secretary to expand this funding to the spouses of Coast Guard, 
the Commissioned Corps of NOAA and U.S. Public Health Service.
    Our Association thanks you for establishing a pilot program to 
secure internships for military spouses with Federal agencies. Military 
spouse are anxious for the program to launch and look forward to 
enhanced career opportunities through the pilot program. We hope 
Congress will monitor the implementation of the program to ensure 
spouses are able to access the program and eligible spouses are able to 
find Federal employment after successful completion of the internship 
program.
    To further spouse employment opportunities, we recommend an 
expansion to the Workforce Opportunity Tax Credit for employers who 
hire spouses of active duty and Reserve component servicemembers, and 
to provide tax credits to military spouses to offset the expense in 
obtaining career licenses and certifications when servicemembers are 
relocated to a new duty station within a different State.
    The Services are experiencing a shortage of medical, mental health 
and child care providers. Many of our spouses are trained in these 
professions or would like to seek training in these professions. We 
think the Services have an opportunity to create portable career 
opportunities for spouses seeking in-demand professions. In addition to 
the MyCAA funding, what can the Services do to encourage spouse 
employment and solve provider shortages? We would like to see the 
Services reach out to military spouses and offer affordable, flexible 
training programs in high demand professions to help alleviate provider 
shortages.
    Our Association urges Congress to recognize the value of military 
spouses by fully funding the MyCAA program, and by creating training 
programs and employment opportunities for military spouses in high 
demand professions to help fill our provider shortages.
Military Families--Our Nation's Families
    We thank you for your support of our servicemembers and their 
families and we urge you to remember their service as you work to 
resolve the many issues facing our country. Military families are our 
Nation's families. They serve with pride, honor, and quiet dedication. 
Since the beginning of the war, government agencies, concerned citizens 
and private organizations have stepped in to help. This increased 
support has made a difference for many servicemembers and families, 
yet, some of these efforts overlap while others are ineffective. In our 
testimony, we believe we have identified improvements and additions 
that can be made to already successful programs while introducing 
policy or legislative changes that address the ever-changing needs of 
our military families. Working together, we can improve the quality of 
life for all these families.

    Senator Webb. Thank you very much.
    Mr. Cline.

    STATEMENT OF MASTER SERGEANT MICHAEL CLINE, USA (RET.), 
EXECUTIVE DIRECTOR, ENLISTED ASSOCIATION OF THE NATIONAL GUARD 
                      OF THE UNITED STATES

    Mr. Cline. Mr. Chairman, we thank you, on behalf of the 
Enlisted Association of the National Guard of the United States 
and the Military Coalition, for holding these hearings.
    Mr. Chairman, over 142,000 National Guard and Reserve 
servicemembers are serving on Active Duty. Since September 11, 
2001, more than 752,000 of our citizens, soldiers, airmen, 
sailors, marines, Guard and Reserve servicemembers, have been 
called up, including well over 200,000 who have served multiple 
tours.
    With your permission, Mr. Chairman, I'd like to cut out the 
fluff and just get to the point of the needs of our Guard and 
Reserve people and their families.
    The next step in modernizing the Reserve retirement system 
is to provide equal retirement age reduction credit for all 
activated service rendered since September 11, 2001. The 
current law that credits only active service since January 28, 
2008, disenfranchises and devalues the service of hundreds of 
thousands of Guard and Reserve members who have served combat 
tours, many with multiple combat tours, between 2001 and 2008.
    The statute also must be amended to eliminate the inequity 
inherent in the current fiscal year retirement calculation, 
which only credits 90 days of active service for early 
retirement purposes if it occurs within the same fiscal year. 
The current rule significantly penalizes members who deploy in 
July or August, versus those deploying earlier in the fiscal 
year. It is potently unfair, as the current law requires giving 
3 months retirement-age credit for 90-day tours served from 
January through March, but only half credit for 120-day tours 
served from August through November, because the latter covers 
60 days in each of the 2 fiscal years.
    Mr. Chairman, we fully understand the budgetary problems 
facing our country, but we're also aware that more than $700 
billion was given to banks, financial institutions, automakers; 
$3 billion for Cash for Clunkers was spent, in 3 weeks, that 
did nothing more than reduce the inventory of autodealers; the 
American people, many of which are the very veterans who have 
been passed by, are looking at a trillion-dollar healthcare 
bill. If CBO figures are accurate, it will cost $2.1 billion 
over 10 years, or just about $21 million a year, to provide 
retroactivity for early retirement for those who have protected 
our freedom. It's the right thing to do to honor the unselfish 
heroes and their families who have given up so much to protect 
us and our way of life.
    For the near term, we place particular priority on 
authorizing early retirement credit for all qualifying post-
September 11 Active Duty service performed by Guard and Reserve 
members, and eliminating the fiscal-year-specific accumulator 
that bars equal credit for members deploying for equal periods 
during different months of the year. Ultimately, we believe we 
must move forward to provide a reduced-age entitlement for 
retired pay and health coverage for all Reserve component 
members that is an age-service formula or outright eligibility, 
if otherwise qualified, at age 55.
    Further, we urge repeal of the annual cap of 130 days of 
inactive duty points that may be credited towards a Reserve 
retirement.
    Yellow Ribbon. We urge the subcommittee to hold oversight 
hearings and to direct additional improvements in coordination 
and collaboration and consistency of Yellow Ribbon services. 
DOD must ensure that State-level best practices, such as those 
in Maryland, Minnesota, and New Hampshire, are applied for all 
operational Reserve Force members and their families, and that 
Federal Reserve veterans have equal access to services and 
support available to National Guard veterans. Community groups, 
employers, and Service organizations' efforts need to be 
encouraged and better coordinated to supplement unit, 
component, Service, and VA outreach and service.
    We are grateful to you, in Congress, for inclusion of a 
critical ``earn as you serve'' principle, in the post-September 
11 GI Bill, which allows operational reservists to accumulate 
additional benefits for each aggregate call-up of 90 days or 
more on Active Duty. However, Active Duty members of the 
National Guard serving under Title 32 orders were not included 
in the new program, despite their critical role in homeland 
defense, counterdrug, border control, and other missions. We 
urge this subcommittee to work with the Veterans Affairs 
Committee to include Title 32 AGRs in the post-September 11 
statute.
    The Military Coalition's longstanding recommendation of 
coordinating and integrating various educational benefit 
programs has been made more challenging with the post-September 
11 GI Bill. For example, benefits for initially joining the 
Guard and Reserve, as authorized under Chapter 1606 of title 
10, continue to decline in proportion to the Active Duty 
Montgomery GI Bill, Chapter 30, title 38, in the new post-
September 11 GI Bill. Reserve MGIB benefit levels have slipped 
to 24 percent of the Active Duty MGIB benefit, compared to 47 
to 50 percent during the first 15 years of the program. 
Restoration of the original ratio would raise basic Reserve 
rates from the current $333 a month to $643 to $684 a month for 
full-time duty. TMC maintains that restoring the ratio is not 
only a matter of equity, but essential to long-time success of 
the Guard and Reserve recruiting program.
    Continuing healthcare insurance options for the Guard and 
Reserve. The Coalition is very grateful for the passage of 
TRICARE for gray-area retirees; however, we're very 
disappointed that it's going to take DOD 18 months to implement 
the new program. As we have sent letters to you, we ask that 
you intervene with DOD to speed this program up. It's a 
benefit----
    Senator Graham. Absolutely.
    Mr. Cline.--that is needed.
    Senator Graham. Absolutely.
    Mr. Cline. When we look at the TRICARE Reserve Select 
Program, a disturbing fact is that only 6 to 7 percent of our 
eligible beneficiaries are taking advantage of the TRICARE 
Reserve Select Program. DOD and the Services and the Reserve 
components must do more to advertise the TRS program.
    The Coalition also believes that Congress is missing an 
opportunity to reduce long-term healthcare costs and increase 
beneficiary satisfaction by authorizing eligible members the 
option of electing a DOD subsidy of their civilian insurance 
during periods of activation. Current law already authorizes 
payment of up to 24 months of FEHBP premiums for activated 
members who are civilian employees of the Defense Department. 
Over the long term, the Guard and Reserve activations can be 
expected at a reduced pace. This option would offer 
considerable savings opportunities, relative to DOD permanent, 
year-round TRICARE.
    We recommend to the subcommittee--require a GAO review of 
DOD's methodology for determining TRS costs for premium 
adjustment purposes to assess whether it includes any costs of 
maintaining readiness or ``costs of doing business'' for DOD 
that don't contribute to beneficiary benefit values, and thus 
excluded from cost premium calculations.
    Mr. Chairman, I look forward to any questions that you or 
Senator Graham may have.
    Senator Webb. Thank you very much.
    Ms. Holleman.

 STATEMENT OF DEIRDRE PARKE HOLLEMAN, EXECUTIVE DIRECTOR, THE 
                  RETIRED ENLISTED ASSOCIATION

    Ms. Holleman. Good morning. Mr. Chairman----
    Senator Webb. Good afternoon, actually. [Laughter.]
    Ms. Holleman. Good afternoon.
    Senator Graham. My stomach says it's afternoon.
    Ms. Holleman. Life goes quickly, right?
    It is an honor to speak to you today about the Military 
Coalition's legislative goals concerning military retirees and 
military survivors. I know you will not be surprised that TMC 
is urging you to, once and for all, end the unfair offset of 
military retired pay by VA disability pay.
    We are grateful for the great strides that have been made 
in ending this practice, which we all now acknowledge is 
terribly unfair. But, there are two groups of valiant retirees 
who are not getting the relief that you ordered for the others. 
One group is those longevity retirees with VA disabilities of 
10 to 40 percent. The other group is those servicemembers who 
were forced to medically retire with less than 20 years, due to 
an injury or medical condition that is not deemed combat-
related under the Combat Related Special Compensation program. 
Even in these tough economic times, simple fairness should call 
for the end of the offset for all. But, even more dramatically, 
the President, for the second year, has proposed, in his 
budget, to end the offset for medical retirees. To have the 
administration propose a change that, in the past, was the goal 
of only you, in Congress, is a historic opportunity. We 
strongly urge you to join the President in this laudable goal 
and end the offset for medical retirees now.
    It is also clearly time to finally end the Survivor Benefit 
Plan (SBP)/Dependency and Indemnity Compensation (DIC) offset. 
SBP is an employee benefit, while DIC is an indemnity program 
for survivors of those who died because of their service in the 
military. The present practice of taking a dollar from a 
survivor's SBP payment for every dollar paid by the VA's DIC 
program is unfair and illogical. Legislation to end this offset 
is pending in both Houses of Congress. Now that Senator Bill 
Nelson's S. 535 has 55 cosponsors, and Representative Ortiz's 
H.R. 811 has 319 cosponsors, it is clear that a majority of the 
Members of Congress agree that this offset should end. It 
should end now, while our servicemembers are fighting in two 
wars and at risk throughout the world.
    While these two issues are of great and continuing concern 
to all of the members of the Coalition, there are several 
additional matters that we believe are critically important. We 
urge you to support Senator Blanche Lincoln's soon-to-be-
introduced legislation that will be a companion bill to 
Representative Walter Jones's H.R. 613. Their Military Retirees 
Survivor Comfort Acts would authorize the retention of the full 
month's retired pay of the last month of a retiree's life by 
his or her surviving spouse. Presently, DFAS removed the 
month's retired pay from the retiree account, calculates how 
much is owed by how many days the retiree lived in the month 
that he or she died in, and then returns the prorated share to 
the survivor. This method can cause confusion and even bounce 
checks during a tremendously tense and sorrowful time. Senator 
Lincoln's bill would stop this, and treat military retiree 
survivors the same way as disabled veteran survivors are 
treated concerning the disability payments.
    The Uniformed Services Former Spouse Protection Act 
desperately needs improvement. While some organizations want 
dramatic fundamental changes, and other groups adamantly do 
not, it truly is time that we had a hearing on this rather 
explosive issue. There are already several improvements that 
DOD has supported, for years, that could be made during this 
session. These changes include basing the amount awarded in a 
divorce on the grade and years of service at the time of the 
divorce, rather than at the time of retirement, and prohibiting 
the inclusion of imputed income in a divorce property award, 
which often forces Active Duty members into retirement. A full 
list of our suggestions can be found in our written testimony.
    Finally, we urge that DFAS be allowed to make SBP payments 
into a Special Needs Trust. Presently, they may only pay SBP to 
a person. This means that a permanently disabled survivor 
cannot make use of this State-created legal device that allows 
a disabled person to protect their eligibility for SSI, 
Medicaid, and State means-tested programs. With the help of 
supporters like you, Chairman Webb, we hope that this change 
will be made. It would only affect a few people, but for those 
survivors, this small change would be an enormous help.
    Thank you for your time, and may I have the honor to 
introduce Colonel Strobridge.
    Senator Webb. Thank you very much for your testimony.
    Colonel Strobridge.

  STATEMENT OF STEVEN P. STROBRIDGE, USAF (RET.), DIRECTOR OF 
 GOVERNMENT RELATIONS, MILITARY OFFICERS ASSOCIATION OF AMERICA

    Colonel Strobridge. Mr. Chairman, Senator Graham, my 
testimony is going to focus on healthcare and Wounded Warrior 
issues.
    The primary issue for all beneficiaries is access. The 
primary threat to access continues to be the perpetual threat 
of major cuts in Medicare and TRICARE payments to doctors. We 
fully realize that's beyond the authority of this subcommittee, 
but it is the number-one healthcare issue among our 
beneficiaries.
    On national healthcare reform, the principal issues for our 
members in the coalition are ensuring protection of military-
unique health benefits, including TRICARE For Life, and 
protection of uniformed services beneficiaries from taxation on 
the value of those benefits.
    On TRICARE fees, we're grateful that the administration has 
not proposed any increases for fiscal year 2011, however, 
without congressional action, the TRICARE standard outpatient 
deductible will be increased administratively by more than $110 
per day as of October 1. Last October, the subcommittee acted, 
during conference action on the National Defense Authorization 
Act, to stop that change. We urge you to put a provision in 
law, capping the outpatient deductible at the current $535 per 
day, which the coalition believes is plenty high enough and 
should not be increased for the foreseeable future.
    We also ask you to put a ``Sense of Congress'' provision in 
the National Defense Authorization Act, as the Senate approved 
last year, highlighting the importance of military health 
benefits in offsetting the adverse conditions of service and 
recognizing that military people pay large upfront premiums 
through decades of service and sacrifice, over and above their 
cash fees.
    On Wounded Warriors, we're concerned that the change of the 
administration has left many senior positions vacant for more 
than a year, and that close joint oversight previously provided 
by top leaders has been delegated and diffused back along 
agency-centric lines. The coalition is particularly concerned 
that the diminution of the Senior Oversight Committee, or SOC, 
has weakened day-to-day oversight of, and priority on, joint 
agency operations and management. We urge revitalization of the 
SOC, or a similar joint agency staffed with senior officials 
with full-time primary oversight responsibility for seamless 
transition initiatives.
    Similarly, the transition from Active Duty to retiree care 
or to VA coverage still catches many wounded warriors and their 
families unaware. They need the same protections that we 
provide when someone dies on Active Duty: 3 years of continued 
Active Duty-level coverage to ensure a smooth transition to the 
next phase of their life.
    We appreciate the subcommittee's efforts last year to 
provide caregiver benefits on a par with what's provided by the 
VA. The Veterans Affairs Committees are now finalizing 
significant upgrades for caregivers, and we hope you'll act to 
reestablish comparability of DOD programs once that happens.
    Regarding psychological health, PTSD, and TBI, we know the 
subcommittee and DOD and the Services are pursuing a wide range 
of initiatives to enhance access to care and counseling, and to 
remove the stigma from seeking care. Unfortunately, some facets 
of the military environment continue to undermine those 
efforts. In that regard, many who suffer after-effects of 
combat continue being barred from reenlistment, or separated 
for other reasons, because service disciplinary and 
administrative systems are much less flexible and resilient 
than we're asking military people to be. We hope the 
subcommittee will continue its efforts to protect returnees 
from these lower profile, but still devastating, secondary 
effects of war.
    Mr. Chairman, that concludes my remarks.
    [The prepared statement of The Military Coalition follows:]
              Prepared Statement by The Military Coalition
    Mr. Chairman and distinguished members of the subcommittee. On 
behalf of The Military Coalition (TMC), a consortium of nationally 
prominent uniformed services and veterans' organizations, we are 
grateful to the committee for this opportunity to express our views 
concerning issues affecting the uniformed services community. This 
testimony provides the collective views of the following military and 
veterans' organizations, which represent approximately 5.5 million 
current and former members of the 7 uniformed services, plus their 
families and survivors.

          Air Force Association
          Air Force Sergeants Association
          Air Force Women Officers Associated
          American Logistics Association
          AMVETS (American Veterans)
          Army Aviation Association of America
          Association of Military Surgeons of the United States
          Association of the United States Army
          Association of the United States Navy
          Chief Warrant Officer and Warrant Officer Association, U.S. 
        Coast Guard
          Commissioned Officers Association of the U.S. Public Health 
        Service, Inc.
          Enlisted Association of the National Guard of the United 
        States
          Fleet Reserve Association
          Gold Star Wives of America, Inc.
          Iraq and Afghanistan Veterans of America
          Jewish War Veterans of the United States of America
          Marine Corps League
          Marine Corps Reserve Association
          Military Chaplains Association of the United States of 
        America
          Military Officers Association of America
          Military Order of the Purple Heart
          National Association for Uniformed Services
          National Guard Association of the United States
          National Military Family Association
          National Order of Battlefield Commissions
          Naval Enlisted Reserve Association
          Noncommissioned Officers Association
          Reserve Enlisted Association
          Reserve Officers Association
          Society of Medical Consultants to the Armed Forces
          The Retired Enlisted Association
          United States Army Warrant Officers Association
          United States Coast Guard Chief Petty Officers Association
          Veterans of Foreign Wars of the United States

    The Military Coalition, Inc., does not receive any grants or 
contracts from the Federal Government.
                           executive summary
Wounded Warrior Care
    Institutional Oversight
    The Coalition believes there's no substitute for a permanent 
Department of Defense (DOD)-Department of Veterans Affairs (VA) Senior 
Oversight Committee or other Joint Seamless Transition Office, staffed 
with senior officials working together full-time and charged with 
innovation and daily oversight of initiatives to institutionalize and 
sustain a culture of cross-department seamless transition.
    Continuity of Health Care
    The Coalition recommends:

         Authorizing active-duty level TRICARE benefits, 
        independent of availability of VA care, for 3 years after 
        medical retirement to help ease transition from DOD to VA;
         Authorizing blanket waiver authority for VA physicians 
        treating active duty patients with multiple medical trauma 
        conditions for all aspects of the member's treatment, including 
        referral outside the VA/TRICARE system if needed; and
         Either exempting severely wounded, ill, or injured 
        members who must be medically retired from paying Medicare Part 
        B premiums until age 65 or authorizing a special DOD allowance 
        to help offset the cost of such premiums until age 65.
    Mental/Behavioral Health Issues
    TMC recommends:

         Increased efforts to promote the destigmatization on 
        all levels in service/unit administrative and strict 
        accountability programs with outlined and enforced consequences 
        to non-compliancy to ensure unit actions are consistent with 
        leadership pronouncements;
         Continuing priority efforts to deliver information and 
        assistance on-line, confidential options for counseling and 
        uniformed access and availability to telemedicine services;
         Substantial increases in outreach efforts to provide 
        such services and resources to Guard and Reserve members, rural 
        populations and all families who don't live near military or VA 
        facilities;
         Priority efforts to educate private sector providers 
        on the unique needs of military and veteran patients and family 
        members, and deliver needed information via on-line services, 
        including contact points for discussion/consultation with 
        military and VA providers;
         Consistent implementation of pre- and post-deployment 
        evaluations and follow-up programs, particularly for Guard and 
        Reserve members who may be leaving active duty;
         Establishing common DOD and VA protocols for 
        diagnosis, treatment, and rehabilitation for Traumatic Brain 
        Injury (TBI) conditions, as well as an electronic system to 
        share and exchange a patient's medical history and other key 
        medical information;
         Expanding Traumatic Servicemember Group Life Insurance 
        (TSGLI) criteria to include moderate and severe TBI, without 
        onerous ``functions of daily living'' standards that aren't 
        required for other (and often much more functional) TSGLI-
        eligibles;
         Increasing availability and outreach on substance 
        abuse counseling options;
         Pursuing aggressive medication reconciliation and 
        management programs to protect against inadvertent over 
        medication and adverse reactions and or accidental or 
        intentional overdose;
         Requiring TBI and psychological health assessments for 
        members who have been deployed to a combat zone as part of the 
        disciplinary process prior to a decision concerning nonmedical 
        separation; and
         Implementing recommendations from the 2008 RAND report 
        (``Invisible Wounds of War Psychological and Cognitive 
        Injuries, Their Consequences, and Services to Assist 
        Recovery'').
    DOD-VA Disability Evaluation Systems (DES)
    TMC recommends:

         Barring ``fit, but unsuitable'' separations when a 
        member's medical condition prevents continued service;
         Authorizing automatic enrollment in the VA health care 
        system for any medically separated or medically retired 
        servicemember (Chapter 61);
         Ending distinctions between disabilities incurred in 
        combat vice non-combat;
         Monitoring the effectiveness of recent DOD 
        compensation for catastrophically injured or ill servicemembers 
        requiring assistance with activities of daily living authorized 
        in the 2010 NDAA;
         Ensuring benefits afforded members wounded, ill, or 
        disabled in the line of duty are applied equally for all 
        uniformed services;
         Ensuring that the VA is the single authority for 
        rating service-connected disabilities for military disability 
        retirements and separations;
         Preserving the statutory 30 percent disability 
        threshold for medical retirement and lifetime TRICARE coverage 
        for members injured while on active duty;
         Continued monitoring of Service/DOD Medical-Physical 
        Evaluation Boards, DOD DES Pilot Project, and the Physical 
        Disability Board of Review, to assess needed DES changes;
         Eliminating member premiums for TSGLI;
         Barring ``pre-existing condition'' determinations for 
        any member who deploys to a combat zone;
         Ensuring that any adjustment to the disability 
        retirement system does not result in a member receiving less 
        disability retired pay than he or she would receive under the 
        current system; and
         Ensuring that members electing accelerated disability 
        retirement/separation are fully counseled on any possible 
        negative changes in compensation, health care and other 
        benefits, with consideration to allowing a limited time to 
        reverse a regrettable decision.
    Caregiver/Family Support Services
    The Coalition recommends:

         Upgraded compensation and assistance for caregivers of 
        severely disabled active duty members, consistent with pending 
        legislative action to improve compensation/assistance for 
        caregivers of veterans; and
         Authorizing up to 1 year of continued residence in on-
        base housing facilities for medically retired, severely wounded 
        servicemembers and their families.
Active Forces and Their Families
    Military End Strength
    The Coalition urges the subcommittee to:

         Continue end strength growth as needed to sustain the 
        war and other operational commitments while materially 
        increasing dwell time for servicemembers and families;
         Sustain adequate recruiting and retention resources to 
        enable the uniformed services to achieve required optimum-
        quality personnel strength; and
         Seek a 2011 defense budget of at least 5 percent of 
        Gross Domestic Product that funds both people and weapons 
        needs.
    Military Pay Comparability
    The Coalition believes a basic pay raise of at least 1.9 
percent--.5 percent above the Employment Cost Index (ECI) standard--is 
the bare minimum the Nation should do to sustain its military pay 
comparability commitment for 2011.
    Family Readiness and Support
    The Coalition recommends that the subcommittee:

         Press DOD to assess the effectiveness of programs and 
        support mechanisms to assist military families with deployment 
        readiness, responsiveness, and reintegration;
         Ensure that effective programs--including the Family 
        Readiness Council--are fully funded and their costs are 
        included in the annual budget process;
         Provide authorization and funding to accelerate 
        increases in availability of child care to meet both Active and 
        Reserve component requirements;
         Insist DOD implement flexible spending accounts to let 
        active duty and Selected Reserve families pay out-of-pocket 
        dependent and health care expenses with pre-tax dollars;
         Monitor and continue to expand family access to mental 
        health counseling;
         Promote expansion of military spouse opportunities to 
        further educational and career goals;
         Ensure additional and timely funding of Impact Aid 
        plus continued DOD supplemental funding for highly-impacted 
        military schools; and
         Mitigate the impact of Service transformation, 
        overseas rebasing initiatives, housing privatization and base 
        realignment on school facility needs and educational programs 
        affecting military children.
    Permanent Change of Station (PCS) Allowances
    The Coalition urges the subcommittee to continue its efforts to 
upgrade permanent change-of-station allowances to better reflect 
expenses imposed on servicemembers, with priority on:

         Shipping a second vehicle on overseas accompanied 
        assignments;
         Authorizing at least some reimbursement for house-
        hunting trip expenses; and
         Increasing PCS mileage rates to more accurately 
        reflect members' actual transportation costs.
    Education Enhancements
    The Coalition urges the subcommittee to support amending the 
statute to authorize all otherwise-qualifying members of the 
``uniformed services'' to transfer Post-September 11 GI Bill benefits 
to family members.
    Morale, Welfare, and Recreation (MWR) and Quality of Life (QoL) 
        Programs
    TMC urges the subcommittee to:

         Protect funding for critical family support and QoL 
        programs and services to meet the emerging needs of 
        beneficiaries and the timelines of the Services' transformation 
        plans;
         Oppose any initiative to withhold or reduce 
        appropriated support for family support and QoL programs to 
        include: recreation facilities, child care, exchanges and 
        commissaries, housing, health care, education, family centers, 
        and other traditional and innovative support services;
         Prevent any attempts to consolidate or civilianize 
        military service exchange and commissary programs; and
         Sustain funding for support services and 
        infrastructure at both closing and gaining installations 
        throughout the entire transformation process, including 
        exchange, commissary, and TRICARE programs.
National Guard and Reserve
    Operational Reserve Sustainment and Reserve Retirement
    For the near term, the Military Coalition places particular 
priority on authorizing early retirement credit for all qualifying 
post-September 11 active duty service performed by Guard/Reserve 
servicemembers and eliminating the fiscal-year-specific accumulator 
that bars equal credit for members deploying for equal periods during 
different months of the year.
    Ultimately, TMC believes we must move forward to provide a reduced 
age entitlement for retired pay and health coverage for all Reserve 
component members--that is, an age/service formula or outright 
eligibility, if otherwise qualified, at age 55.
    Further, TMC urges repeal of the annual cap of 130 days of inactive 
duty training points that may be credited towards a reserve retirement.
    Guard and Reserve Yellow Ribbon Readjustment
    TMC urges the subcommittee to hold oversight hearings and to direct 
additional improvements in coordination, collaboration, and consistency 
of Yellow Ribbon services. DOD must ensure that State-level best 
practices--such as those in Maryland, Minnesota, and New Hampshire--are 
applied for all Operational Reserve Force members and their families, 
and that Federal Reserve veterans have equal access to services and 
support available to National Guard veterans. Community groups, 
employers and service organization efforts need to be encouraged and 
better coordinated to supplement unit, component, Service and VA 
outreach and services.
    Guard/Reserve GI Bill
    TMC urges the subcommittee to work with the Veterans Affairs 
Committee to include Title 32 AGRs in the Post-September 11 statute.
    Based on the DOD/Services' 10-year record of indifference to the 
basic Selected Reserve GI Bill under Chapter 1606, 10 U.S.C., TMC 
recommends either: restoring Reserve benefits to 47-50 percent of 
active duty benefits or transferring the chapter 1606 statute from 
title 10 to title 38 so that it can be coordinated with other 
educational benefits programs in a 21st century GI Bill architecture. 
TMC also supports assured academic reinstatement, including guaranteed 
re-enrollment, for returning operational reservists.
    Special and Incentive Pays
    The Coalition urges the subcommittee to ensure equitable treatment 
of Guard and Reserve vs. active duty members for the full range of 
special and incentive pays.
Retiree Issues
    Concurrent Receipt
    The Coalition's continuing goal is to fully eliminate the deduction 
of VA disability compensation from earned military retired pay for all 
disabled retirees. In pursuit of that goal, the Coalition's immediate 
priorities include:

         Phasing out the disability offset for all Chapter 61 
        (medical) retirees; and
         Correcting the Combat-Related Special Compensation 
        (CRSC) formula to ensure the intended compensation is 
        delivered.
    Proposed Military Retirement Changes
    TMC urges the subcommittee to:

         Reject any initiatives to ``civilianize'' the military 
        system without adequate consideration of the unique and 
        extraordinary demands and sacrifices inherent in a military vs. 
        a civilian career; and
         Eliminate the Career Status Bonus for servicemembers 
        as it significantly devalues their retirement over time. In the 
        short term, the Services should be required to better educate 
        eligible members on the severe long-term financial penalty 
        inherent in accepting the REDUX option.
    Disability Severance Pay
    The Coalition urges the subcommittee to amend the eligibility rules 
for disability severance pay to include all combat--or operations--
related injuries, using same definition as CRSC. For the longer term, 
the Coalition believes the offset should be ended for all members 
separated for service-caused disabilities.
    Former Spouse Issues
    The Coalition requests a hearing to address Uniformed Services 
Former Spouse Protection Act (USFSPA) inequities. In addition, we 
recommend legislation to include all of the following:

         Base the award amount to the former spouse on the 
        grade and years of service of the member at time of divorce 
        (and not retirement);
         Prohibit the award of imputed income, which 
        effectively forces active duty members into retirement;
         Extend 20/20/20 benefits to 20/20/15 former spouses;
         Permit the designation of multiple Survivor Benefit 
        Plan (SBP) beneficiaries with the presumption that SBP benefits 
        must be proportionate to the allocation of retired pay;
         Eliminate the ``10-year Rule'' for the direct payment 
        of retired pay allocations by the Defense Finance and 
        Accounting Service (DFAS);
         Permit SBP premiums to be withheld from the former 
        spouse's share of retired pay if directed by court order;
         Permit a former spouse to waive SBP coverage;
         Repeal the 1-year deemed election requirement for SBP; 
        and
         Assist DOD and Services with greater outreach and 
        expanded awareness to members and former spouses of their 
        rights, responsibilities, and benefits upon divorce.
Survivor Issues
    SBP-DIC Offset
    The Coalition urges repeal of the SBP-DIC offset. TMC further 
recommends:

         Authorizing payment of SBP annuities for disabled 
        survivors into a Special Needs Trust;
         Allowing SBP eligibility to switch to children if a 
        surviving spouse is convicted of complicity in the member's 
        death; and
         Reinstating SBP for survivors who previously 
        transferred payments to their children at such time as the 
        youngest child attains majority, or upon termination of a 
        second or subsequent marriage.
    Final Retired Paycheck
    TMC urges the subcommittee to authorize survivors of retired 
members to retain the final month's retired pay for the month in which 
the retiree dies.
Health Care Issues
    Defense Health Program Cost Requirements
    The Coalition urges the subcommittee to take all possible steps to 
ensure continued full funding for Defense Health Program needs.
    National Health Reform
    TMC urges that any national health reform legislation must:

         Protect the unique TRICARE, TRICARE For Life (TFL), 
        and VA health care benefits from unintended consequences such 
        as reduced access to care;
         Bar any form of taxation of TRICARE, TFL, or VA health 
        care benefits, including those provided in nongovernmental 
        venues; and
         Preserve military and VA beneficiaries' choices.
    TRICARE Fees
    Establish a ``Sense of Congress'' which recognizes that military 
retiree health benefits are an essential offset to arduous service 
conditions which have been paid for upfront.
    Military vs. Civilian Cost-Sharing Measurement
    The Coalition believes that military beneficiaries from whom 
America has demanded decades of extraordinary service and sacrifice 
have earned coverage that is the best America has to offer.
    Large Retiree Fee Increases Can Only Hurt Retention
    Reducing military retirement benefits would be particularly ill-
advised when an overstressed force already is at increasing retention 
risk despite the current downturn of the economy and current recruiting 
successes.
    Pharmacy
    The Coalition urges the subcommittee to ensure continued 
availability of a broad range of medications, including the most-
prescribed medications, in the TRICARE pharmacy system, and to ensure 
that the first focus on cost containment should be on initiatives that 
encourage beneficiaries to take needed medications and reduce program 
costs without shifting costs to beneficiaries.
    Alternative Options to Make TRICARE More Cost-Efficient
    The Coalition has offered a long list of alternative cost-saving 
possibilities, including:

         Positive incentives to encourage beneficiaries to seek 
        care in the most appropriate and cost effective venue;
         Encouraging improved collaboration between the direct 
        and purchased care systems and implementing best business 
        practices and effective quality clinical models;
         Focusing the military health system, health care 
        providers, and beneficiaries on quality measured outcomes;
         Improving MHS financial controls and avoiding overseas 
        fraud by establishing TRICARE networks in areas fraught with 
        fraud;
         Establishing TRICARE networks in areas of high TRICARE 
        Standard utilization to take full advantage of network 
        discounts;
         Promoting retention of other health insurance by 
        making TRICARE a true second-payer to other insurance (far 
        cheaper to pay another insurance's co-pay than have the 
        beneficiary migrate to TRICARE);
         Encouraging DOD to effectively utilize their data from 
        their electronic health record to better monitor beneficiary 
        utilization patterns to design programs which truly match 
        beneficiaries needs;
         Sizing and staffing military treatment facilities to 
        reduce reliance on network providers and develop effective 
        staffing models which support enrolled capacities;
         Reducing long-term TRICARE Reserve Select (TRS) costs 
        by allowing servicemembers the option of a government subsidy 
        of civilian employer premiums during periods of mobilization;
         Doing far more to promote use of mail-order pharmacy 
        system and formulary medications via mailings to users of 
        maintenance medications, highlighting the convenience and 
        individual expected cost savings; and
         Encouraging retirees to use lowest-cost-venue military 
        pharmacies at no charge, rather than discouraging such use by 
        limiting formularies, curtailing courier initiatives, etc.
    TMC Healthcare Cost Principles
    The Coalition strongly recommends that Congress establish statutory 
findings, a sense of Congress on the purpose and principles of military 
health care benefits earned by a career of uniformed service that 
states:

         Active duty members and families should be charged no 
        fees except retail pharmacy co-payments, except to the extent 
        they make the choice to participate in TRICARE Standard or use 
        out-of-network providers under TRICARE Prime;
         The TRICARE Standard inpatient copay should not be 
        increased further for the foreseeable future. At $535 per day, 
        it already far exceeds inpatient copays for virtually any 
        private sector health plan;
         There should be no enrollment fee for TRICARE Standard 
        or TFL, since neither offers assured access to TRICARE-
        participating providers. An enrollment fee implies enrollees 
        will receive additional services, as Prime enrollees are 
        guaranteed access to participating providers in return for 
        their fee. Congress already has required TFL beneficiaries to 
        pay substantial Medicare Part B fees to gain TFL coverage;
         All retired servicemembers earned equal health care 
        coverage by virtue of their service; and
         DOD should make all efforts to provide the most 
        efficient use of allocated resources and cut waste prior to 
        proposing additional or increased fees on eligible 
        beneficiaries.
    TRICARE Prime
    The Military Coalition urges the subcommittee to require reports 
from DOD and from the managed care support contractors, on actions 
being taken to improve Prime patient satisfaction provide assured 
appointments within Prime access standards, reduce delays in 
preauthorization and referral appointments, and provide quality 
information to assist beneficiaries in making informed decisions.
TRICARE Standard
    TRICARE Standard Provider Participation
    The Coalition urges the subcommittee to insist on immediate 
delivery of an adequacy threshold for provider participation, below 
which additional action is required to improve such participation. The 
Coalition also recommends requiring a specific report on participation 
adequacy in the localities where Prime Service Areas will be 
discontinued under the new TRICARE contracts.
    TRICARE Reimbursement Rates
    The Coalition places primary importance on securing a permanent fix 
to the flawed statutory formula for setting Medicare and TRICARE 
payments to doctors.
    To the extent a Medicare rate freeze continues, we urge the 
subcommittee to encourage DOD to use its reimbursement rate adjustment 
authority as needed to sustain provider acceptance.
    The Coalition urges the subcommittee to require a Comptroller 
General report on the relative propensity of physicians to participate 
in Medicare vs. TRICARE, and the likely effect on such relative 
participation of a further freeze in Medicare/TRICARE physician 
payments along with the effect of an absence of bonus payments.
Dental Care
    Active Duty Dependent Dental Plan
    The Coalition recommends increasing the DOD subsidy for the Active 
Duty Dependent Dental Plan to 72 percent and increasing the cap on 
orthodontia payments to $2,000.
Guard and Reserve Healthcare
    Continuum of Health Care Insurance Options for The Guard and 
        Reserve
    The Coalition recommends the subcommittee:

         Require a GAO review of DOD's methodology for 
        determining TRS costs for premium adjustment purposes to assess 
        whether it includes any costs of maintaining readiness or 
        ``costs of doing business'' for the Defense Department that 
        don't contribute to beneficiary benefit value and thus should 
        be excluded from cost/premium calculations;
         Authorize development of a cost-effective option to 
        have DOD subsidize premiums for continuation of a Reserve 
        employer's private family health insurance during periods of 
        deployment as an alternative to ongoing TRS coverage;
         Allow eligibility in Continued Health Care Benefits 
        Program (CHCBP) for Selected reservists who are voluntarily 
        separating and subject to disenrollment from TRS;
         Authorize members of the IRR who qualify for a Reserve 
        retirement at age 60 to participate in TRICARE Retired Reserve 
        (TRR) as an incentive for continued service (and higher 
        liability for recall to active duty);
         Monitor implementation of the new TRR authority to 
        ensure timely action and that premiums do not exceed 100 
        percent of the TRS premium; and
         Allow FEHB plan beneficiaries who are selected 
        reservists the option of participating in TRS.
    Guard and Reserve Mental Health
    TMC believes that Guard and Reserve members and their families 
should have access to evidence-based treatment for PTSD, TBI, 
depression, and other combat-related stress conditions. Further, Post 
Deployment Health examinations should be offered at the member's home 
station, with the member retained on active duty orders until 
completion of the exam.
    Guard and Reserve Health Information
    The Coalition believes there should be an effort to improve the 
electronic capture of non-military health information into the 
servicemember's medical record.
    TRICARE For Life
    Coalition priorities for TFL-eligibles include:

         Securing a permanent fix to the flawed formula for 
        setting Medicare/TRICARE payments to providers;
         Resisting any effort to establish an enrollment fee 
        for TFL, given that many beneficiaries already experience 
        difficulties finding providers who will accept Medicare 
        patients; and
         Including TFL beneficiaries in DOD programs to 
        incentivize compliance with preventive care and healthy 
        lifestyles.
    Restoration of Survivors' TRICARE Coverage
    The Coalition recommends restoration of TRICARE benefits to 
previously eligible survivors whose second or subsequent marriage ends 
in death or divorce.
    Base Realignment and Closure (BRAC) and Rebasing
    The Coalition recommends requiring an annual DOD report on the 
adequacy of health resources, funding, services, quality and access to 
care for beneficiaries affected by BRAC/rebasing.
                                overview
    Mr. Chairman, The Military Coalition extends our thanks to you and 
the entire subcommittee for your steadfast support of our Active Duty, 
Guard, Reserve, retired members, and veterans of the uniformed services 
and their families and survivors. Your efforts have had a dramatic, 
positive impact in the lives of the entire uniformed services 
community.
    Last year was an extremely tumultuous, difficult year. As our 
servicemembers continued to fight terror on two separate fronts, our 
Nation slowly started to recover from an economic crisis, the worst 
seen since the great depression. Congress and the administration had 
difficult choices to make as they attempted to ``jump start'' the 
economy while faced with a record budget deficit.
    We are grateful that both the Defense Department and Congress put 
top priority on personnel issues last year. As we enter the ninth year 
of extremely stressful wartime conditions, the Coalition believes that 
this prioritization should continue for fiscal year 2011.
    Despite ever-increasing pressures on them at home and abroad, men 
and women in uniform are still answering the call--thanks in no small 
measure to the subcommittee's strong and consistent support--but only 
at the cost of ever-greater sacrifices.
    Troubling indicators such as dramatic increases in suicide and 
divorce rates may reflect the effects of the long-term consequences we 
know are coming as we require the same people to return to combat again 
and again and yet again.
    In these times of growing political and economic pressures, the 
Coalition relies on the continued good judgment of the Armed Services 
Committees to ensure the Nation allocates the required resources to 
sustain a strong national defense, and in particular, to properly meet 
the pressing needs of the less than 1 percent of the American 
population--servicemembers and their families--who protect the freedoms 
of the remaining 99 percent.
    In this testimony, The Coalition offers our collective 
recommendations on what needs to be done to meet these essential needs.
                          wounded warrior care
    Much has been done in the last 3 years to address the grievous and 
negligent conditions that were brought to light since the tragic 
incident at Walter Reed Army Medical Center, where wounded and disabled 
troops and their families had fallen through the cracks as they 
transitioned from the military to VA health care and benefits systems.
    Subsequently, the subcommittee has worked hard to address these 
difficulties, and significant progress has been made on that score.
    But the extent and complexity of the challenges remain daunting, 
requiring continuing coordination of effort between the military 
services; the Department of Defense (DOD); the Department of Veterans 
Affairs (VA); several Centers of Excellence; a multitude of civilian 
contractors and nongovernmental agencies; and the two Armed Services, 
two Veterans Affairs, and two Appropriations Committees.
    The Coalition looks forward to working with the subcommittee this 
year in its ongoing efforts to identify and ease significant remaining 
problems.
DOD-VA Seamless Transition
    Institutional Oversight
    While many legislative and fiscal changes have improved the care 
and support of our wounded and disabled members, the Coalition is 
concerned that the recent dissolution of the Senior Oversight Committee 
(SOC) poses significant risks for effective day-to-day leadership and 
coordination of DOD and VA seamless transition efforts.
    Last year, the Coalition expressed concern that the change of 
administration would pose a significant challenge to the two 
departments' continuity of joint effort, as senior leaders whose 
personal involvement had put interdepartmental efforts back on track 
left their positions and were replaced by new appointees who had no 
experience with past problems and no personal stake in ongoing 
initiatives.
    Unfortunately, those concerns are being realized, as many 
appointive positions in both departments have gone unfilled for a year, 
responsibilities have been reorganized, and oversight duties previously 
assumed by senior officials have been divested to lower-level 
administrators who are less regularly engaged with their cross-
department counterparts.
    The result has been more uncertainty and degradation of 
cooperation, communication, and collaboration between the two 
departments over the last year.
    The Coalition is concerned that, having exerted major efforts to 
address the most egregious problems, there is a significant potential 
to fall victim to a ``business as usual'' operating mode, even though 
the difficult journey to true seamless transition between the 
departments has just begun.
    While many well-meaning and hard working military and civilians are 
doing their best to keep pushing progress forward, transitions in 
leadership and mission changes clearly are challenging and require 
formal and more standardized structures, policies, and programs that 
won't be as subject to disruption by one participant's unilateral 
organizational changes.
    It sends a message about departmental priorities when these 
responsibilities are pushed to lower-level officials.
    The Coalition believes there's no substitute for a permanent DOD-VA 
Senior Oversight Committee or other Joint Seamless Transition Office, 
staffed with senior officials working together full-time and charged 
with innovation and daily oversight of initiatives to institutionalize 
and sustain a culture of cross-department seamless transition.
    Continuity of Health Care
    Transitioning between DOD and VA health care systems remains 
challenging, confusing, and overwhelming to those trying to navigate 
and use these systems. Systemic, cultural, and bureaucratic barriers 
often prevent the servicemember or veteran from receiving the necessary 
continuity of care they need to heal and have productive and a high 
level of quality of life they so desperately need and desire.
    While servicemembers and their families tell us that DOD has done 
much to address trauma care, acute rehabilitation, and basic short-term 
rehabilitation, they are less satisfied with their transition from the 
military health care systems to longer-term care and support in 
military and veterans medical systems.
    We hear regularly from members who experienced significant 
disruptions of care upon separation or medical retirement from service.
    One is in the area of cognitive therapy, which is available to 
retired members under TRICARE only if it is not available through the 
VA. Unfortunately, members are caught in the middle because of 
differences between DOD and VA authorities on what constitutes 
cognitive therapy and the degree to which effective, evidenced-based 
therapy is available.
    The NDAA for Fiscal Year 2010 requires a report on such issues, but 
action is needed to protect the wounded and disabled. The subcommittee 
has acted previously to authorize 3 years of active-duty-level TRICARE 
coverage for the family members of those who die on active duty. The 
Coalition believes we owe equal transition care continuity to those 
whose service-caused illnesses or injuries force their retirement from 
service.
    Another significant issue faced by many members forced from active 
duty by severe service-caused disabilities is that the severity of 
their disability qualifies them for Medicare. In such cases, TRICARE is 
second-payer to Medicare.
    Under laws that were designed for elderly retirees but apply 
equally to all Medicare-eligible military beneficiaries, these younger 
disabled warriors must pay Medicare Part B premiums ($110 per month in 
2010) to retain any coverage under TRICARE.
    The Coalition believes it's wrong that members whose service caused 
them to become severely wounded, ill or injured should have to pay more 
for their care than they would if not injured by service, and believes 
they should either be exempt from paying the Part B premium until age 
65 or DOD should help them offset the cost of such payments.
    Finally, doctors at VA polytrauma centers indicate that one of 
their biggest problems is the requirement to get multiple 
authorizations from DOD to provide a variety of specialty care for 
active duty members with multiple medical problems.
    When an active duty member is referred to VA facility for care, DOD 
should grant an automatic waiver of preauthorization/referral 
requirements to allow the VA providers to deliver needed care without 
bureaucratic delays.
    The Coalition recommends:

         Authorizing active-duty-level TRICARE benefits, 
        independent of availability of VA care, for 3 years after 
        medical retirement to help ease transition from DOD to VA;
         Authorizing blanket waiver authority for VA physicians 
        treating active duty patients with multiple medical trauma 
        conditions for all aspects of the member's treatment, including 
        referral outside the VA/TRICARE system if needed; and
         Either exempting severely wounded, ill, or injured 
        members who must be medically retired from paying Medicare Part 
        B premiums until age 65 or authorizing a special DOD allowance 
        to help offset the cost of such premiums until age 65.
    Mental/Behavioral Health Issues
    The military community is experiencing a crisis of demand for 
mental/behavior health care, both for servicemembers and their spouses 
and children.
    The subcommittee included several initiatives in the NDAA for 
Fiscal Year 2010 aimed at increasing the number of military providers 
in this field and improving access for members and families.
    While the Coalition is very grateful for these initiatives, we 
respectfully request that the subcommittee continue, and more 
importantly expand, its efforts in addressing the growing epidemic of 
difficulties regarding post-traumatic stress disorder (PTSD), traumatic 
brain injuries (TBI), depression, and other mental/behavioral health 
issues disproportionally plaguing our military and veteran communities.
    Today our servicemembers, their spouses and children are facing 
immense stresses and uncertainties associated with repeated deployments 
and protracted separations. Our country is at war on multiple fronts 
and we must take all the necessary actions to ensure the mental well 
being of all those involved, at home and those on the frontlines.
    One of the most prevalent obstacles in successfully identifying and 
treating mental/behavioral health conditions is the stigma which the 
military's warrior culture continues to associate with such conditions 
and the threat or fear that admission of experiencing them may affect 
one's peer standing, security clearance, promotions, or ability to 
remain in service.
    Despite the continued efforts by senior leaders to reduce the 
stigmas associated with mental health issues, the unit-level reality is 
far different. The reality is that many officers, NCOs, and peers 
continue to view these conditions as signs of weakness or inability to 
coup.
    Furthermore, many servicemembers are deterred from seeking care by 
cases of friends who have been disciplined or separated as a result of 
using the available support systems the military has implemented.
    As a direct result, the suicide and divorce rates, as well as 
childhood depression diagnosis' continue to climb within the military 
and veteran communities. DOD openly acknowledges that stigmas remain 
within the ranks, despite their efforts of significantly ramping up 
efforts and outreach programs composed of anti-stigma campaigns, upper-
level training programs, and easier access to mental health providers.
    The Coalition stresses our grave concerns to the subcommittee 
regarding the current state of DOD's inability to effectively handle 
the increasing demands/need for mental health services and outreach to 
all demographics of today's military forces. While our forces and their 
families display extraordinary strengths, resiliency and undaunted 
tenacity in the face of all stresses associated with service; it is 
vital that we never forget that these same stressors of service to this 
country are in all likelihood, leading to untreated mental and physical 
health conditions.
    The Coalition believes that due to the numerous unrealistic 
standards and high expectations of resiliency and coping abilities we 
have somehow come to expect from our servicemembers and their families, 
that the current military administrative and disciplinary systems being 
used are not effectively meeting the mental health needs, whether 
proactive or reactive, of the same people to whom we expect so much. 
DOD and VA have an obligation to provide the best care available to any 
servicemember who sustains an injury as a result of their service.
    Unfortunately, many of today's servicemembers have mental wounds 
that are undiagnosed and thus untreated. This lack of care or treatment 
for PTSD, TBI, or any one of the numerous stressors associated with 
service, is leading to an increased number of early separations or even 
more alarming, being barred from reenlisting due to a charge of 
misconduct, such as a driving under the influence (DUI) or other such 
incident, by a servicemember who has never previously displayed any 
such behaviors. These uncharacteristic behaviors are only one of the 
symptoms associated with untreated mental/behavioral health conditions. 
Ironically, some civil authorities often are more tolerant and offer 
more assistance in dealing with such cases involving combat veterans 
than military authorities.
    As a result of such circumstances, thousands, if not countless, of 
affected servicemembers, veterans and their family members have gone 
unidentified, untreated, or deterred from being given the opportunity 
to seek the care they deserve. Moreover, many have difficulty accessing 
and utilizing programs that are in place.
    In addition to expanding the availability of providers, the 
Coalition believes that two key elements will be in expanding the 
opportunities for confidential access to counseling or treatments and 
achieving more consistency between leadership campaigns for 
destigmatization/individual resiliency and the practical demonstration 
of greater resiliency and rehabilitation initiatives at the unit/
administrative level.
    TMC recommends:

         Increased efforts to promote the de-stigmatization on 
        all levels in service/unit administrative and strict 
        accountability programs with outlined and enforced consequences 
        to non-compliancy to ensure unit actions are consistent with 
        leadership pronouncements;
         Continuing priority efforts to deliver information and 
        assistance on-line, confidential options for counseling and 
        uniformed access and availability to telemedicine services;
         Substantial increases in outreach efforts to provide 
        such services and resources to Guard and Reserve members, rural 
        populations and all families who don't live near military or VA 
        facilities;
         Priority efforts to educate private sector providers 
        on the unique needs of military and veteran patients and family 
        members, and deliver needed information via on-line services, 
        including contact points for discussion/consultation with 
        military and VA providers;
         Consistent implementation of pre-and post-deployment 
        evaluations and follow-up programs, particularly for Guard and 
        Reserve members who may be leaving active duty;
         Establishing common DOD and VA protocols for 
        diagnosis, treatment, and rehabilitation for TBI conditions, as 
        well as an electronic system to share and exchange a patient's 
        medical history and other key medical information;
         Expanding Traumatic Servicemember Group Life Insurance 
        (TSGLI) criteria to include moderate and severe TBI, without 
        onerous ``functions of daily living'' standards that aren't 
        required for other (and often much more functional) TSGLI-
        eligibles;
         Increasing availability and outreach on substance 
        abuse counseling options;
         Pursuing aggressive medication reconciliation and 
        management programs to protect against inadvertent over 
        medication and adverse reactions and/or accidental or 
        intentional overdose;
         Requiring TBI and psychological health assessments for 
        members who have been deployed to a combat zone as part of the 
        disciplinary process prior to a decision concerning non-medical 
        separation; and
         Implementing recommendations from the 2008 RAND report 
        (``Invisible Wounds of War, Psychological and Cognitive 
        Injuries, Their Consequences, and Services to Assist 
        Recovery'').
    DOD-VA Disability Evaluation Systems (DES)
    Several recommendations made by various commissions, task forces 
and committees were addressed in the National Defense Authorization 
Acts for Fiscal Year 2008, 2009, and 2010; however, more needs to be 
done.
    One of the most emotional issues that emerged from the Walter Reed 
scandal was the finding that Services were ``low-balling'' disabled 
servicemembers' disability ratings, with the result that many 
significantly disabled members were being separated and turned over to 
the VA rather than being medically retired (which requires a 30 percent 
or higher disability rating).
    Encouraging rhetoric was heard from leadership in both the DOD and 
VA that this would be addressed by having DOD accept the (usually 
higher) disability ratings awarded by the VA.
    Congress has taken positive steps to correct previous ``low-ball'' 
ratings and streamline the DES. Congress created the Physical 
Disability Board of Review (PDBR) to give previously separated 
servicemembers an opportunity to appeal their ``low-balled'' disability 
rating.
    They also authorized a jointly executed DOD-VA DES pilot in the 
2008 NDAA, and feedback from members and families who participated in 
the pilot program is that it has simplified the process and provided a 
more standardized disability rating outcome.
    TMC was further encouraged that wounded, ill, and injured members 
would benefit from the 19 Dec 07 Under Secretary of Defense (Personnel 
and Readiness) Directive Type Memorandum (DTM) which added 
``deployability'' as a consideration in the DES decision process--
permitting medical separation/retirement based on a medical condition 
that renders a member nondeployable.
    Unfortunately, several cases have surfaced indicating the Services 
have failed to incorporate the DTM in their DES process.
    In this regard, the services continue to issue findings that a 
member is ``fit, but unsuitable'' for service. Under this system, a 
member found ``fit'' by the PEB, is deemed by the service to be 
``unsuitable'' for continued service--and administratively separated--
because the member's medical condition prevents them from being able to 
deploy or maintain their current occupational skill.
    The Coalition believes strongly that medical conditions which 
preclude servicemembers from continuing to serve should be deemed 
``unfitting''--not ``unsuitable.''
    In addition, we remain concerned about language used by some 
indicating a wish to remove DOD from the DES process (i.e., DOD 
determines fitness and VA determines disability). This simplified 
process could result in neglect of DOD's employer responsibilities, 
such as TRICARE eligibility for disabled members and their families.
    The Coalition believes strongly that members determined by parent 
service to be 30 percent or more disabled should continue to be 
eligible for a military disability retirement with all attendant 
benefits, including lifetime TRICARE eligibility for the member and 
his/her family. We do not support efforts to disconnect health care 
eligibility from disability retired pay eligibility. The Coalition also 
agrees with the opinion expressed by Secretary Gates that a member 
forced from service for wartime injuries should not be separated, but 
should be awarded a high enough rating to be retired for disability.
    TMC recommends:

         Barring ``fit, but unsuitable'' separations when a 
        member's medical condition prevents continued service;
         Authorizing automatic enrollment in the VA health care 
        system for any medically separated or medically retired 
        servicemember (Chapter 61);
         Ending distinctions between disabilities incurred in 
        combat vice non-combat;
         Monitoring the effectiveness of recent DOD 
        compensation for catastrophically injured or ill servicemembers 
        requiring assistance with activities of daily living authorized 
        in the 2010 NDAA;
         Ensuring benefits afforded members wounded, ill, or 
        disabled in the line of duty are applied equally for all 
        uniformed services;
         Ensuring that the VA is the single authority for 
        rating service-connected disabilities for military disability 
        retirements and separations;
         Preserving the statutory 30 percent disability 
        threshold for medical retirement and lifetime TRICARE coverage 
        for members injured while on active duty;
         Continued monitoring of Service/DOD Medical-Physical 
        Evaluation Boards, DOD DES Pilot Project, and the Physical 
        Disability Board of Review, to assess needed DES changes;
         Eliminating member premiums for Traumatic 
        Servicemember Group Life Insurance (TSGLI);
         Barring ``pre-existing condition'' determinations for 
        any member who deploys to a combat zone;
         Ensuring that any adjustment to the disability 
        retirement system does not result in a member receiving less 
        disability retired pay than he or she would receive under the 
        current system; and
         Ensuring that members electing accelerated disability 
        retirement/separation are fully counseled on any possible 
        negative changes in compensation, health care and other 
        benefits, with consideration to allowing a limited time to 
        reverse a regrettable decision.
    Caregiver/Family Support Services
    The sad reality is that, for the most severely injured 
servicemembers, family members or other loved ones are often required 
to become full-time caregivers. Many have lost their jobs, homes, and 
savings in order to meet caregiver needs of a servicemember who has 
become incapacitated due to service-caused wounds, injuries or illness.
    The Coalition believes the government has an obligation to provide 
reasonable compensation and training for such caregivers, who ever 
dreamed that their own well-being, careers, and futures would be 
devastated by military-caused injuries to their servicemembers.
    Last year, the subcommittee authorized a special payment to an 
active duty servicemember to allow compensation of a family member or 
professional caregiver. The authorized payment was in the same amount 
authorized by the VA for veterans' aid-and-attendance needs, reflecting 
the subcommittee's thinking that caregiver compensation should be 
seamless when the member transitions from active duty to VA care, as 
long as the caregiver requirements remain the same.
    The Coalition supported this initiative, but recognizes that both 
chambers have since approved legislation to authorize more significant 
VA assistance and compensation for caregivers.
    Once the House and Senate versions of the VA caregiver legislation 
have been reconciled in conference, the Coalition hopes the 
subcommittee will propose similar upgrades for caregivers of members 
while on active duty, consistent with the ``seamless transition'' 
philosophy adopted last year.
    In a similar vein, many wounded or otherwise-disabled members 
experience significant difficulty transitioning to medical retirement 
status. To assist in this process, consideration should be given to 
authorizing medically retired members and their families to remain in 
on-base housing for up to 1 year after retirement, in the same way that 
families are allowed to do so when a member dies on active duty.
    The Coalition recommends:

         Upgraded compensation and assistance for caregivers of 
        severely disabled active duty members, consistent with pending 
        legislative action to improve compensation/assistance for 
        caregivers of veterans; and
         Authorizing up to 1 year of continued residence in on-
        base housing facilities for medically retired, severely wounded 
        servicemembers and their families.
                    active forces and their families
    In our overview, the Coalition expressed our collective concern 
over the stressors our servicemembers and their families are 
experiencing due to the long, repeated deployments and unrelenting 
operations tempo. In order to sustain a sufficient, highly trained and 
highly capable Active Force, the continuing overriding requirement is 
to find additional ways to ease the terrible burden of stress on 
servicemembers and their families.
Military End Strength
    Increased end strength is the only effective way to reduce stress 
on forces and families as long as deployment requirements not only 
continue, but actually increase.
    The creators of the All-Volunteer Force never envisioned that the 
force would be deployed into combat 1 year out of 3--let alone every 
other year, as has been the case with many ground units.
    Regrettably, the scenario faced by today's forces is not unlike the 
World War II ``Catch-22'' situation described by Joseph Heller, in 
which aircrews braving horrendous enemy flak had their wartime mission 
requirements increased again and again, until they perceived that the 
terrible sacrifices being demanded of them would never end.
    Unfortunately, many in government and among the public seem to have 
become desensitized to the truly terrible sacrifices that the current 
mismatch between missions and force levels has already imposed on those 
in uniform. They acknowledge the problem, but most assume that 
servicemembers and families will simply continue to accept these--or 
even greater--levels of sacrifice indefinitely.
    Many point to the achievement of service recruiting and retention 
goals as indicators that all is well.
    Such perceptions grossly underestimate the current stresses on the 
force and the risk that poses for readiness and national security. The 
Coalition believes any complacency about retention is sadly misplaced, 
and that the status of the current force should be viewed in the 
context of a rubber band that has been stretched to its limit. The fact 
that it has not yet broken is of little comfort.
    Well-respected studies have shown that 20 to 30 percent of combat 
returnees have experienced PTSD, TBI, or depression, and that the 
likelihood of a servicemember returning as a changed person rises with 
each subsequent deployment. Other studies have shown that rising 
cumulative family separations are having significant negative effects 
on servicemembers' children.
    These are not mere academic exercises. They are well-known facts of 
life to those who are alone in actually experiencing them.
    A far truer, and truly tragic, indicator of these extremely 
troubling circumstances has been the significant rise in 
servicemembers' suicide and divorce rates.
    So the Coalition is very grateful for the subcommittee's support 
for end strength increases for all Services in the National Defense 
Authorization Act for Fiscal Year 2010, and for fending off the efforts 
of those who proposed cutting force levels to fund hardware needs.
    But we must not understate the reality that the increases approved 
to date will not significantly improve dwell time for military families 
anytime in the near future, given increasing operational requirements 
in Afghanistan.
    New requirements for massive humanitarian aid in Haiti and 
elsewhere only exacerbate the already grievous situation.
    The Coalition is relieved that the administration is requesting an 
increase to the overall defense budget by $100 billion over the next 5 
years--we just hope it's enough.
    The Coalition urges the subcommittee to:

         Continue end strength growth as needed to sustain the 
        war and other operational commitments while materially 
        increasing dwell time for servicemembers and families;
         Sustain adequate recruiting and retention resources to 
        enable the uniformed services to achieve required optimum-
        quality personnel strength; and
         Seek a 2011 defense budget of at least 5 percent of 
        Gross Domestic Product that funds both people and weapons 
        needs.
    Military Pay Raise
    The Coalition thanks the subcommittee for its sustained commitment 
to restoring full military pay comparability--a fundamental 
underpinning of the All-Volunteer Force.
    To that end, we are grateful for the committee's leadership in 
approving a 3.4 percent military pay raise for 2010--vs. the 2.9 
percent proposed in the defense budget submission.
    Throughout the 1980s and 1990s, military pay raises consistently 
were capped below private sector pay growth, causing a ``pay 
comparability gap'' that reached 13.5 percent in 1998-1999, and 
contributed significantly to serious retention problems.
    Every year since then, the subcommittee has acted to pare the gap 
by approving military raises that have been at least .5 percent above 
private sector pay growth.
    Now that significant progress has been made and the ``erosion of 
pay and benefits'' retention-related problems have abated, some have 
renewed calls to cut back on military raises, create a new 
comparability standard, or substitute more bonuses for pay raises in 
the interests of ``efficiency.''
    The Defense Department has proposed a new comparability standard 
under which each pay and longevity cell would represent the 70th 
percentile of compensation for similarly-educated civilians. A recent 
Congressional Budget Office report asserted that, considering 
adjustments in housing allowances, military people actually are paid 10 
percent more than their civilian counterparts in terms of Regular 
Military Compensation (RMC), composed of basic pay, food and housing 
allowances, and the tax advantage that accrues because the allowances 
are tax-free.
    The Coalition believes such assertions are fundamentally flawed.
    First, the RMC concept was developed in the 1960s, when all 
servicemembers received the same allowances, regardless of location, 
and the allowances were arbitrary figures that weren't actually based 
on anything. In the interim, Congress has transformed the allowances 
into reimbursements for actual food costs and median locality-based 
housing costs.
    If one were to use the RMC comparability methodology in this 
scenario, basic pay--the largest element of military pay and the one 
that drives retired pay--would become ``flex'' compensation element. 
With tax rates and allowances figures set independently, a year in 
which average housing allowances rose (e.g., based on growth in high-
cost areas) and taxes increased could actually yield a requirement to 
cut basic pay (and future retirement value) to restore 
``comparability.''
    Second, the Coalition is not convinced that the civilian comparison 
cohort or percentile comparison point proposed by DOD are the proper 
ones, given that the military:

         Recruits from the top half of the civilian aptitude 
        population;
         Finds that only about 25 percent of America's youth 
        qualify for entry;
         Requires career-long education and training 
        advancement;
         Enforces a competitive ``up-or-out'' promotion system; 
        and
         Imposes severe limits on personal freedoms (e.g., not 
        being able to quit when you want; risking a felony conviction 
        for refusing an order).

    A fundamental requirement for any pay comparability standard is 
that it should be transparent and understandable. The Coalition has 
asked for, but has never been provided by DOD, any data on what 
civilian comparison cohort was selected and why, and what rationale was 
used to establish a specific percentile comparison point.
    Third, the Coalition believes it is essential to recognize that 
compensation is not simply the amount one is paid. It is pay divided by 
what's required of the recipient to earn that pay. If we increase pay 
25 percent but require 100 percent more sacrifice to earn it, that's 
not a pay raise.
    In that context, today's conditions of service are far more arduous 
than anything envisioned 40 years ago by the creators of the All-
Volunteer Force, who believed a protracted war would require 
reinstitution of the draft.
    Finally, private sector pay growth between 2008 and 2009 would set 
the military pay raise for 2011 at 1.4 percent--the smallest military 
pay raise in almost 50 years, even while servicemembers are being asked 
to endure the most arduous service conditions in more than 60 years. 
Further, the Coalition observes that there is a lag of more than a year 
between the time the civilian pay growth is measured and the time it is 
applied to the military.
    The Coalition agrees with the approach the subcommittee has taken 
consistently -that the best comparability measure is a comparison of 
the military basic pay raise percentage with the percentage growth in 
the ECI.
    The government uses the ECI for every other measure of private pay 
growth, and it's very transparent to government leaders and 
servicemembers alike. As of 2010, cumulative military basic pay 
increases lag cumulative private sector pay growth by 2.4 percent since 
1982--the last time it was generally agreed that a state of 
comparability existed.
    Given the historic low raise produced by the ECI for 2011, the 
historic sacrifices being asked of servicemembers in this time of 
protracted war, and the dubious rationale for alternative pay raise 
proposals, any assertion that military people are overpaid is grossly 
off the mark.
    The Coalition believes a basic pay raise of at least 1.9 
percent--.5 percent above the ECI standard--is the bare minimum the 
Nation should do to sustain its military pay comparability commitment 
for 2011.
    Family Readiness and Support
    A fully funded, robust family readiness program continues to be 
crucial to overall readiness of our military, especially with the 
demands of frequent and extended deployments.
    Resource issues continue to plague basic installation support 
programs. At a time when families are dealing with increased 
deployments, they often are being asked to do without in other 
important areas. We are grateful that the subcommittee included a 
provision in last year's defense bill that will help improve family 
readiness and support though greater outreach. The Department's 
establishment of a comprehensive benefits web site for servicemembers 
and their families will help provide virtual assistance regardless of 
their physical proximity to installation-supported networks.
    Additionally, we could not agree more with last year's ``Sense of 
Congress'' regarding the establishment of flexible spending accounts 
(FSAs) for members of the uniformed services. We urge the subcommittee 
to continue to press the Defense Department until servicemembers are 
provided the same eligibility to participate in FSAs that all other 
Federal employees enjoy.
    Quality education is a top priority to military families. 
Servicemembers are assigned all across the United States and the world. 
Providing appropriate and timely funding of Impact Aid through the 
Department of Education is critical to ensuring quality education 
military children deserve, regardless of where they live.
    The Coalition believes that several initiatives could have 
unintended negative consequences on school facility needs and 
educational programs affecting military children. Service 
transformation, overseas rebasing initiatives, housing privatization, 
base realignment and closure actions all have the potential to affect 
the military family and their access to quality education programs.
    The Coalition recommends that the subcommittee:

         Press DOD to assess the effectiveness of programs and 
        support mechanisms to assist military families with deployment 
        readiness, responsiveness, and reintegration;
         Ensure that effective programs--including the Family 
        Readiness Council--are fully funded and their costs are 
        included in the annual budget process;
         Provide authorization and funding to accelerate 
        increases in availability of child care to meet both Active and 
        Reserve component requirements;
         Insist DOD implement flexible spending accounts to let 
        active duty and Selected Reserve families pay out-of-pocket 
        dependent and health care expenses with pre-tax dollars;
         Monitor and continue to expand family access to mental 
        health counseling;
         Promote expansion of military spouse opportunities to 
        further educational and career goals;
         Ensure additional and timely funding of Impact Aid 
        plus continued DOD supplemental funding for highly-impacted 
        military schools; and
         Mitigate the impact of Service transformation, 
        overseas rebasing initiatives, housing privatization and base 
        realignment on school facility needs and educational programs 
        affecting military children.
    Permanent Change of Station (PCS) Allowances
    It's an unfortunate fact that members and their families are forced 
to incur significant out-of-pocket expenses when complying with 
government-directed moves.
    For example, the current Monetary Allowance in Lieu of 
Transportation (MALT) rate used for PCS moves still fall significantly 
short of meeting members' actual travel costs. The current rate of 24 
cents per mile is less than half of the 50 cents per mile authorized 
for temporary duty travel. Also, military members must make any advance 
house-hunting trips at personal expense, without any government 
reimbursements such as Federal civilians receive.
    DOD states that the MALT rate was not intended to reimburse 
servicemembers for travel by automobile, but simply a payment in lieu 
of providing transportation in-kind.
    The Coalition believes strongly that the MALT concept is an 
outdated one, having been designed for a conscripted, single, non-
mobile force.
    Travel reimbursements should be adjusted to reflect the reality 
that today's all-volunteer servicemembers do, in fact, own cars and 
that it is unreasonable not to reimburse them for the cost of driving 
to their next duty stations in conjunction with PCS orders.
    Simply put, PCS travel is no less government-ordered than is TDY 
travel, and there is simply no justification for paying less than half 
the TDY travel rate when personal vehicle use is virtually essential.
    Additionally, the government should acknowledge that reassigning 
married servicemembers within the United States (including overseas 
locations) usually requires relocation of two personal vehicles. In 
that regard, the overwhelming majority of service families consist of 
two working spouses, making two privately owned vehicles a necessity. 
Yet the military pays for shipment of only one vehicle on overseas 
moves, including moves to Hawaii and Alaska, which forces relocating 
families into large out-of-pocket expenses, either by shipping a second 
vehicle at their own expense or selling one car before leaving the 
States and buying another upon arrival.
    At a minimum, the Coalition believes military families being 
relocated to Alaska, Hawaii, and U.S. territories should be authorized 
to ship a second personal vehicle, as the subcommittee has rightly 
supported in the past.
    The Coalition urges the subcommittee to continue its efforts to 
upgrade permanent change-of-station allowances to better reflect 
expenses imposed on servicemembers, with priority on:

         Shipping a second vehicle on overseas accompanied 
        assignments;
         Authorizing at least some reimbursement for house-
        hunting trip expenses; and
         Increasing PCS mileage rates to more accurately 
        reflect members' actual transportation costs.
    Education Enhancements
    The Post-September 11 GI Bill was a truly historic achievement that 
will provide major long-term benefits for military people and for 
America; however, the Coalition remains sensitive that transferability 
of the benefit to family members was restricted to members of the 
``Armed Forces.''
    The Coalition believes all members of the uniformed services, 
including commissioned officers of the U.S. Public Health Service and 
NOAA Corps, should be able to transfer their benefit to family members. 
All previous GI Bill provisions have applied equally to all uniformed 
services, and the Post-September 11 GI Bill should not be an exception.
    The Coalition urges the subcommittee to support amending the 
statute to authorize all otherwise-qualifying members of the 
``uniformed services'' to transfer Post-September 11 GI Bill benefits 
to family members.
Morale, Welfare, and Recreation (MWR) and Quality of Life (QoL) 
        Programs
    MWR activities and QoL programs have become ever more critical in 
helping servicemembers and their families cope with the extended 
deployments and constant changes going on in the force.
    The availability of appropriated funds to support MWR activities is 
an area of continuing concern for the Coalition. We are especially 
apprehensive that additional reductions in funding or support services 
may occur due to slow economic recovery and record budget deficits.
    BRAC actions pose an additional concern as DOD is struggling to 
meet the 2011 deadline at many BRAC locations. Two reports issued by 
the Government Accountability Office indicate significant challenges 
remain in areas of funding, facilities, and overall management.
    The Coalition is very concerned whether needed infrastructure and 
support programs will be in place in time to meet families' needs.
    TMC urges the subcommittee to:

         Protect funding for critical family support and QoL 
        programs and services to meet the emerging needs of 
        beneficiaries and the timelines of the Services' transformation 
        plans;
         Oppose any initiative to withhold or reduce 
        appropriated support for family support and QoL programs to 
        include: recreation facilities, child care, exchanges and 
        commissaries, housing, health care, education, family centers, 
        and other traditional and innovative support services;
         Prevent any attempts to consolidate or civilianize 
        military service exchange and commissary programs; and
         Sustain funding for support services and 
        infrastructure at both closing and gaining installations 
        throughout the entire transformation process, including 
        exchange, commissary and TRICARE programs.
                       national guard and reserve
    Over 142,000 Guard and Reserve service men and women members are 
serving on active duty.
    Since September 11, 2001, more than 752,000 Guard and Reserve 
service men and women have been called up, including well over 200,000 
who have served multiple tours. There is no precedent in American 
history for this sustained reliance on citizen-soldiers and their 
families. To their credit, Guard and Reserve combat veterans continue 
to reenlist, but the current pace of routine, recurring deployments 
cannot be sustained indefinitely.
    Guard and Reserve members and families face unique challenges in 
their readjustment following active duty service. Unlike active duty 
personnel, many Guard and Reserve members return to employers who 
question their contributions in the civilian workplace, especially as 
multiple deployments have become the norm. Many Guard-Reserve troops 
return with varying degrees of combat-related injuries and stress 
disorders, and encounter additional difficulties after they return that 
can cost them their jobs, careers and families.
    Despite the continuing efforts of the Services and Congress, most 
Guard and Reserve families do not have access to the same level of 
counseling and support that active duty members have. In short, the 
Reserve components face increasing challenges virtually across the 
board, including major equipment shortages, end-strength requirements, 
wounded-warrior health care, and pre- and post-deployment assistance 
and counseling.
Operational Reserve Retention and Retirement Reform
    Congress took the first step in modernizing the Reserve 
compensation system with enactment of early retirement eligibility for 
certain reservists activated for at least 90 continuous days served 
since January 28, 2008. This change validates the principle that 
compensation should keep pace with service expectations and work as an 
inducement to retention and sustainment of the Operational Reserve 
Force.
    Guard/Reserve mission increases and a smaller Active-Duty Force 
mean Guard/Reserve members must devote a much more substantial portion 
of their working lives to military service than ever envisioned when 
the current retirement system was developed in 1948.
    Repeated, extended activations make it more difficult to sustain a 
full civilian career and impede reservists' ability to build a full 
civilian retirement, 401(k), etc. Regardless of statutory protections, 
periodic long-term absences from the civilian workplace can only limit 
Guard/Reserve members' upward mobility, employability and financial 
security. Further, strengthening the Reserve retirement system will 
serve as an incentive to retaining critical mid-career officers and 
NCOs for continued service and thereby enhance readiness.
    As a minimum, the next step in modernizing the Reserve retirement 
system is to provide equal retirement-age-reduction credit for all 
activated service rendered since September 11, 2001. The current law 
that credits only active service since January 28, 2008 disenfranchises 
and devalues the service of hundreds of thousands of Guard/Reserve 
members who served combat tours (multiple tours, in thousands of cases) 
between 2001 and 2008.
    The statute also must be amended to eliminate the inequity inherent 
in the current fiscal year retirement calculation, which only credits 
90 days of active service for early retirement purposes if it occurs 
within the same fiscal year. The current rule significantly penalizes 
members who deploy in July or August vs. those deploying earlier in the 
fiscal year.
    It is patently unfair, as the current law requires, to give 3 
months retirement age credit for a 90-day tour served from January 
through March, but only half credit for a 120-day tour served from 
August through November (because the latter covers 60 days in each of 2 
fiscal years).
    For the near term, the Military Coalition places particular 
priority on authorizing early retirement credit for all qualifying 
post-September 11 active duty service performed by Guard/Reserve 
servicemembers and eliminating the fiscal-year-specific accumulator 
that bars equal credit for members deploying for equal periods during 
different months of the year.
    Ultimately, TMC believes we must move forward to provide a reduced 
age entitlement for retired pay and health coverage for all Reserve 
component members--that is, an age/service formula or outright 
eligibility, if otherwise qualified, at age 55.
    Further, TMC urges repeal of the annual cap of 130 days of inactive 
duty training points that may be credited towards a Reserve retirement.
Guard and Reserve Yellow Ribbon Readjustment
    Congress has provided increased resources to support the transition 
of warrior-citizens back into the community. But program execution 
remains spotty from State to State and falls short for returning 
Federal Reserve warriors in widely dispersed regional commands. 
Military and civilian leaders at all levels must improve the 
coordination and delivery of services for the entire Operational 
Reserve Force. Many communities are eager to support and many do that 
well. But, yellow ribbon efforts in a number of locations amount to 
little more than PowerPoint slides and little or no actual 
implementation.
    TMC is grateful for the subcommittee's attention to this issue and 
for including reporting requirements on progress in the National 
Defense Authorization Act for Fiscal Year 2010.
    Making Yellow Ribbon work effectively is a major Coalition 
priority, and our hope is that the NDAA-required reports will point the 
way for further subcommittee action in this important area.
    TMC urges the subcommittee to hold oversight hearings and to direct 
additional improvements in coordination, collaboration, and consistency 
of Yellow Ribbon services. DOD must ensure that State-level best 
practices--such as those in Maryland, Minnesota and New Hampshire--are 
applied for all Operational Reserve Force members and their families, 
and that Federal Reserve veterans have equal access to services and 
support available to National Guard veterans. Community groups, 
employers, and service organization efforts need to be encouraged and 
better coordinated to supplement unit, component, Service and VA 
outreach and services.
Guard/Reserve GI Bill
    TMC is grateful to Congress for inclusion of a critical ``earn as 
you serve'' principle in the new Post-September 11 GI Bill, which 
allows operational reservists to accrue educational benefits for each 
aggregate call-up of 90 days or more active duty. Inexplicably, 
however, active duty members of the National Guard serving under Title 
32 orders were not included in the new program despite their critical 
role in homeland defense, counter-drug, border control, and other 
missions.
    TMC urges the subcommittee to work with the Veterans Affairs 
Committee to include Title 32 AGRs in the Post-September 11 statute.
    TMC's longstanding recommendation of coordinating and integrating 
various educational benefit programs has been made more challenging 
with the Post-September 11 GI Bill.
    For example, benefits for initially joining the Guard or Reserve as 
authorized in Chapter 1606, 10 U.S.C. continue to decline in proportion 
to the active duty Montgomery GI Bill (Chap. 30, 38 U.S.C.) and the new 
Post-September 11 GI Bill. Reserve MGIB benefit levels have slid to 24 
percent of the active duty MGIB benefit, compared to 47-50 percent 
during the first 15 years of the program. Restoration of the original 
ratio would raise basic Reserve rates from the current $333 per month 
to $643-$684 per month for full-time study.
    TMC maintains that restoring the ratio is not only a matter of 
equity, but essential to long-term success of Guard and Reserve 
recruiting programs.
    Based on the DOD/Services' 10-year record of indifference to the 
basic Selected Reserve GI Bill under Chapter 1606, 10 U.S.C., TMC 
recommends either: restoring Reserve benefits to 47-50 percent of 
active duty benefits or transferring the Chapter 1606 statute from 
title 10 to title 38 so that it can be coordinated with other 
educational benefits programs in a 21st century GI Bill architecture. 
TMC also supports assured academic reinstatement, including guaranteed 
re-enrollment, for returning operational reservists.
Special and Incentive Pays
    Increased reliance on Guard and Reserve Forces to perform active 
duty missions has highlighted differentials and inconsistencies between 
treatment of active duty vs. Guard and Reserve members on a range of 
special and incentive pays. Congress has acted to address some of these 
disparities, but more work is needed.
    The Coalition urges the subcommittee to ensure equitable treatment 
of Guard and Reserve vs. Active Duty members for the full range of 
special and incentive pays.
                             retiree issues
    The Military Coalition remains grateful to the subcommittee for its 
support of maintaining a strong military retirement system to help 
offset the extraordinary demands and sacrifices inherent in a career of 
uniformed service.
Concurrent Receipt
    In the NDAA for Fiscal Year 2003 and Fiscal Year 2004, Congress 
acknowledged the inequity of the disability offset to earned retired 
pay and established a process to end or phase out the offset for many 
disabled retirees. The Coalition is extremely grateful with the 
subcommittee's efforts to continue progress in easing the adverse 
effects of the offset.
    Last year we were very optimistic that another very deserving group 
of disabled retirees would become eligible for concurrent receipt when 
the White House included a concurrent receipt proposal in the Budget 
Resolution--the first time in history any administration had ever 
proposed such a fix.
    The administration's proposal, again submitted in this year's 
budget, would expand concurrent receipt eligibility over a 5 year 
period to all those forced to retire early from Service due to a 
disability, injury, or illness that was service-connected (chapter 61 
retirees).
    Thanks to the strong support of Armed Services Committee leaders, 
the proposal was included in the House version of the NDAA for Fiscal 
Year 2010. The Coalition was dismayed that, despite your leadership 
efforts and White House support, the provision failed to survive 
conference--an extremely disappointing outcome for a most deserving 
group of disabled retirees.
    Our fervent hope is that the subcommittee will redouble its efforts 
to authorize this initiative for fiscal year 2011.
    Additionally, the Coalition is concerned that an inadvertent 
problem exists in the statutory Combat-Related Special Compensation 
(CRSC) computation formula causes many seriously disabled and clearly 
eligible members to receive little or nothing in the way of CRSC. The 
Defense Department has acknowledged the problem in discussions with the 
subcommittee staff, and the Coalition urges the subcommittee to correct 
this technical problem.
    The Coalition believes strongly in the principle that career 
military members earn their retired pay by service alone, and that 
those unfortunate enough to suffer a service-caused disability in the 
process should have any VA disability compensation from the VA added 
to, not subtracted from their service-earned military retired pay and 
this remains a key goal in 2010--regardless of years of service or 
severity of their disability rating.
    The Coalition's continuing goal is to fully eliminate the deduction 
of VA disability compensation from earned military retired pay for all 
disabled retirees. In pursuit of that goal, the Coalition's immediate 
priorities include:

         Phasing out the disability offset for all Chapter 61 
        (medical) retirees; and
         Correcting the CRSC formula to ensure the intended 
        compensation is delivered.
Proposed Military Retirement Changes
    The Coalition remains concerned that as budgets get tighter and 
calls to establish a new entitlement or debt-reduction commission grow 
louder, the military retirement system may come under greater scrutiny 
to seek savings or ``efficiencies.''
    Our concern is based on past experience that seeking to wring 
savings from military retirement programs poses a significant threat to 
long-term retention and readiness by decreasing the attractiveness of 
serving for 2 or 3 decades in uniform, with all of the extraordinary 
demands and sacrifice inherent in such extended career service.
    For example, the Coalition is very concerned that proposals to 
``civilianize'' military retirement benefits, such as the changes 
recommended by the 10th Quadrennial Review of Military Compensation 
(QRMC) fail utterly to recognize the fundamental purpose of the 
military retirement system in offsetting service conditions that are 
radically more severe than those experienced by the civilian workforce.
    The QRMC proposed converting the military retirement system to a 
civilian-style plan under which full retired pay wouldn't be paid until 
age 57-60; vesting retirement benefits after 10 years of service; and 
using flexible ``gate pays'' and separation pay at certain points of 
service to encourage continued service in certain age groups or skills 
and encourage others to leave, depending on service needs for certain 
kinds of people at the time.
    Reduced to its essence, this admittedly cost-neutral plan would 
take money from people who stay for a career in order to pay additional 
benefits to those who leave the military short of a career.
    If this system were in place today, a 10-year infantryman facing 
his or her fourth combat tour would be offered a choice between: (a) 
allowing immediate departure with a vested retirement; vs. (b) 
continuing under current service conditions for another 10-20 years and 
having to wait until age 58 for immediate retired pay.
    The Coalition believes strongly that, if such a system existed for 
today's force under today's service conditions, the military services 
would already be mired in a deep and traumatic retention crisis.
    Further, the QRMC proposal is so complicated that people evaluating 
career decisions at the 4- to 10-year point would have no way to 
project their future military retirement benefits. Gate pays available 
at the beginning of a career could be cut back radically if the force 
happened to be undergoing a strength reduction later in a member's 
career.
    In contrast, the current military retirement system makes it very 
clear from the pay table what level of retired pay would be payable, 
depending how long one served and how well one progressed in grade.
    The sustained drawing power of the 20-year retirement system 
provides an essential long-term moderating influence that keeps force 
managers from over-reacting to short-term circumstances. Had force 
planners had such a system in effect during the drawdown-oriented 
1990s, the Services would have been far less prepared for the post-
September 11 wartime environment.
    Many such proposals have been offered in the past, and have been 
discarded for good reasons. The only initiative to substantially 
curtail/delay military retired pay that was enacted--the 1986 REDUX 
plan--and only a remnant remain as the mandatory REDUX was scrapped 13 
years later after it began inhibiting retention.
    The only remnant that remains--and has been in place unchanged 
since 1999--is a voluntary program known as the Career Status Bonus--a 
$30,000 ``bonus'' bait and switch--where the servicemember can receive 
$30,000 at their 15 year point as long as they accept REDUX.
    That ``bonus'' was a bad deal at the time and it gets worse with 
every passing year as pay (and retired pay) increases.
    After taxes, the so-called bonus is more like $22,000 or $23,000. 
To get that, the typical NCO who retires with 20 years of service must 
agree to sacrifice more than $300,000 in future retired pay (those who 
live longer than average sacrifice far more). That's how much less 
REDUX is worth compared to the normal system.
    TMC urges the subcommittee to:

         Reject any initiatives to ``civilianize'' the military 
        system without adequate consideration of the unique and 
        extraordinary demands and sacrifices inherent in a military vs. 
        a civilian career; and
         Eliminate the Career Status Bonus for servicemembers 
        as it significantly devalues their retirement over time. In the 
        short term, the Services should be required to better educate 
        eligible members on the severe long-term financial penalty 
        inherent in accepting the REDUX option.
Disability Severance Pay
    The Coalition is grateful for the subcommittee's inclusion of a 
provision in the NDAA for Fiscal Year 2008 that ended the VA 
compensation offset of a servicemember's disability severance for 
people injured in the combat zone.
    However, we are concerned that the language of this provision 
imposes much stricter eligibility than that used for Combat-Related 
Special Compensation.
    The Coalition urges the subcommittee to amend the eligibility rules 
for disability severance pay to include all combat--or operations--
related injuries, using same definition as CRSC. For the longer term, 
the Coalition believes the offset should be ended for all members 
separated for service-caused disabilities.
    Former Spouse Issues
    For nearly a decade the recommendations of the Defense Department's 
September 2001 report to Congress on the Uniformed Services Former 
Spouse Protection Act (USFSPA) have gone nowhere. For several years, 
DOD submitted many of the report's recommendations annually to Congress 
only to have one or two supported by the subcommittee while many others 
were dropped.
    The USFSPA is a very emotional topic with two distinct sides to the 
issue--just as any divorce has two distinct parties affected. The 
Coalition believes strongly that there are several inequities in the 
act that need to be addressed and corrected that could benefit both 
affected parties--the servicemember and the former spouse.
    But in order to make progress, we believe Congress cannot piecemeal 
DOD's recommendations. We support a collective grouping of legislation 
that would provide benefit to both affected parties. Absent this 
approach, the legislation will be perceived as supporting one party 
over the other and go nowhere.
    To fairly address the problems with the act, all affected parties 
need to be heard--and the Coalition would greatly appreciate the 
opportunity to address the inequities in a hearing before the 
subcommittee.
    The Coalition requests a hearing to address USFSPA inequities. In 
addition, we recommend legislation to include all of the following:

         Base the award amount to the former spouse on the 
        grade and years of service of the member at time of divorce 
        (and not retirement);
         Prohibit the award of imputed income, which 
        effectively forces active duty members into retirement;
         Extend 20/20/20 benefits to 20/20/15 former spouses;
         Permit the designation of multiple Survivor Benefit 
        Plan (SBP) beneficiaries with the presumption that SBP benefits 
        must be proportionate to the allocation of retired pay;
         Eliminate the ``10-year Rule'' for the direct payment 
        of retired pay allocations by the Defense Finance and 
        Accounting Service (DFAS);
         Permit SBP premiums to be withheld from the former 
        spouse's share of retired pay if directed by court order;
         Permit a former spouse to waive SBP coverage;
         Repeal the 1-year deemed election requirement for SBP; 
        and
         Assist the DOD and Services with greater outreach and 
        expanded awareness to members and former spouses of their 
        rights, responsibilities, and benefits upon divorce.
                            survivor issues
    The Coalition is grateful to the subcommittee for its significant 
efforts in recent years to improve the Survivor Benefit Plan (SBP), 
especially its major achievement in eliminating the significant benefit 
reduction previously experienced by SBP survivors upon attaining age 
62.
SBP-DIC Offset
    The Coalition believes strongly that current law is unfair in 
reducing military SBP annuities by the amount of any survivor benefits 
payable from the DIC program.
    If the surviving spouse of a retiree who dies of a service-
connected cause is entitled to DIC from the Department of Veterans 
Affairs and if the retiree was also enrolled in SBP, the surviving 
spouse's SBP annuity is reduced by the amount of DIC. A pro-rata share 
of the SBP premiums is refunded to the widow upon the member's death in 
a lump sum, but with no interest. This offset also affects all 
survivors of members who are killed on active duty.
    The Coalition believes SBP and DIC payments are paid for different 
reasons. SBP is insurance purchased by the retiree and is intended to 
provide a portion of retired pay to the survivor. DIC is a special 
indemnity compensation paid to the survivor when a member's service 
causes his or her premature death. In such cases, the VA indemnity 
compensation should be added to the SBP annuity the retiree paid for, 
not substituted for it.
    It should be noted as a matter of equity that surviving spouses of 
Federal civilian retirees who are disabled veterans and die of 
military-service-connected causes can receive DIC without losing any of 
their Federal civilian SBP benefits.
    The reality is that, in every SBP-DIC case, active duty or retired, 
the true premium extracted by the Service from both the member and the 
survivor was the ultimate one--the very life of the member. This 
reality was underscored by the August 2009 Federal Court of Appeals 
ruling in Sharp v. U.S. which found ``After all the servicemember paid 
for both benefits: SBP with premiums; DIC with his life.''
    The Veterans Disability Benefits Commission (VDBC) was tasked to 
review the SBP-DIC issue, among other DOD/VA benefit topics. The VDBC's 
final report to Congress agreed with the Coalition in finding that the 
offset is inappropriate and should be eliminated.
    In 2005, Speaker Pelosi and all House leaders made repeal of the 
SBP-DIC offset a centerpiece of their GI Bill of Rights for the 21st 
Century. Leadership has made great progress in delivering on other 
elements of that plan, but the only progress to date on the SBP-DIC 
offset has been the enactment a small monthly Special Survivor 
Indemnity Allowance (SSIA).
    The Coalition recognizes that the subcommittee's initiative in the 
fiscal year 2008 defense bill to establish a special survivor indemnity 
allowance (SSIA) was intended as a first, admittedly very modest, step 
in a longer-term effort to phase out the Dependency and Indemnity 
Compensation (DIC) offset to SBP.
    We appreciate the subcommittee's subsequent work to extend the SSIA 
to survivors of members who died while on active duty in the NDAA for 
Fiscal Year 2009, as well as its good-faith effort to provide a 
substantial increase in SSIA payments as part of the Family Smoking 
Prevention and Tobacco Control Act.
    The Coalition was extremely disappointed that the final version of 
that legislation greatly diluted the House-passed provision and 
authorized only very modest increases several years in the future.
    While fully acknowledging the subcommittee's and full committee's 
good-faith efforts to win more substantive progress, the Coalition 
shares the extreme disappointment and sense of abandonment of the SBP-
DIC widows who are being forced to sacrifice up to $1,110 each month 
and being asked to be satisfied with a $60 monthly rebate.
    For years, legislative leaders touted elimination of this ``widow's 
tax'' as a top priority. The Coalition understands the mandatory-
spending constraints the subcommittee has faced in seeking redress, but 
also points out that those constraints have been waived for many, many 
far more expensive initiatives. The Coalition believes widows whose 
sponsors' deaths were caused by military service should not be last in 
line for redress.
    The Coalition urges repeal of the SBP-DIC offset. TMC further 
recommends:

         Authorizing payment of SBP annuities for disabled 
        survivors into a Special Needs Trust; (Certain permanently 
        disabled survivors can lose eligibility for Supplemental 
        Security Income (SSI) and Medicaid and access to means-tested 
        State programs because of receipt of SBP. This initiative is 
        essential to put disabled SBP annuitants on an equal footing 
        with other SSI/Medicaid-eligibles who have use of special needs 
        trusts to protect disabled survivors.)
         Allowing SBP eligibility to switch to children if a 
        surviving spouse is convicted of complicity in the member's 
        death; and
         Reinstating SBP for survivors who previously 
        transferred payments to their children at such time as the 
        youngest child attains majority, or upon termination of a 
        second or subsequent marriage.
Final Retired Pay Check
    Under current law, DFAS recoups from military widows' bank accounts 
all retired pay for the month in which a retiree dies. Subsequently, 
DFAS pays the survivor a pro-rated amount for the number of days of 
that month in which the retiree was alive. This often creates hardships 
for survivors who have already spent that pay on rent, food, etc., and 
who routinely are required to wait several months for DFAS to start 
paying SBP benefits.
    The Coalition believes this is an extremely insensitive policy 
imposed by the government at the most traumatic time for a deceased 
member's next of kin. Unlike his or her active duty counterpart, a 
retiree's survivor receives no death gratuity. Many older retirees do 
not have adequate insurance to provide even a moderate financial 
cushion for surviving spouses.
    The VA is required by law to make full payment of the final month's 
VA disability compensation to the survivor of a disabled veteran. The 
disparity between DOD and VA policy on this matter is simply 
indefensible. Congress should do for retirees' widows the same thing it 
did 10 years ago to protect veterans' widows.
    TMC urges the subcommittee to authorize survivors of retired 
members to retain the final month's retired pay for the month in which 
the retiree dies.
                           health care issues
    The Coalition appreciates the subcommittee's strong and continuing 
interest in keeping health care commitments to military beneficiaries. 
We are particularly grateful for your support for the last few years in 
refusing to allow the Department of Defense to implement 
disproportional beneficiary health care fee increases.
    The Coalition is encouraged that the current administration so far 
has declined to pursue such increases, but has worked to reestablish a 
mutually constructive dialogue with beneficiary representatives.
    The unique package of military retirement benefits--of which a key 
component is a top-of-the-line health care benefit--is the primary 
offset afforded uniformed servicemembers for enduring a career of 
unique and extraordinary sacrifices that few Americans are willing to 
accept for 1 year, let alone 20 or 30. It is an unusual, and essential, 
compensation package that a grateful Nation provides for a relatively 
small fraction of the U.S. population who agree to subordinate their 
personal and family lives to protecting our national interests for so 
many years. This sacrifice, in a very real sense, constitutes a pre 
paid premium for their future healthcare.
Defense Health Program Cost Requirements
    The Coalition is grateful for the subcommittee's support for 
maintaining--and expanding where needed--the healthcare benefit for all 
military beneficiaries and especially for the Guard, Reserve, and 
military children, consistent with the demands imposed upon them.
    It's true that many private sector employers are choosing to shift 
an ever-greater share of health care costs to their employees and 
retirees, and that's causing many still-working military retirees to 
fall back on their service-earned TRICARE coverage. Fallout from the 
recent economic recession is likely to reinforce this trend.
    In the bottom-line-oriented corporate world, many firms see their 
employees as another form of capital, from which maximum utility is to 
be extracted at minimum cost, and those who quit are replaceable by 
similarly experienced new hires. But that can't be the culture in the 
military's closed, all-volunteer personnel system, whose long-term 
effectiveness is dependent on establishing a sense of mutual, long-term 
commitment between the servicemember and his/her country.
    The Coalition believes it's essential to bear other considerations 
in mind when considering the extent to which military beneficiaries 
should share in military health care costs.
    First and foremost, the military health system is not built for the 
beneficiary, but to sustain military readiness. Each Service maintains 
its unique facilities and systems to meet its unique needs, and its 
primary mission is to sustain readiness by keeping a healthy force and 
to be able to treat casualties from military actions. That model is 
built neither for cost efficiency nor beneficiary welfare. It's built 
for military readiness requirements.
    When military forces deploy, the military medical force goes with 
them, and that forces families, retirees and survivors to use the more 
expensive civilian health care system in the absence of so many 
uniformed health care providers.
    These military-unique requirements have significantly increased 
readiness costs. But those added costs were incurred for the 
convenience of the military, not for any beneficiary consideration, and 
beneficiaries should not be expected to bear any share of that cost -
particularly in wartime.
    The Coalition urges the subcommittee to take all possible steps to 
ensure continued full funding for Defense Health Program needs.
National Health Reform
    The Coalition opposes any effort to integrate TRICARE and VA health 
care systems in any proposal that Congress may develop as part of 
national health care reform. These two programs are integral to 
military readiness and are designed expressly to meet the unique needs 
of servicemembers, military retirees, veterans, wounded servicemembers, 
guardsmen and reservists, their families, and survivors.
    TMC urges that any national health reform legislation must:

         Protect the unique TRICARE, TRICARE For Life, and VA 
        health care benefits from unintended consequences such as 
        reduced access to care;
         Bar any form of taxation of TRICARE, TRICARE For Life, 
        or VA health care benefits, including those provided in 
        nongovernmental venues; and
         Preserve military and VA beneficiaries' choices.
Military vs. Civilian Cost-Sharing Measurement
    Defense leaders have in the past, and may in the future, assert 
that substantial military fee increases are needed to bring military 
beneficiary health care costs more in line with civilian practices. But 
merely contrasting military vs. civilian cash cost-shares is a grossly 
misleading, ``apple-to-orange'' comparison.
    For all practical purposes, those who wear the uniform of their 
country are enrolled in a 20- to 30-year prepayment plan that they must 
complete to earn lifetime health coverage. In this regard, military 
retirees and their families paid enormous ``upfront'' premiums for that 
coverage through their decades of service and sacrifice. Once that 
prepayment is already rendered, the government cannot simply pretend it 
was never paid, and focus only on post-service cash payments.
    DOD and the Nation--as good-faith employers of the trusting members 
from whom they demand such extraordinary commitment and sacrifice--have 
a reciprocal health care obligation to retired servicemembers and their 
families and survivors that far exceeds any civilian employer's to its 
workers and retirees.
    The Coalition believes that military beneficiaries from whom 
America has demanded decades of extraordinary service and sacrifice 
have earned coverage that is the best America has to offer.
Large Retiree Fee Increases Can Only Hurt Retention
    The reciprocal obligation of the government to maintain an 
extraordinary benefit package to offset the extraordinary sacrifices of 
career military servicemembers is a practical as well as moral 
obligation. Mid-career military losses can't be replaced like civilians 
can.
    Eroding benefits for career service can only undermine long-term 
retention/readiness. Today's servicemembers are very conscious of 
Congress' actions toward those who preceded them in service. One reason 
Congress enacted TRICARE For Life in 2000 is because the Joint Chiefs 
of Staff at that time said inadequate retiree health care was affecting 
attitudes among active duty servicemembers.
    That's more than backed up by two independent Coalition surveys. A 
2006 Military Officers Association of America survey drew 40,000 
responses, including more than 6,500 from active duty servicemembers. 
Over 92 percent in all categories of respondents opposed the DOD-
proposed fee hikes. There was virtually no difference between the 
responses of active duty servicemembers (96 percent opposed) and 
retirees under 65 (97 percent opposed). A Fleet Reserve Association 
survey showed similar results.
    Reducing military retirement benefits would be particularly ill-
advised when an overstressed force already is at increasing retention 
risk despite the current downturn of the economy and current recruiting 
successes.
Pharmacy
    The Coalition supports a strong TRICARE pharmacy benefit which is 
affordable and continues to meet the pharmaceutical needs of millions 
of eligible beneficiaries through proper education and trust. The TMC 
will oppose any degradation of current pharmacy benefits, including any 
effort to charge fees or copayments for use of military treatment 
facilities.
    The Coalition would oppose the need for pharmacy co-pay increases 
now that Congress has approved Federal pricing for the TRICARE retail 
pharmacy system. The Coalition notes that due to continued legal 
maneuvering, Federal pricing still has not been implemented by the 
executive branch, and this failure is costing DOD tens of millions of 
dollars with every passing month. This is an excellent example of why 
the Coalition objects to basing beneficiary fees on a percentage of DOD 
costs--because DOD all-too-frequently does not act, or is not allowed 
to act, in a prudent way to hold costs down.
    The Coalition has volunteered to conduct a joint campaign with DOD 
to promote beneficiary use of lower-cost medications and distribution 
venues--a ``win-win'' opportunity that will reduce costs for 
beneficiaries and the government alike.
    The Coalition also believes that positive incentives are the best 
way to encourage beneficiaries to continue medication regimens that are 
proven to hold down long-term health costs. In this regard, TMC 
believes eliminating copays for medications to control chronic 
conditions (e.g., diabetes, asthma, high blood pressure, and 
cholesterol) are more effective than negative ones such as copayment 
increases.
    The Coalition urges the subcommittee to ensure continued 
availability of a broad range of medications, including the most-
prescribed medications, in the TRICARE pharmacy system, and to ensure 
that the first focus on cost containment should be on initiatives that 
encourage beneficiaries to take needed medications and reduce program 
costs without shifting costs to beneficiaries.
Alternative Options to Make TRICARE More Cost-Efficient
    TMC continues to believe strongly that DOD has not sufficiently 
investigated options to make TRICARE more cost-efficient without 
shifting costs to beneficiaries. The Coalition has offered a long list 
of alternative cost-saving possibilities, including:

         Positive incentives to encourage beneficiaries to seek 
        care in the most appropriate and cost effective venue;
         Encouraging improved collaboration between the direct 
        and purchased care systems and implementing best business 
        practices and effective quality clinical models;
         Focusing the military health system, health care 
        providers, and beneficiaries on quality measured outcomes;
         Improving MHS financial controls and avoiding overseas 
        fraud by establishing TRICARE networks in areas fraught with 
        fraud;
         Establishing TRICARE networks in areas of high TRICARE 
        Standard utilization to take full advantage of network 
        discounts;
         Promoting retention of other health insurance by 
        making TRICARE a true second-payer to other insurance (far 
        cheaper to pay another insurance's co-pay than have the 
        beneficiary migrate to TRICARE);
         Encouraging DOD to effectively utilize their data from 
        their electronic health record to better monitor beneficiary 
        utilization patterns to design programs which truly match 
        beneficiaries needs;
         Sizing and staffing military treatment facilities to 
        reduce reliance on network providers and develop effective 
        staffing models which support enrolled capacities;
         Reducing long-term TRICARE Reserve Select (TRS) costs 
        by allowing servicemembers the option of a government subsidy 
        of civilian employer premiums during periods of mobilization;
         Doing far more to promote use of mail-order pharmacy 
        system and formulary medications via mailings to users of 
        maintenance medications, highlighting the convenience and 
        individual expected cost savings; and
         Encouraging retirees to use lowest-cost-venue military 
        pharmacies at no charge, rather than discouraging such use by 
        limiting formularies, curtailing courier initiatives, etc.

    The Coalition is pleased that DOD has begun to implement some of 
our suggestions, and stands ready to partner with DOD to investigate 
and jointly pursue these and other options that offer potential for 
reducing costs.
TMC Healthcare Cost Principles
    The Military Coalition believes strongly that the recent fee 
controversy is caused in part by the lack of any statutory record of 
the purpose of military health care benefits and the specific benefit 
levels earned by a career of service in uniform. Under current law, the 
Secretary of Defense has broad latitude to make administrative 
adjustments to fees for TRICARE Prime and the pharmacy systems. Absent 
congressional intervention, the Secretary can choose not to increase 
fees for years at a time or can choose to quadruple fees in 1 year.
    Until a few years ago, this was not a particular matter of concern, 
as no Secretary had previously proposed dramatic fee increases. Given 
recent years' unsettling experience, the Coalition believes strongly 
that the subcommittee needs to establish more specific and permanent 
principles, guidelines, and prohibitions to protect against dramatic 
budget-driven fluctuations in this most vital element of 
servicemembers' career compensation incentive package.
    The Coalition strongly recommends that Congress establish statutory 
findings, a sense of Congress on the purpose and principles of military 
health care benefits earned by a career of uniformed service that 
states:

         Active duty members and families should be charged no 
        fees except retail pharmacy co-payments, except to the extent 
        they make the choice to participate in TRICARE Standard or use 
        out-of-network providers under TRICARE Prime;
         The TRICARE Standard inpatient copay should not be 
        increased further for the foreseeable future. At $535 per day, 
        it already far exceeds inpatient copays for virtually any 
        private sector health plan;
         There should be no enrollment fee for TRICARE Standard 
        or TRICARE For Life (TFL), since neither offers assured access 
        to TRICARE-participating providers. An enrollment fee implies 
        enrollees will receive additional services, as Prime enrollees 
        are guaranteed access to participating providers in return for 
        their fee. Congress already has required TFL beneficiaries to 
        pay substantial Medicare Part B fees to gain TFL coverage;
         All retired servicemembers earned equal health care 
        coverage by virtue of their service; and
         DOD should make all efforts to provide the most 
        efficient use of allocated resources and cut waste prior to 
        proposing additional or increased fees on eligible 
        beneficiaries.
TRICARE Prime
    The Coalition is very concerned about growing dissatisfaction among 
TRICARE Prime enrollees--which is actually higher among active duty 
families than among retired families. The dissatisfaction arises from 
increasing difficulties experienced by beneficiaries in getting 
appointments, referrals to specialists, and sustaining continuity of 
care from specific providers.
    Increasingly, beneficiaries with a primary care manager in a 
military treatment facility find they are unable to get appointments 
because so many providers have deployed, PCSed, or are otherwise 
understaffed/unavailable.
    The Coalition supports the implementation of a pilot study by TMA 
in each of the three TRICARE Regions to study the efficacy of 
revitalizing the resource sharing program used prior to the 
implementation of the TRICARE-The Next Generation (T-NEX) contracts 
under the current Managed Care Support contract program.
    The Coalition supports adoption of the ``Medical Home'' patient-
centered model to help ease such problems.
    But the new TRICARE contracts and the attendant reduction of Prime 
service areas outside the vicinity of military installations will 
exacerbate anxieties by forcing disenrollment of many thousands of 
current Prime beneficiaries.
    The Coalition strongly advocates the transparency of healthcare 
information via the patient electronic record between both the MTF 
provider and network providers. Additionally, institutional and 
provider healthcare quality information should be available to all 
beneficiaries so that they can make better informed decisions.
    The Military Coalition urges the subcommittee to require reports 
from DOD and from the managed care support contractors, on actions 
being taken to improve Prime patient satisfaction, provide assured 
appointments within Prime access standards, reduce delays in 
preauthorization and referral appointments, and provide quality 
information to assist beneficiaries in making informed decisions.
                            tricare standard
TRICARE Standard Provider Participation
    The Coalition appreciates the subcommittee's continuing interest in 
the specific problems unique to TRICARE Standard beneficiaries. TRICARE 
Standard beneficiaries need assistance in finding participating 
providers within a reasonable time and distance from their home. This 
is particularly important with the expansion of TRICARE Reserve Select 
and the upcoming change in the Prime Service Areas, which will place 
thousands more beneficiaries into TRICARE Standard.
    The Coalition is concerned that DOD has not yet established any 
standard for adequacy of provider participation, as required by section 
711(a)(2) of the NDAA for Fiscal Year 2008. Participation by half of 
the providers in a locality may suffice if there is not a large 
Standard beneficiary population. The Coalition hopes to see an 
objective participation standard (perhaps number of beneficiaries per 
provider) that would help shed more light on which locations have 
participation shortfalls of Primary Care Managers and Specialists that 
require positive action.
    The Coalition urges the subcommittee to insist on immediate 
delivery of an adequacy threshold for provider participation, below 
which additional action is required to improve such participation. The 
Coalition also recommends requiring a specific report on participation 
adequacy in the localities where Prime Service Areas will be 
discontinued under the new TRICARE contracts.
TRICARE Reimbursement Rates
    Physicians consistently report that TRICARE is virtually the 
lowest-paying insurance plan in America. Other national plans typically 
pay providers 25-33 percent more. In some cases the difference is even 
higher.
    While TRICARE rates are tied to Medicare rates, TRICARE Managed 
Care Support Contractors make concerted efforts to persuade providers 
to participate in TRICARE Prime networks at a further discounted rate. 
Since this is the only information providers receive about TRICARE, 
they see TRICARE as lower-paying than Medicare.
    This is exacerbated by annual threats of further reductions in 
TRICARE rates due to the statutory Medicare rate-setting formula. 
Physicians may not be able to afford turning away Medicare patients, 
but many are willing to turn away a small number of patients who have 
low-paying, high-administrative-hassle TRICARE coverage.
    The TRICARE Management Activity has the authority to increase the 
reimbursement rates when there is a provider shortage or extremely low 
reimbursement rate for a specialty in a certain area and providers are 
not willing to accept the low rates. In some cases, a State Medicaid 
reimbursement for a similar service is higher than that of TRICARE. But 
the Department has been reluctant to establish a standard for adequacy 
of participation to trigger higher payments.
    The Coalition places primary importance on securing a permanent fix 
to the flawed statutory formula for setting Medicare and TRICARE 
payments to doctors.
    To the extent a Medicare rate freeze continues, we urge the 
subcommittee to encourage DOD to use its reimbursement rate adjustment 
authority as needed to sustain provider acceptance.
    The Coalition urges the subcommittee to require a Comptroller 
General report on the relative propensity of physicians to participate 
in Medicare vs. TRICARE, and the likely effect on such relative 
participation of a further freeze in Medicare/TRICARE physician 
payments along with the effect of an absence of bonus payments.
Dental Care
    The Coalition appreciates the subcommittee's action in continuing 
active duty-level dental coverage for dependent survivors and allowing 
transitional dental care for Reserve members who separate after 
supporting contingency missions.
    Active Duty Dependent Dental Plan
    TMC is sensitive to beneficiary concerns that Active Duty Dental 
Plan coverage for orthodontia has been eroded by inflation over a 
number of years.
    The current orthodontia payment cap is $1,500, which has not been 
changed since 2001. In the intervening years, the orthodontia cost has 
risen from an average of $4,000 to more than $5,000.
    The Coalition understands that, under current law, increasing this 
benefit could require a reduction in some other portion of the benefit, 
which we do not support.
    The Coalition notes that current law assumes a 60 percent DOD 
subsidy for the active duty dental plan, whereas other Federal health 
programs (e.g., FEHB Plan and TRS) are subsidized at 72 percent.
    The Coalition recommends increasing the DOD subsidy for the Active 
Duty Dependent Dental Plan to 72 percent and increasing the cap on 
orthodontia payments to $2,000.
Guard and Reserve Healthcare
    Continuum of Health Care Insurance Options for The Guard and 
        Reserve
    The Coalition is very grateful for passage of TRICARE Retired 
Reserve (TRR) coverage for ``gray area'' reservists in the NDAA for 
Fiscal Year 2010.
    The Coalition notes that DOD complied with direction from Congress 
to reduce TRICARE Reserve Select (TRS) premiums to the actual cost of 
coverage. For 2009, monthly TRS premiums were reduced to $47.51 (vs. 
$81) for member-only coverage and to $180.17 (vs. $253) for family 
coverage.
    TMC believes a review of the current statutory methodology for 
adjusting premiums based on program costs should be conducted to assess 
whether any of the costs currently included are, in fact, costs of 
maintaining readiness or ``costs of doing business'' for the Defense 
Department that don't contribute to delivering benefit value to 
beneficiaries (and therefore should be excluded, with the expected 
result that premiums would go down). In principle, TMC believes 
Congress should establish a moratorium on TRS premium increases and 
direct DOD to make a determined effort for the most efficient use of 
resources allocated and to cut waste prior to the consideration of any 
adjustment in such premiums.
    Moreover, TMC believes that holding the line on TRS premiums will 
encourage more families to enroll. DOD, the Services, and the Reserve 
components must do much more to advertise the TRS program which stands 
at only 6-7 percent of eligible beneficiaries.
    The Coalition also believes Congress is missing an opportunity to 
reduce long-term health care costs and increase beneficiary 
satisfaction by authorizing eligible members the option of electing a 
DOD subsidy of their civilian insurance premiums during periods of 
activation.
    Current law already authorizes payment of up to 24 months of FEHBP 
premiums for activated members who are civilian employees of the 
Defense Department. The Coalition believes all members of the Selected 
Reserve should have a similar option to have continuity of their 
civilian family coverage.
    Over the long term, when Guard and Reserve activations can be 
expected at a reduced pace, this option would offer considerable 
savings opportunity relative to funding permanent, year-round TRICARE 
coverage.
    DOD could calculate a maximum monthly subsidy level that would 
represent a cost savings to the government, so that each member who 
elected that option would reduce TRICARE costs.
    The Coalition recommends the subcommittee:

         Require a GAO review of DOD's methodology for 
        determining TRS costs for premium adjustment purposes to assess 
        whether it includes any costs of maintaining readiness or 
        ``costs of doing business'' for the Defense Department that 
        don't contribute to beneficiary benefit value and thus should 
        be excluded from cost/premium calculations;
         Authorize development of a cost-effective option to 
        have DOD subsidize premiums for continuation of a Reserve 
        employer's private family health insurance during periods of 
        deployment as an alternative to ongoing TRS coverage;
         Allow eligibility in Continued Health Care Benefits 
        Program (CHCBP) for Selected reservists who are voluntarily 
        separating and subject to disenrollment from TRS;
         Authorize members of the IRR who qualify for a Reserve 
        retirement at age 60 to participate in TRR as an incentive for 
        continued service (and higher liability for recall to active 
        duty);
         Monitor implementation of the new TRR authority to 
        ensure timely action and that premiums do not exceed 100 
        percent of the TRS premium; and
         Allow FEHB plan beneficiaries who are Selected 
        reservists the option of participating in TRS.
    Guard and Reserve Mental Health
    The Coalition is concerned that Guard and Reserve members and their 
families are at particular risk for undetected effects of the unseen 
injuries of war. The risk is compounded by Reserve component members' 
anxiety to return to their families as soon as possible, which 
typically entails expedited departure from active duty and return to a 
community where military health care and other support systems are 
limited.
    Unfortunately, most such members view the current post deployment 
health self-assessment program at demobilization sites as an impediment 
to prompt return to their families. Under this scenario, strong 
disincentives for self-reporting exacerbate an already wide variation 
in the diagnosis and treatment of post-traumatic stress disorder 
(PTSD), traumatic brain injury (TBI), depression, and other combat-
related stress conditions.
    The Coalition believes redeploying Reserve component members should 
be allowed to proceed to their home station and retained on active duty 
orders to complete post-deployment examination requirements at the home 
station. This change is important to improve proper diagnosis, 
reporting and treatment of physical and mental injuries; to help 
perfect potential service connected disability claims with the VA; and 
to help correct the non-reporting of injuries at the demobilization 
site.
    The Coalition believes that Guard and Reserve members and their 
families should have access to evidence-based treatment for PTSD, TBI, 
depression, and other combat-related stress conditions. Further, post-
deployment health examinations should be offered at the member's home 
station, with the member retained on active duty orders until 
completion of the exam.
    Guard and Reserve Health Information
    The Coalition is concerned that the current health records for many 
Guard and Reserve members do not contain treatment information that 
could be vital for diagnosis and treatment of a condition while on 
active duty. The capture of nonmilitary treatment is an integral part 
of the member's overall health status.
    The Coalition believes there should be an effort to improve the 
electronic capture of nonmilitary health information into the 
servicemember's medical record.
TRICARE For Life (TFL)
    When Congress enacted TFL in 2000, it explicitly recognized that 
this coverage was fully earned by career servicemembers' decades of 
sacrifice, and that the Medicare Part B premium would serve as the cash 
portion of the beneficiary premium payment. The Coalition believes that 
this remains true today and will oppose any new additional fees. 
Additionally, the Coalition believes that means-testing has no place in 
setting military health fees.
    The Coalition is aware of the challenges imposed by Congress' 
mandatory spending rules, and appreciates the subcommittee's efforts to 
include TFL-eligibles in the preventive care pilot programs included in 
the NDAA for Fiscal Year 2009. We believe their inclusion would, in 
fact, save the government money and hope the subcommittee will be able 
to find a more certain way to include them than the current 
discretionary authority, which DOD has declined to implement.
    The Coalition also hopes the subcommittee can find a way to resolve 
the discrepancy between Medicare and TRICARE treatment of medications 
such as the shingles vaccine, which Medicare covers under pharmacy 
benefits and TRICARE covers under doctor visits. This mismatch, which 
requires TFL patients to absorb the cost in a TRICARE deductible or 
purchase duplicative Part D coverage, deters beneficiaries from seeking 
this preventive medication.
    Coalition priorities for TFL-eligibles include:

         Securing a permanent fix to the flawed formula for 
        setting Medicare/TRICARE payments to providers;
         Resisting any effort to establish an enrollment fee 
        for TFL, given that many beneficiaries already experience 
        difficulties finding providers who will accept Medicare 
        patients; and
         Including TFL beneficiaries in DOD programs to 
        incentivize compliance with preventive care and healthy 
        lifestyles.
Restoration of Survivors' TRICARE Coverage
    When a TRICARE-eligible widow/widower remarries, he/she loses 
TRICARE benefits. When that individual's second marriage ends in death 
or divorce, the individual has eligibility restored for military ID 
card benefits, including SBP coverage, commissary/exchange privileges, 
etc.--with the sole exception that TRICARE eligibility is not restored.
    This is out of line with other Federal health program practices, 
such as the restoration of CHAMPVA eligibility for survivors of 
veterans who died of service-connected causes. In those cases, VA 
survivor benefits and health care are restored upon termination of the 
remarriage. Remarried surviving spouses deserve equal treatment.
    The Coalition recommends restoration of TRICARE benefits to 
previously eligible survivors whose second or subsequent marriage ends 
in death or divorce.
Base Realignment and Closure (BRAC) and Rebasing
    Military transformation and BRAC become more pressing issues as the 
Pentagon approaches the BRAC deadline set for September 15, 2011. The 
impact on the MHP is significant and concern about the impact on 
beneficiaries is of high priority to TMC. Specific areas of interest to 
the TMC include:

         Supporting a Health Facilities Program that uses 
        evidenced-based design to update or replace Military Treatment 
        Facilities (MTFs) to maintain world-class health care delivery 
        capability in support of all eligible beneficiaries;
         Protecting full access, availability and services to 
        beneficiaries and their families during the entire military 
        transformation (BRAC and global rebasing) process, with added 
        focus on Walter Reed Army Medical Center, Bethesda National 
        Naval Medical Center, DeWitt Healthcare Network, and San 
        Antonio Army Medical Center, while seeking full and timely 
        funding for these world-class projects;
         Encouraging DOD to establish and sustain provider 
        networks and capacity at both closing and gaining installations 
        and units impacted by transformation;
         Promoting the coordination of efforts between Managed 
        Care Support Contractors to ensure smooth beneficiary 
        transition from one geographic area to another;
         Codifying the requirement to continue Prime benefits 
        and assistance in localities affected by realignment and 
        closure actions; and
         Monitoring the National Capitol Region Medical Joint 
        Task Force activities to ensure the most effective use of 
        resources to improve access and quality.

    The Coalition recommends requiring an annual DOD report on the 
adequacy of health resources, funding, services, quality and access to 
care for beneficiaries affected by BRAC/rebasing.

    Senator Webb. Thank you very much.
    I want to thank all of you for your testimony. The feedback 
is important to us. It's useful. It's not only useful, it's 
valuable. It will be taken into full consideration.
    There are a dozen really important points that were raised, 
from my perspective, listening to your testimony.
    TRICARE will not be affected, as long as I have anything to 
do with it. I know Senator Graham feels the same way. I've seen 
the benefits in my own family, I've seen it with my mother 
right now.
    When you mention the SBP situation, my father paid into SBP 
for 28 years. When he died in 1997, they took it out of my 
mother's Social Security. Luckily, we had that situation fixed, 
but we will give the situation you mentioned a hard look. I'm 
on Senator Bill Nelson's bill.
    With respect to commissary benefits, I grew up in the 
military. I used to work in a commissary, actually; I was a 
bagboy for 2\1/2\ years when I was in high school. [Laughter.]
    But, I've always looked at commissary benefits in the same 
way that we articulate the healthcare benefits to people. 
It's--the idea of being able to go to the commissary after you 
retire is something that people count on while they're in the 
military. That's something we don't think about, I think, as 
much as we need to up here.
    Your comment, Ms. Moakler, about family difficulties and 
the need to get on top of that, there was a period in my life 
when my dad was either deployed or stationed where there was no 
family housing, for 3\1/2\ years. We had no structure in--at 
that period. We were--this idea of the family as a part of the 
operational military was not even in its infancy at the time.
    I also recall when I was in the Marine Corps and I got back 
from Vietnam, in Quantico--they did a study of the Quantico 
school system, and I think the statistic at the time was that 
the kids in the Quantico school system--the high school--had 
three times the level of emotional difficulties as the national 
level at the time, because of the intensity of the Vietnam war. 
About 100,000 killed or wounded in the U.S. Marine Corps. 
People forget that. We had more total killed or wounded in 
Vietnam than we did in World War II, in the Marine Corps. The 
stress of these 13-month deployments on the marines, and 
wondering what your dad was doing, and, at that time, he could 
be dead. Enormous impact.
    I really salute you for bringing the issue to us the way 
that you did today.
    I had one question, quickly. I know we're way behind 
schedule here, and I know Senator Graham wants to also 
participate here. But, there's a lot of experience in this 
panel--military experience. I am really puzzled when I keep 
hearing the statistic that two-thirds of the--your phraseology 
was ``optimally-aged potential enlistees'' are not qualifying, 
and that defies historical trends. If you go back, for 
instance, to the Vietnam era, which I've done a lot of study 
on, obviously, over my life--one-third of the entire age group 
served--9 million out of 27 million actually served. We're now 
saying that only one-third of an age group could even qualify 
to serve. What are your thoughts on that? Are the standards not 
fitting the potential? Or are the physical and mental 
capabilities different? Where do we get this--and what could we 
do about it?
    Mr. Barnes. Mr. Chairman, I'll speak to that first. Those 
statistics are from recruiting--Navy Recruiting Command----
    Senator Webb. Yes, I've actually heard them in other 
hearings, so----
    Mr. Barnes. Exactly. I think there are a number of facets 
associated with that. Number one, it's the All-Volunteer Force, 
which has obviously been up and functioning since the early 
1970s. The service requirements across the Services as to what 
the expectations are with regard to them; social issues, with 
practices and whatever, that are not conducive or not 
compatible with the requirements; perhaps drug use or other 
things that are happening.
    So, it's a multifaceted issue. It's very troubling to our 
Association. We have a number of recognition programs, work 
very closely with Navy, Marine Corps, and Coast Guard 
recruiting communities, I share your concern about that. It's 
kind of a staggering statistic, but it's held consistent for 
several years, now.
    Senator Webb. Does anyone else have any thoughts on that?
    Colonel Strobridge. Yes, sir. I attended a briefing by Dr. 
Curt Gilroy recently, the DOD Director of Accession Policy. I 
think one of the things he emphasized is--and, as a matter of 
fact, he--the number he gave was, only 25 percent qualify. One 
of the changes, I think, is obesity. We have a significantly 
larger number of people who are overweight today than we did in 
the past. Another thing is, kind of, the incongruity, perhaps, 
in some of the drug issues. If you report to Basic Training and 
say you experimented once with marijuana, they'll let you stay, 
but if you had a conviction for possession of a marijuana 
cigarette when you were 18, you can't come in. So, there is a 
variety of things like that, I think.
    Ms. Moakler. I think we also need to look at the converse 
of that. You have an example of this, Chairman Webb, as do I. 
I'm the mother of two soldiers. It behooves us to keep our 
promises to our families so that our children see that the 
military lifestyle is a rewarding one. We're already teaching 
them self-sacrifice. So many of our children are eligible, 
because they see that physical fitness is an important part of 
everyday life, because they are discouraged from using drugs, 
and because they seek that life of selfless service. So, that's 
just another aspect to look on it, as well.
    Mr. Cline. Mr. Chairman, we have similar problems in the 
Guard and Reserve. Standards today in the Guard and Reserve are 
much higher--back in the day when I joined. The education 
requirements, the drug problems are just higher today than they 
are.
    We're living in a day of fast food, as Colonel Strobridge 
mentioned. Overweight problems. We're constantly weeding out 
people who cannot meet the physical fitness requirements.
    Senator Webb. I know Senator Graham has to go, and he 
wanted to----
    Senator Graham. Well, one, we've been doing this together 
for several years now, and you all really do a good job of 
making the case for benefit increases and inequities. That's 
what your job is, and our job is to listen and try to meet as 
many needs as we can, understanding we can't be everything for 
everybody all the time because of budget problems.
    The thing about TRICARE--I want to just let Senator Webb 
know that, working with Senator Clinton and others, we're able 
to make the Guard and Reserve Force eligible for TRICARE year 
round. The belief is that 25 percent did not have healthcare in 
the private sector; it gives them a healthcare home. It will 
allow them to have healthcare throughout their military 
service, which is an incentive to stay in.
    I'm very disheartened by the numbers you gave me. We're 
going to do everything we can on this subcommittee to let 
people know, this benefit is there, you've earned it; it's a 
good deal, compared to the private sector; and try to get 
people to take more advantage of it. So, I promise you--18 
months is too long, so we're going to start--about the other 
problem you mentioned, about 18 months to implement the GI 
stuff, benefits.
    So, this really helps us understand how these programs 
actually work. Because when I go around talking about them, I'm 
very proud of it, but only 6 or 7 percent of the force is 
joining up, there's a disconnect. You all are really fair 
arbitrators of that.
    One thing I would suggest, Mr. Chairman, is that this 
country has to come to grips with Medicare and Social Security 
and entitlement programs that have no end in sight and 
beginning to eat up the budgets of everything else we do. The 
same is true for military healthcare. We haven't had a premium 
increase since 1995. I understand that what the past 
administration tried to do was just too much, too quick. I 
mean, it's just--couple hundred percent. Lowering the 
deductible from 500, or whatever it is, to 100 is just kind of 
a--just pretty rapid change that hits the wallet pretty hard.
    But, I would suggest that we try to work with these groups. 
You all have done a--remember when we had that big meeting a 
couple years ago? How could you lower the cost of military 
healthcare? How could you improve access and quality? What 
things could we put on the table, that are preventive, that 
would allow the military member and their family to get better 
treatment, but actually lower cost?
    I think it would be--probably behoove us to look at that 
again, before we ask for more money; to really go into this 
system and see, is it serving, an optimal level, the 
beneficiaries? Are we doing preventive medicine things that 
will lower costs and improve quality of life? But also 
understand one word: sustainability. None of these programs are 
going to be sustainable if we don't do something about that. 
That's what I would like to have this subcommittee look at, if 
we could, a way to get sustainable medical healthcare benefits 
for the retired force, the active and Guard force, and their 
families, so you can recruit and retain, but not have the 
dilemma of taking money away from a budget where you also are 
going to need to fight the war and buy equipment.
    That's the challenge of our lifetime, quite frankly, and 
you and your organization that you represent can really be 
helpful here.
    Mr. Chairman, thank you. You--obviously----
    Senator Webb. Well said.
    Senator Graham. Just listening to you--I mean, you have so 
many experiences. I don't know how you got through school. 
[Laughter.]
    I mean, changing schools that many times. Can you imagine 
the stress on that? I didn't know that. I didn't know that more 
Marines were killed in Vietnam, and wounded, than World War II.
    Senator Webb. More total casualties----
    Senator Graham. I did not know that, so----
    Senator Webb.--killed in World War II, more total 
casualties.
    Senator Graham. You have lived the life that these people 
are talking about, from personal and from your parents' point 
of view, and let's take that knowledge and put it to good use.
    Senator Webb. It's a pleasure to be working with you, 
Senator Graham, and I take all your points on track.
    I want to make one 30-second point here, just to wrap up 
this question I had about percentage of people who might be 
able to come in.
    I think we undervalue what we can get out of people who 
haven't yet finished high school, who fall out of the system, 
who can come into the military. I've seen too many success 
stories from the Marine Corps with--we have about the same 
percentage of people now who aren't finishing high school as 
did when I was in the Marine Corps. We took them, some of my 
best friends, some of my close friends in my life, people like 
Carlton Sherwood, high school dropout, three Purple Hearts in 
Vietnam, became a Pulitzer Prize-winning investigative 
reporter. Walter Anderson, Chief Executive Officer of Parade 
Magazine, Parade Enterprises, high school dropout, went in the 
Marine Corps, came back, and was valedictorian of his college 
class.
    I mean, there's a pool of people out there who, with the--
if you take their mental scores, the capability they have, who 
are looking for structure in their life, and can come in and 
really add value to our society. Maybe we ought to take that 
piece and look at it and talk to DOD about it, if we want to 
increase this pool.
    It's been a great discussion; and Senator Graham, it's a 
pleasure working with you.
    The hearing is adjourned. Thank you all.
    [Questions for the record with answers supplied follow:]
             Question Submitted by Senator Daniel K. Akaka
                    catastrophic injuries assistance
    1. Senator Akaka. Dr. Stanley, Mr. Lamont, Mr. Garcia, and Mr. 
Ginsberg, the 2010 National Defense Authorization Act includes a 
provision concerning the special compensation for members of the 
uniformed services with catastrophic injuries or illnesses requiring 
assistance in everyday living. (Subtitle A, Sec. 603 of the Conf Report 
to accompany H.R. 2647) Please provide an update on the Department of 
Defense's (DOD) actions concerning this provision.
    Dr. Stanley. The program was briefed at the March 18, 2010 Senior 
Oversight Committee (SOC) meeting, co-chaired by the Deputy Secretary 
of Defense, and the SOC decided the level to set monthly payments. We 
anticipate a decision establishing eligibility for this program will be 
made this month. The Services support providing compensation to 
catastrophically wounded, ill, and injured servicemembers for the 
assistance provided by designated caregivers. We anticipate completing 
formal coordination and signing a DOD-level Directive Type Memorandum 
by the end of May to implement this program.
    Mr. Lamont. The DOD Wounded Warrior Care and Transition Program 
Office (WWCTP) began developing a Directive-Type Memorandum (DTM) in 
December 2009 to provide guidance to the Services for the 
implementation of the provisions of Section 603 of Public Law 111-84, 
the National Defense Authorization Act for Fiscal Year 2010. To 
accomplish this task, the WWCTP established a work group consisting of 
representatives from all Services, the TRICARE Management Agency, the 
Defense Finance and Accounting Service, and other key stakeholders in 
the implementation of the special compensation program. The DTM is 
nearing completion.
    Mr. Garcia. The Office of the Secretary of Defense (OSD) is in the 
final stages of developing draft policy for coordination with the 
Services prior to implementing in April.
    Mr. Ginsberg. The Air Force is working with Army, Navy, and the OSD 
to implement this program in April 2010. OSD is finalizing a DTM for 
the Services to review and coordinate. Because we have been working on 
this together for several weeks, it is anticipated that the review will 
be finalized very quickly by the Services and signed by the Under 
Secretary of Defense (Personnel & Readiness) in the next few weeks. It 
is our desire to implement this special monthly compensation as quickly 
as possible to offer the financial assistance caregivers of our 
catastrophically wounded, ill, and injured servicemembers deserve when 
dedicating their time to assisting these servicemembers with daily 
living activities.
                                 ______
                                 
              Questions Submitted by Senator Kay R. Hagan
          census bureau tabulation of deployed servicemembers
    2. Senator Hagan. Dr. Stanley, I am very concerned that 
servicemembers that are deployed during the conduct of the 2010 Census 
will be counted in a way that negatively impacts communities that host 
military installations. North Carolina currently has approximately 
41,200 servicemembers deployed as a part of the overseas contingencies, 
and in the event that they are counted as prescribed by the U.S. Census 
Bureau, areas with large concentrations of military personnel will be 
significantly undercounted, and underfunded for the next 10 years. What 
is preventing the Defense Manpower Data Center from providing the U.S. 
Census Bureau with information regarding the base of last assignment or 
permanent U.S. duty station as the primary response for deployed 
servicemembers currently engaged in overseas contingencies?
    Dr. Stanley. While there is no law specifying how to count 
servicemembers deployed overseas, for the 2010 census the Census Bureau 
has directed use of the same procedures used in the 1990 and 2000 
Censuses. These procedures were developed based on a bill that passed 
the House of Representatives in 1990 (H.R. 4903) and recognition of 
strong bipartisan congressional support for including overseas military 
personnel in the census.
    The decision for specific methodology used falls under the purview 
of the Census Bureau, and the Department follows its guidance for this 
accounting. The Census Bureau believes that the current methodology 
provides the benefit of consistency over time.
    The directed methodology counts overseas military personnel, both 
stationed and deployed (including the National Guard), as part of the 
U.S. overseas population. The Department uses the following hierarchy 
(based on data availability): State home of record, State of legal 
residence, and State of last duty station (i.e., base of last 
assignment). While servicemembers deployed overseas at the time of the 
census will be included in the federally affiliated overseas count for 
apportionment purposes, their families residing in the U.S. will be 
counted through the standard census questionnaire.
    The Department understands the potentially beneficial effects 
counting by ``last duty station'' first could have on States with a 
large military population and has discussed this and other 
methodologies with the Census Bureau. Clear legislation would resolve 
questions and codify the methodology to count deployed servicemembers. 
The Department stands ready to discuss all possible methodologies with 
the Census Bureau and Congress.

                       post-september 11 gi bill
    3. Senator Hagan. Dr. Stanley, due to the Post-September 11 GI 
Bill, servicemember benefits were increased to rates that are 100 
percent of in-State public university tuition rates. Eligible veterans 
are also provided with a housing allowance in order to offset living 
expenses. These benefits have been extended to officers that had their 
bachelor degrees funded through attendance at the service academies or 
through ROTC programs. However, servicemembers that served in the 
Reserves prior to commissioning and received benefits under Chapter 
1606 while funding their own educational expenses, are not similarly 
included under the Post-September 11 GI Bill. Additionally, several 
programs that were included under the GI Bill, such as vocational 
programs, are not included under the Post-September 11 GI Bill. Now 
that the Post-September 11 GI Bill has been fully implemented, do you 
feel that technical correction legislation would be appropriate in 
order to reconcile some of the program inequities that have been 
identified?
    Dr. Stanley. DOD does not believe technical changes are necessary 
to the Post-September 11 GI Bill at this time. The Department supports 
the widest possible usage of benefits for our former Active and Reserve 
servicemembers, who served on active duty since September 11, 2001.

    4. Senator Hagan. Mr. Lamont, Mr. Garcia, and Mr Ginsberg, at a 
time when the Nation is relying more and more on its Reserve Forces, 
there now appears to be the largest historical gap in the relative 
value of education benefits provided under Chapter 1606 when compared 
to those under Chapters 30 or 33 of the GI Bill. Do you anticipate that 
the disparity in educational benefits will have a negative impact on 
Reserve recruiting?
    Mr. Lamont. The Army Reserve and Army National Guard components 
exceeded its accession goal last year. There are no indicators at this 
time that enactment of the Post-September 11 GI Bill has had a negative 
influence among potential candidates for either Active or Reserve 
components.
    Mr. Garcia. Both Navy and Marine Corps reservists are poised to 
take advantage of Post-September 11 GI Bill benefits (Chapter 33) as 
well as other VA education programs to include Chapter 30, Chapter 1607 
(REAP), and Chapter 1606 (MGIB-SR). It is because our reservists are 
answering the call to service that their education benefits continue to 
expand and grow. RC members continue to have the opportunity to choose 
which VA education benefits they would like to use based on their 
eligibility. These benefits will continue to have a strong positive 
impact on recruiting and on retention in the RC well into the future.
    Mr. Ginsberg. The disparity in Chapters 1606, 30 and 33 educational 
benefits has proven not to have a negative impact on recruiting. The 
Air Force Reserve (AFR) continues to exceed recruiting goals despite 
the disparity. Although Reserve and active duty component recruiters 
compete in the same marketplace, our products are distinctly 
different--specifically, part-time versus full time employment. 
Accordingly, there will be a continual ``full-time/part time'' benefit 
disparity among MGIB programs. (The disparity between Chapters 1606 and 
30 has increased and is currently at 26 percent). In addition, Chapter 
30 was created as a reward for service whereas Chapter 33 is primarily 
a retention tool--increasing monetary benefits and allowing members to 
commit to additional service in exchange for transferring educational 
benefits to dependents.

          unemployment rate among returning military personnel
    5. Senator Hagan. Mr. Lamont, Mr. Garcia, and Mr. Ginsberg, the 
current economic climate has been difficult for all of America's 
families; statistics show it has been especially difficult for 
returning military personnel serving in the National Guard and 
Reserves. For combat veterans returning home, it is especially 
challenging as they make the transition back to being a citizen 
soldier, while at the same time, having to deal with symptoms commonly 
associated with Post Traumatic Stress Disorder (PTSD). With an all-
volunteer military that relies upon the National Guard and Reserves as 
essential components of the total force structure, what steps are being 
taken in order to provide more comprehensive transitional assistance 
for servicemembers returning home, and what are the significant gaps 
that remain?
    Mr. Lamont. We are doing whatever is necessary to help Reserve 
soldiers transition back to everyday life. Reserve soldiers are briefed 
at the demobilization station on the Transitional Assistance Management 
Program (180 days of TRICARE coverage post mobilization), Veteran's 
Healthcare Benefits, Yellow Ribbon, Military OneSource (counseling 
services at no cost to our soldiers), Joint Family Assistance Program 
(augments existing family programs to provide a continuum of support 
and services), Strong Bonds Program (relationship training to Singles, 
Couples and Families) and Recovery Care Coordinators (facilitators 
assigned to work with recovering Army Reserve soldiers to include those 
with psychological health conditions and/or Traumatic Brain Injury 
(TBI)).
    The Army Reserve has partnered with the Department of Labor and is 
implementing an Employer Awareness Campaign which will provide 
employers with access to education and informational tools regarding 
psychological health and TBI, as well as a variety of other topics 
located at America's Heroes at Work website.
    A significant gap is the transition assistance programs are of 
limited duration and are temporary programs (tied to contingency 
operations); continued support to ensure the programs are properly 
resourced is essential. Another gap is when an Army Reserve soldier is 
released from active duty; the soldier is no longer eligible for 
support. For example, the Army Emergency Relief only offers financial 
assistance to soldiers and their Family members when the soldier is in 
an active duty status. Providing transitioning Army Reserve soldiers 
access to all Services afforded Active component soldiers will bridge 
some current gaps.
    The National Guard soldiers and airman go through a number of steps 
in their transition phase, from an active duty status back to a Reserve 
status. The first step begins with a demobilization process with the 
active component. During this step they process through various 
stations to address issues such as financial, personnel, logistics, 
medical and dental services, and benefits.
    In the medical station both physical and behavioral areas, such as 
PTSD, are assessed. In the benefits station a Veterans Administration 
representative reviews the services provided through the Veterans 
Health Administration and can enroll the Guard member for care at a 
Veterans Affairs hospital in their local area when they return home.
    The next step occurs when the National Guard soldier is at home. 
Through the Yellow Ribbon Program there are a series of events at 30-, 
60-, and 90-day intervals. Each of these events revisits the various 
processes they went through at the demobilization station. These 
meetings remind Guard soldiers and their families of the services and 
benefits as well as an introduction to the various local community 
resources that are available. These resources include our own internal 
Warrior Support team consisting of an Employer Support of the Guard/
Reserve, Psychological Health, and Family Program representatives, and 
a Transition Assistance Advisor.
    Working in concert with the National Guard Yellow Ribbon 
Reintegration Program, Employer Support, and Warrior Support offices 
participate in Yellow Ribbon Reintegration events and activities to 
ensure that all returning servicemembers are made aware of their 
employment rights under law as well as employment opportunities within 
the States and Territories to include the District of Columbia. 
Additionally, the National Guard is working with the DOD Transition 
Assistance Task Force to recommend change to the current Transition 
Assistance Program legislation to reflect the specific needs of the 
Guard and Reserve in relation to transition assistance.
    Mr. Garcia. Both the Navy and Marine Corps offer Transition 
Assistance Programs to separating and retiring servicemembers. Program 
outcomes are intended to provide participants with the skills they need 
to obtain appropriate post-service employment and make the transition 
back to being a citizen soldier. These services are provided at Navy 
and Marine Corps installations worldwide.
    In accordance with title 10 U.S.C., section 1142 and 1143, 
Transitional Assistance Management Program (TAMP) services are provided 
to all servicemembers who are released from active duty/separated/
retired who serve 180 continuous days or longer on active duty. 
Although existing transition programs were originally designed for the 
active component, the program supports reservists, as members of the 
total force, provided eligibility requirements are met (i.e., served 
180 continuous days or longer on active duty, and are within 12-months 
from separation, or are within 24-months from retirement).
    Reserve servicemembers are provided information on their rights 
under the Uniformed Services Employment and Reemployment Rights Act 
(USERRA) which is intended to minimize the disadvantages to an 
individual that can occur when a person needs to be absent from his or 
her civilian employment in order to serve in the uniformed services.
    In addition to providing assistance with career, employment, 
education and training benefits, Pre-separation Counseling, which is 
required by title 10 U.S.C., section 1142, includes information on how 
to maximize the use of benefits earned through their service such as 
determining health and life insurance requirements, financial planning, 
and Veteran's benefits and entitlements.
    The Yellow Ribbon Reintegration Program (YRRP), which was created 
by P.L. 110-181 (NDAA for Fiscal Year 2008), provides access to 
programs, resources, and services to minimize stresses on National 
Guard and Reserve members and their families before, during, and after 
deployments of 90 days or more.
    The Warrior Transition Program was established in Kuwait and 
provides a place and time for sailors to decompress and transition from 
the war zone to life back home. Through small group discussions 
facilitated by chaplains and medical personnel, Warrior Transition 
Workshops prepare sailors for resumption of family and social 
obligations, return to civilian employment, and reintegration with the 
community.
    The Returning Warrior Workshop (RWW) is another important step in 
the demobilization and reintegration process for the Total Force and 
their families. The RWW is designed to remove stigma and direct family 
members to appropriate support programs. Originally developed by and 
for the Navy Reserve, the RWW has expanded to include Navy active and 
Marine Corps Reserve members and their families.
    The Navy's Operational Stress Control (OSC) and Marine Corps' 
Combat and Operational Stress Control (COSC) programs are a set of 
policies, programs, training and tools to enable leaders, marines, 
sailors, family members, and caregivers to deal effectively with the 
stress of operational deployment and training.
    The Marine Corps also developed a specific ``Demobilization Tool 
Kit'' and Career Guide CD which supplement our existing transition 
program. These Kits were designed to meet the unique needs and concerns 
of demobilizing Reserve marines and family members as they return to 
civilian life and workforce. Toolkits were not re-distributed in fiscal 
year 2010 since the OSD Office of Wounded Warrior Care and Transition 
Policy is in the process of creating a toolkit that will serve both the 
transitioning Active Duty and Reserve community.
    The Deputy Under Secretary of Defense, Office of Wounded Warrior 
Care and Transition Policy is leading an effort to expand transition 
support to the National Guard and Reserves through an amendment to the 
current law as well as revision of the DODD 1332.35 and DODD 1332.36. 
The Marine Corps is also convening an Operational Planning Team (OPT) 
to look at program improvements, such as starting the transition 
process 2 years earlier (recognizing that over 65 percent leave the 
Marine Corps after the first term) and offering tiered delivery of 
services, such as Education, Training, and Employment Job Placement.
    Mr. Ginsberg. The AFR and Air National Guard (ANG) enlist the 
resources of a variety of programs to ease the transition of its 
members back to civilian status. The YRRP is the comprehensive DOD 
program used by all components to provide assistance to members and 
families. In addition, because health care and employment issues are 
particularly important to returning veterans, the AFR and ANG have 
programs and resources that place particular emphasis on these areas.
Yellow Ribbon
    The AFR and ANG employ the Yellow Ribbon Program as a key component 
to effectively address the transition back to civilian life. Experts 
who participate regularly in Yellow Ribbon events--pre-deployment, 
during deployment, and post-deployment--include the DOD contracted 
Military Family Life Consultants (MFLCs), Military OneSource, and 
Personal Financial Readiness. Since the standup of the Yellow Ribbon 
Program by the AFR Command in August 2008, comprehensive support to 
airman, families, and employers throughout the deployment cycle 
minimizes the stress of deployment and family separation. During the 
period from August 2008 through 1 March 2010, the Yellow Ribbon Program 
held 156 total events across 39 Wings/Groups with 5,668 Reserve members 
and 5,288 family members participating.
    National Guard soldiers and airman go through a number of steps in 
their transition from an active duty status back to a Reserve status. 
The first step begins with their participation in a demobilization 
process along with the active component. During this step they go 
through various stations with subject matter experts to address issues 
such as financial, personnel, logistics, medical, dental, services, and 
benefits. In the medical station both physical and behavioral areas, 
such as PTSD, are assessed. In the benefits station a Veterans 
Administration representative reviews the services provided through the 
Veterans Health Administration and can enroll the Guard member for care 
at a VA hospital in their local area when they return home.
    The next step occurs when the National Guardsman is at home. The 
Yellow Ribbon program conducts a series of events at 30-, 60-, and 90-
day intervals. Each of these events reassembles the various experts 
that were available at the demobilization station. These events remind 
Guardsmen and their Families of the services and benefits as well as 
introduce them to the available local community resources. These 
resources include an internal Warrior Support team consisting of an 
Employer Support of the Guard/Reserve Specialist, Psychological Health, 
Family Program representatives, and a Transition Assistance Advisor. 
The Warrior Support team members are available via phone, email and 
personal meetings for the Guard member or their family at any time and 
serve as a resource and referral advocate for them. In addition, the 
creation of the Joint Services Support portal covers all transitional 
assistance programs and initiatives to enable all Guardsmen and their 
families to access information about support and services available in 
their local areas.
Health Care
    Both the AFR and ANG have placed particular emphasis on mental 
health. The AFR employs Psychological Health Advocates (PHAs), 
reservists who are mental health or clinical nurses and enlisted 
personnel, and are qualified to provide assessment and referrals for 
mental health services. The PHAs and MFLCs work in concert with one 
another to ensure comprehensive services are available to reservists 
and their families. The ANG has placed Directors of Psychological 
Health in each State and territory to perform as an assessment and 
referral resource and act as the subject matter expert to the State/
territory with regards to psychological health matters. In its 
inaugural year (fiscal year 2009) they intervened in 255 critical cases 
that were deemed high risk suicide/homicide situations.
    Air Force Reserve Command (AFRC) is also working cooperatively with 
Department of Veterans Affairs Veterans Health Administration to ensure 
implementation of the Combat Veteran Heath Care Benefits and Co-Pay 
Exemption Post-Discharge from Military Service. Reserve personnel 
returning from any theater of combat operations are briefed by VHA 
representatives and given the opportunity to apply for Veterans Health 
care. This allows reservists to receive medical care, to include 
treatment for post-traumatic stress disorder (PTSD) at VA health 
facilities with no co-pay. In addition, those who serve in combat 
theater for not less than 90-days are informed of their eligibility for 
one-time correction of dental conditions if they had not had dental 
care while deployed.
Employment Assistance
    In addition to providing assistance with benefits and entitlements 
associated with active service, Air Force Reserve Airman and Family 
Readiness Centers provide employment assistance. Unemployment in the 
civilian sector is a growing concern for the AFR, but not a ubiquitous 
problem. Much of the unemployment seems to be associated with the 
economic situation where a reservist resides. Several locations, with 
one full-time Airman and Family Readiness staff member, offer 
employment-related classes similar to those offered during a Transition 
Assistance Program (TAP) seminar including resume writing, 
interviewing, job search skills, how to dress for career fairs and job 
interviews. The employment focus of TAP is to make the reservist more 
marketable in an environment where there are few or no jobs. reservists 
are often tied to communities where their spouses have employment so 
relocation for job opportunites may create another problem. This is not 
unlike situations active duty spouses find themselves in the job 
market.
    For the ANG, Employer Support, and Warrior Support offices 
participate in Yellow Ribbon Reintegration events and activities to 
ensure that all returning servicemembers are made aware of their 
employment rights under law as well as employment opportunities within 
the States and Territories (to include the District of Columbia). The 
National Guard is working with the DOD Transition Assistance Task Force 
to change the current Transition Assistance Program legislation to 
reflect the specific needs of the Guard and Reserve in relation to 
transition assistance. Finally, the National Guard Employer Support 
Program Support Specialist located in each Joint Force Headquarters 
State is responsible to connect returning Guardsman with Federal, 
State, local, and private agencies to obtain employment referrals. In 
many cases these referrals may involve additional training and 
education to compete for areas of future employment. Additionally, the 
National Guard Program Support Specialist advise returning Guardsman of 
specific unemployment trends and retraining benefits in their local 
area.
                                 ______
                                 
            Questions Submitted by Senator Roland W. Burris
           defense integrated military human resources system
    6. Senator Burris. Dr. Stanley, now that the Defense Integrated 
Military Human Resources System (DIMHRS) is being canceled by the 
Secretary of Defense, what is the plan to look at other options to 
manage personnel and pay under a single system for the DOD?
    Dr. Stanley. When the Department determined to terminate the DIMHRS 
program, the decision also included direction for a way forward. There 
are no plans to review options for a single DOD system to manage 
military personnel and pay; rather each of the Services will implement 
enterprise standards in their own systems.
    The software configured to support the original DIMHRS effort has 
been provided to each Service for their individual development efforts 
called Service Integrated Personnel and Pay Systems (SIPPS). SIPPS-Army 
is currently the most mature effort and expects to begin deployment in 
fiscal year 2013. A governance structure is also in place to manage 
development of the individual Service systems that includes the DIMHRS 
Transition Council, mandated by Congress in the National Defense 
Authorization Act for Fiscal Year 2010. A Joint Enterprise Change 
Management Board was put in place to ensure changes to the Service 
systems do not adversely impact the Enterprise Standards compliance. 
This body is co-chaired by the OUSD (P&R) Director, Information 
Management and the Director, Defense Finance and Accounting Service, 
Financial Management Center of Excellence.
    I am confident this governance structure ensures the individual 
Service development programs support and execute military personnel and 
pay policies accurately, equitably, and in a timely manner for our 
servicemembers.

                               minorities
    7. Senator Burris. Dr. Stanley, what are the percentages of 
minorities by category and women in the Senior Executive Service (SES) 
General and Flag Officer ranks of the Armed Services, and DOD 
headquarters?
    Dr. Stanley. For the General and Flag officer population, gender 
composition is 93.6 percent males and 6.4 percent females. The race/
ethnic composition is 89.8 percent White, 6.0 percent Black, 1.6 
percent Hispanic, 1.3 percent Asian/Pacific, .2 percent American 
Indian/Alaskan Native and 1.1 percent Other. These data are current as 
of March 2010
    For the SES population, gender composition is 76.3 percent males 
and 23.7 percent females. The race composition is 90.53 percent White, 
4.48 percent Black/African American, 1.6 percent Hispanic, 2.10 percent 
Asian, 0.14 percent Native Hawaiian/Pacific Islander, 0.87 percent 
Multiracial; 0.14 percent ID Pending; and 1.3 percent Unspecified. The 
Unspecified group primarily consists of individuals designated as 
Hispanic but who do not have a race specification. The percentage of 
SES population identified as Hispanic ethnicity is 1.73 percent. These 
data are current as of January 2010.

                           civilian employees
    8. Senator Burris. Dr. Stanley, civilian employees that participate 
in the Thrift Savings Plan (TSP) are entitled to receive matching 
agency contributions to their TSP account, yet military members do not. 
When will this disparity be addressed for our military personnel?
    Dr. Stanley. To address the appropriateness of providing agency 
matching contributions to military members, it is important to consider 
and compare the role of the TSP in the civilian and military 
compensation systems.
    For a civilian employee under the Federal Employee Retirement 
System (FERS), the funds provided by the government in the form of 
matching contributions are one of the key components of retirement. 
Under FERS, in addition to receiving matching contributions, the 
employee contributes to a defined benefit plan and receives an annuity 
upon retirement after reaching a specified age and years of service.
    For a military member, the government provides a defined benefit 
retirement plan more generous than FERS and fully funded by the 
government. Unlike the civilian employee under FERS, the military 
member does not contribute to the defined benefit plan and receives 
monthly retired pay immediately upon retirement, but at an earlier age 
with many working years ahead.
    The military member is also allowed to contribute to the TSP. 
However, the ability to participate in the TSP was not designed as a 
key component of the military member's retirement. For the military 
member, participation in the TSP is a valuable, additional benefit, one 
that facilitates long-term saving. Although participation in the TSP 
may be a common element across both military retirement and FERS, the 
roles of the TSP and the need for and purpose of providing agency 
matching contributions are different.
    In the past, the Department has investigated the impact on 
recruiting and retention and the cost effectiveness of providing 
military members with agency matching contributions. Based on data of 
members currently contributing to TSP, the cost of providing agency 
matching contributions is estimated to be between $840 million and $2.8 
billion annually, depending upon the level of participation.
    RAND and the Center for Naval Analyses (CNA) have both investigated 
the issue of providing agency matching contributions. RAND reviewed an 
Army pilot program which offered agency matching contributions from 
2006 through 2008 to new enlistees who selected longer enlistments and 
enlisted in hard-to-fill specialties. RAND found no appreciable 
increase as a result of providing agency matching contributions. CNA 
also studied the issue of providing agency matching contributions and 
determined providing agency matching contributions would have minimal 
impact on retention.

                         don't ask, don't tell
    9. Senator Burris. Dr. Stanley, how will a moratorium on Don't Ask, 
Don't Tell (DADT) affect the pending cases of servicemembers facing 
discharge?
    Dr. Stanley. The Secretary of Defense has appointed a high-level 
Working Group to review how to implement repeal of 10 U.S.C. Sec. 654. 
As the Secretary has said, he does not support a moratorium while this 
Working Group is undertaking its review. In general, a moratorium would 
prohibit the separation of servicemembers on the basis of homosexual 
conduct until the moratorium ends. This would presumably have the 
effect of allowing openly gay and lesbian servicemembers to continue 
serving on active duty for the duration of the moratorium and would, in 
that respect, have an effect very similar to repeal of section 654.

                              end strength
    10. Senator Burris. Mr. Lamont, given the operational tempo placed 
on the forces, particularly as it relates to the Army Reserve 
components, do you feel there is a need for the end strength of the 
Army Reserve and Army National Guard to increase?
    Mr. Lamont. Yes. The Army is considering if additional funded end 
strength is needed for the Reserve components in order to optimize Army 
National Guard and Army Reserve Trainees, Transients, Holdees, and 
Student (TTHS) accounts. Each of the Army's components requires a TTHS 
account to allow them to optimize the management of their force. The 
Active component is authorized approximately 71,000 soldiers (13 
percent of Active component end-strength) within a TTHS account, 
allowing the Active component to segregate nondeployable personnel 
(e.g. non-trained or soldiers in resident training) from units. In 
contrast, the relative small size of the Army National Guard (2.5 
percent) and Army Reserve (2 percent) TTHS accounts are insufficient to 
make full use of a TTHS mechanism and its positive effects on 
readiness.

    11. Senator Burris. Mr. Lamont, the Army has asked for a temporary 
end strength increase, due in part to deployments and now with perhaps 
a bigger burden on the forces given the requirements brought forth from 
the Quadrennial Defense Review, don't you think the Reserve component 
needs additional forces as well?
    Mr. Lamont. The Army is doing an ongoing RAND Study to determine if 
increasing the end strength of the Reserve components (RC) is 
necessary. Should the study show additional end strength is required to 
optimize the RC, we will include additional cost in the next Army 
budget request.

                                reserve
    12. Senator Burris. Mr. Lamont, the Army Reserve has the lowest 
percentage of full time support comparing it with the size of the 
Reserve component forces, followed by, I believe, the Army National 
Guard. Yet, their participation in Overseas Contingency Operations 
(OCO) is more significant than the other Reserve components. How can 
you explain that?
    Mr. Lamont. Adequate full-time support is essential for Reserve 
component (RC) unit readiness, training, administration, logistics, 
family assistance and maintenance. The Commission on the National Guard 
and Reserve found that effective performance of such functions 
correlates directly to a RC unit's readiness to deploy. The Army with 
the largest Reserve operational force has 12.89 percent of its RC end 
strength as full-time support; the Air Force has 25.29 percent of its 
Reserve components as full-time manning. The current full-time support 
levels of the Army's Reserve Components are based, in part, on a 1999 
RAND Study that was revalidated in 2005. The manpower authorization 
levels established by RAND are currently funded at 72 percent of 
validated requirements, which was sufficient for a Strategic Reserve 
Force. Since 2001 the RC's have used personnel on Active Duty 
Operational Support-Reserve Components (ADOS-RC) orders and other full-
time equivalent (FTE) manpower to meet the full-time support 
requirements generated by contingency operations. The Army is 
considering what full-time support for the Guard and Reserve is needed 
to ensure adequate manning for various support functions (organizing, 
manning, training and equipping) required for managing the Reserve 
components as an operational force.

                               recruiting
    13. Senator Burris. Mr. Lamont, is there an initiative to 
consolidate the recruiting programs of the three Army components (Army, 
Army Reserve, and National Guard)?
    Mr. Lamont. While there have been informal discussions about having 
a single Army recruiting command that serves the needs of the total 
force--Regular Army, Army Reserve (USAR) and Army National Guard 
(ARNG)--there are no initiatives to further consolidate recruiting at 
this time.
                                 ______
                                 
             Questions Submitted by Senator Lindsey Graham
                  recruiting health care professionals
    14. Senator Graham. Mr. Lamont, Mr. Garcia, and Mr. Ginsberg, you 
indicated in your written statements that achieving Service recruiting 
goals for doctors, psychologists, nurses, dentists, and other health 
care professionals, in both the active and Reserve components, presents 
significant challenges. Please discuss the challenge of recruiting 
health professionals in this wartime environment in your Service, and 
how you plan to meet this challenge.
    Mr. Lamont. Hiring difficulties continue to stem from remote 
locations, compensation limitations inherent to government employment, 
and a national shortage of qualified providers. The Army is using 
numerous traditional mechanisms to recruit and retain both civilian and 
uniformed providers including Retention Bonuses; Student Loan Repayment 
Program; Special Pay for Certified Nurses; Medical Special Pays for 
Psychiatrists, and a Social Work Program in partnership with 
Fayetteville State University. A non-traditional recruiting approach 
has been the Military Accessions Vital to the National Interest (MAVNI) 
Pilot Program. MAVNI was launched in 2009 to attract high quality 
individuals with exceptional skills in health care professions or 
special language and cultural backgrounds. MAVNI recruits are non-U.S. 
citizens who have been legally present in the United States for 2 or 
more years and are licensed health care professionals or possess 
specific language and cultural capabilities in a language critical to 
the DOD, but who do not have permanent residency.
    Mr. Garcia. Navy has a comprehensive medical recruiting focus, 
which enabled us to exceed our overall medical recruiting goals in 
fiscal years 2008 and 2009. We are on track to meet our overall goal in 
the Active component (AC) in 2010, but are experiencing challenges in 
meeting the Reserve component (RC) goal, which increased by 121 
accessions this year, an increase of 43 percent.
    Increased 2010 recruiting goals notwithstanding, our analysis 
indicates medical professionals do not often consider military service 
a primary career option. Reasons for this include:

         Civilian salaries are more lucrative than military pay 
        and continue to outpace financial incentives we offer to our 
        target market.
         Excessive debt is a major concern for medical 
        professionals, who are able to find low-interest loans outside 
        of the military.
         Percentage of females attending medical school has 
        risen over the past 10 years yet females are less inclined to 
        serve in the military than males.
         Concerns over multiple deployments.
         Potential Reserve medical providers fear a loss of 
        their private practice.

    It should also be noted that we remain in keen competition with the 
private sector, the Department of Veterans Affairs, as well as with the 
other military departments, for the same finite talent pool.
    We are continuing best practices learned during the past 2 years 
and are implementing several new initiatives that we expect will bear 
fruit in our shortfall areas including:

         Adjusting bonuses and incentives for fully trained 
        medical professionals.
         Participating in the Military Accessions Vital to the 
        National Interest (MAVNI) pilot program to access qualified, 
        legal non-citizen medical doctors.
         Initiating an accession process for legal permanent 
        residents who are qualified physicians or medical students.
         Offering loan repayment opportunities for critical 
        medical specialties.
         Expanding use of medical officers to inform 
        undergraduate and professional medical students across the 
        Nation of opportunities in Navy medicine.
         Adding more full time recruiters to recruiting medical 
        professionals.
         Expanding the Health Service Collegiate Program to 
        include Permanent Residents (green card) in critical student 
        specialties.
         Offering bonuses for clinical psychologists, 
        physician's assistants, and social workers.
         Continuing the Critical Wartime Skills Accession Bonus 
        to target physicians (up to $400,000) and dentists (up to 
        $300,000).

    Mr. Ginsberg. Accessing fully qualified professionals is our 
greatest challenge. Air Force recruiting is challenged by the same 
factors our Nation faces in having sufficient health care professions 
such as: nursing, general surgery, family practice, psychology, and 
oral maxillofacial surgery. The Air Force faces keen competition for 
fully qualified specialists from the private sector and other Federal 
agencies, such as the Department of Veterans Affairs and the Public 
Health Service, where multiple deployments are not an issue. Also, 
there are significant pay disparities between the military and private 
sector employers, especially those surgical specialties crucial for 
wartime support. The changing demographics of health professions, with 
increased numbers of women entering the profession who may be less 
inclined to choose military service, also provide a challenging 
environment for our recruiters. Current data suggests less than 7 
percent of eligible graduates consider entering military service.
    Using feedback from exit interviews and informal counseling, the 
Air Force confronts the above challenges in a three-pronged approach: 
(1) education, (2) compensation, and (3) quality of life.

          (1) Education: Due to historical problems in recruiting fully 
        qualified and trained specialists, the Air Force deliberately 
        places increased emphasis and funding into educational 
        scholarship opportunities. We have found great success in 
        ``growing our own,'' either through the scholarship programs or 
        through training in the Uniformed Services University of Health 
        Sciences (USUHS). The highest retention occurs when we control 
        the educational environment. The Health Professions Scholarship 
        Program (HPSP) is a resounding success with 1,466 students 
        currently enrolled. As reflected in the DOD budget for fiscal 
        year 2013, the Air Force has a programmed budget to support a 
        gradual increase to 1,666 students. We have also optimized our 
        enlisted commissioning programs, such as the InterService 
        Physician assistant Program (37 graduates per year), the Nurse 
        Enlisted Commissioning Program (50 graduates per year), or 
        guidance and statutory limitations in Section 2124 of Title 10, 
        capping the total students enrolled DOD-wide in HPSP at 6,000. 
        USUHS programs have physical constraints with the facility and 
        academic accreditation constraints of oversight committees. 
        Enlisted commissioning programs are constrained by the number 
        of training-years programmed and funding against all enlisted 
        training. Even with limitations, education has proven the most 
        successful avenue of accession for the health professions.
          (2) Other ways we entice fully qualified specialists into the 
        Air Force is through compensation, using accession bonuses and 
        incentives. Under the auspices of Health Affairs, the Air Force 
        has funded accession bonuses and incentive pays to entice 
        selected fully qualified specialists. For fiscal year 2011, the 
        Air Force has sufficiently budgeted $16.4 million of this 
        towards accession bonuses for personnel in fully qualified 
        critical specialties based on historical rates of accession. 
        Historically, as outlined in the first paragraph and under 
        section (1), above, our accession bonuses have been of limited 
        success due in part to bonus structures, as section 301d and 
        301e of Title 37 are mutually exclusive of section 302k and 
        302l of Title 37. Because these accession bonuses cannot be 
        taken with a multi-year special pay, we have had limited 
        effectiveness from its use. In fiscal year 2009, 12 of 118 
        fully qualified physicians accessed were eligible for an 
        accession bonus; only 2 actually accepted the bonus. Our 
        greatest success is within the Dental Corps, where 14 of 17 
        billets were filled for fiscal year 2009. Our other programs 
        have limited success with nurse specialties at 120 of 155 
        qualified nurse billets filled. The various specialties of the 
        Biomedical Sciences Corps having only 129 of 321 requested 
        specialty positions filled for fiscal year 2009. As we migrate 
        our compensation portfolio under the new pay authority of 
        section 335 of Title 37, we will be able to initiate specialty 
        pays for the mental health care providers and other critical 
        wartime or shortage specialties that previously were excluded 
        from accession and incentive pays. We feel this will be of 
        great benefit to the Air Force and military health care in 
        general, allowing targeted accession bonuses, incentive pays, 
        and retention bonuses to address the manning shortages in the 
        health professions. Due to the complexity of medical specialty 
        and incentive pays and entitlements, scheduled migration of 
        these contractual agreements under ASD(HA) will take time to 
        fully implement. In general, recruiting many of the fully 
        qualified specialists without bonuses is extremely limited. 
        Level of compensation is an important consideration, but does 
        not entirely ease the burden of multiple deployments.
          (3) Lastly, no recruit enters without discussing quality of 
        life issues, whether this is family services, medical practice, 
        educational or leadership opportunities, or frequency of moves 
        and deployments. We address many of these issues amongst the 
        Air Force agencies. Ongoing projects include the Family Health 
        Initiative, which is a medical model that better leverages our 
        personnel. We are building force sustainment models, analyzing 
        promotion opportunities, and developing a more proactive 
        approach to provide more opportunities for advancement. In 
        specialties with increasing wartime deployments, we are better 
        able to spread the deployment load more evenly among our 
        members. Restructuring of our medical groups allow increased 
        opportunities for all health professions to become leaders in 
        the Air Force.

    We remain committed to obtaining the best in health care for our 
Nation' s military and their familiy members through enhanced 
recruiting efforts maximizing the tools provided for education, 
compensation, and creative quality of life efforts of new health 
professionals.

    15. Senator Graham. Mr. Lamont, Mr. Garcia, and Mr. Ginsberg, what 
about retention of health care professionals; how much visibility do 
you have and oversight do you exercise into how well your medical 
community leaders and personnel chiefs are doing in effectively 
retaining mid-career personnel?
    Mr. Lamont. The Army Medical Department continuously monitors the 
need for behavioral health care providers based on the reliant 
populations' ongoing and changing demand. MEDCOM has increased funding 
for scholarships and bonuses to support expansion of our provider 
inventory. The Army expanded the use of the active Duty Health 
Professions Loan Repayment Program and offers a $20K accessions bonus 
for Medical and Dental Corps health professions scholarship applicants. 
MEDCOM increased the number of Health Professions Scholarship 
Allocations dedicated to Clinical Psychology and the number of seats 
available in the Clinical Psychology Internship Program (CPIP). In 
partnership with Fayetteville State University, MEDCOM developed a 
Masters of Social Work program which graduated 19 in the first class in 
2009. The program has a current capacity of 30 candidates.
    Mr. Garcia. Recruiting and retention rates of health care 
professionals are tracked very closely. I receive updates monthly from 
the Chief of Naval Personnel and the Surgeon General of the Navy, with 
particular emphasis on retention of mid-career medical personnel. 
Additionally, I receive a quarterly update, which is also presented to 
the Chief of Naval Operations. My staff coordinates with the staffs of 
the Bureau of Naval Personnel and Bureau of Medicine and Surgery to 
address any shortfalls, leveraging current policies and legislative 
authorities, consistent with the President's budget to recruit and 
retain these highly skilled professionals along the entire career 
continuum
    Mr. Ginsberg. Within the Air Force I have visibility on a quarterly 
basis into the special pays and retention bonuses offered to the 
Medical Corps, Dental Corps, Biomedical Science Corps, Nurse Corps, and 
Medical Service Corps. My office monitors the amounts offered, the 
number of personnel eligible to elect the special pays, and the 
acceptance rate among our health care professionals, especially those 
in the critical wartime specialties, as well as among the mental health 
professionals. I firmly believe the Air Force medical community is 
sensitive to the health care needs of the population we serve and does 
an exceptional job ensuring the requisite health care professionals are 
retained. My office continues to work closely with the Air Force 
Surgeon General in anticipating requirements and using all available 
authorities to retain trained and experienced health care providers.

    16. Senator Graham. Mr. Lamont, Mr. Garcia, and Mr. Ginsberg, 
please provide a snapshot effective March 1, 2010, of the current 
status of each of your Service's health care professional recruiting 
and retention, clearly indicating where shortfalls exist and also 
indicating by specific officer grade (e.g., O3, O4 , O5).
    Mr. Lamont. As of 22 March 2010, the United States Army Recruiting 
Command (USAREC) Medical Recruiting Brigade (MRB) has achieved 51 
percent (457 of 905) of the fiscal year 2010 Active Duty recruiting 
mission and 46 percent (425 of 926) of the fiscal year 2010 U.S. Army 
Reserve mission. Mission achievement is most problematic in recruiting 
fully qualified military physicians, where only 18 percent (11 of 60) 
of mission is currently achieved, even given the availability of the 
Critical Wartime Skills Accession Bonus, which ranges from $180,000 to 
$400,000 depending on the specialty. The Army Medical Department 
(AMEDD) is currently short at the grade of Major (O4) across the board. 
This is a function of several phenomena; the most notable being the 
loss of officers in the grade of Captain (O3) who had completed their 
obligation prior to implementation of current retention initiatives, 
thus decreasing the number of officers available to promote to the 
grade of O4. While this grade imbalance is true, each Corps also has 
specific specialty shortages at differing grades, signifying a 
potential capability gap. Resolution of specific shortages is being 
addressed through precision recruiting, training and retention 
initiatives. Recent recruiting success has increased the company grade 
inventory that will increase the inventory at the rank of Major if 
these junior officers are retained, select specialty training and are 
promoted. Current projections for the end of fiscal year 2010 suggest 
that all but the Medical and Dental Corps will exceed the aggregate 
Budgeted End Strength. In fiscal year 2011, the Army G-1 will direct 
the recruiting force to emphasize specific qualifications.
    Mr. Garcia. Navy recruiting for health care professionals in the 
active Component is on track to meet program fiscal year 2010 goals, 
while we continue to experience challenges in recruiting health care 
professionals into the Reserve Component.
Active Component (AC):
    We have reached 57 percent of overall AC health professions officer 
accession goals as of March 1, 2010. Student programs are out-
performing the direct accession programs, continuing last year's strong 
student recruiting:

         Dental Corps: 51.6 percent of goal (77 of 149)
         Medical Corps: 44.5 percent of goal (143 of 321)
         Medical Service Corps: 64.1 percent of goal (143 of 
        223)
         Nurse Corps: 75.5 percent of goal (136 of 180)
Reserve Component (RC):
    We have reached 24 percent of overall RC health professions officer 
accession goals as of March 1, 2010. This remains our most significant 
challenge. We are encouraged by recent authorization to establish a 
bonus for RC Nurse Corps officers, the health professions community 
which has the highest accession goal but the lowest attainment to date. 
We anticipate that implementation of this new incentive will favorably 
impact production.

         Medical Corps: 23.6 percent of goal (140)
         Dental Corps: 24 percent of goal (50)
         Medical Service Corps: 40 percent of goal (45)
         Nurse Corps: 19.4 percent of goal (165)

    As of January 1, 2010, retention rate among Navy health profession 
officers is 93.5 percent AC and 85.3 percent RC. Fiscal year 2010 
brings significant changes to Navy Medical Department's manning, such 
as the military to civilian buyback. Individual Corps status is 
summarized below:

         Medical Corps. AC manning is 97.3 percent and RC 
        manning is 70.5 percent.

                 Shortfalls exist in the following critical 
                wartime specialties: General and Orthopedic Surgery, 
                Family Practice and Psychiatry.

         Dental Corps. AC manning is 89.9 percent and RC 
        manning is 102.0 percent.

                 Shortfalls exist among O3-04 officers and in 
                certain subspecialties: Oral Surgeons, Prosthodontists, 
                General Dentists and Endodontists.

         Medical Service Corps. AC manning is 92.0 percent and 
        RC manning is 93.8 percent.

                 Shortfalls exist in Podiatry and the following 
                critical wartime specialties: Clinical Psychology, 
                Physician's assistant and Social Work.
                 Navy is increasing the number of mental health 
                providers to meet operational demand over the next few 
                years, and the focus remains on filling and retaining 
                critical wartime specialties.
                 USD (P&R) authorized establishment of a Health 
                Professions Officer Special Pay to support accession 
                bonuses for Clinical Psychology, Social Work and 
                Physician's assistant, and retention bonuses for 
                Clinical Psychology and Physician's assistant. This 
                special pay package will be critical to meeting 
                accession and retention goals in these specialties.

         Nurse Corps. AC manning is 90.7 percent and RC manning 
        is 83.7 percent. We continue to see improved retention due to 
        new special pays for critical and undermanned specialties.

    It must be noted that we remain in keen competition with the 
private sector, the Department of Veterans Affairs, as well as with the 
other military departments, for the same finite talent pool.
    Mr. Ginsberg. The snapshot requested is best answered by discussing 
the Air Force Medical Service (AFMS) in general, with focus on specific 
specialties as targeted examples. Of the 189 specialties in the AFMS, 
manning by specialty varies.
    AFMS: Current officer manning as of March 1, 2010 shows officer 
manning at 91.2 percent, which includes medical residents but does not 
include other student categories. The Health Professions Scholarship 
Program (HPSP) continues to remain our primary vehicle for the 
recruitment of entry-level medical and dental officers with 82 percent 
of their fiscal year 2010 scholarships awarded. The Nurse Corps (NC) 
and Biomedical Sciences Corps (BSC) also utilize HPSP as an entry into 
these critical specialties, and 76 percent of these Corps' fiscal year 
2010 scholarships are awarded. It is expected the remaining 
scholarships will be filled at the next selection board. The Medical 
Service Corps (MSC) does not participate in this program.
    Accession of fully qualified (FQ) and experienced health 
professions officers remains problematic. It is much easier to access 
new graduates than residency-trained or specialized health care 
professionals. To date, Air Force Recruiting Service has successfully 
accessed only 35 percent of fiscal year 2010 requirements for FQ health 
professions.
    Retention of health care professionals once their initial 
educational obligation is completed is also very problematic, and 
varies by Corps and by specialties within the Corps. Dental Corps (DC) 
retention after completion of educational obligations is 42 percent, an 
increase of 10 percent since 2004. As a Corps, dental officers show a 
small shortfall at the O-5 ranks, which corresponds to a ripple effect 
from retention problems in past years. This is most pronounced in our 
critically manned Oral Maxillofacial Surgeons with has large defects in 
manning within the O-5 rank for those officers with 14 to 19 years of 
commissioned service.
    The Medical Corps has not shown a significant improvement in 
physician retainability even with the sluggish economy. Retention after 
completion of initial education obligation has not risen. There are 
several critical areas of concern with the MC. Foremost are our general 
and trauma surgeons, where we have limited personnel in the skilled O-5 
rank. As surgical training and educational obligation encompasses the 
O-3 and O-4 rank, we find they leave at their earliest opportunity at 
completion of their military obligation in the O-4 and O-5 rank. 
Another concern is psychiatry with decreased retention at the O-4 rank, 
which produces a ripple shortfall to the O-5 rank. Critically important 
are our family practice and internal medicine specialists where we tend 
to lose the O-4 and O-5 experienced specialists, producing a shortage 
of senior skilled physicians in higher ranks.
    Retention of Nurse Corps specialists is improving with the 
selective use of incentive pays with multi-year contracts. For the 
Nurse Corps in general, we have historically noticed a loss of O-3 
officers. This trend is reflected throughout our clinical nurse 
specialties, but is magnified in our Surgical Nurse specialty where we 
have a loss of O-3 ranks and again at the O-4 rank. The implementation 
of our multi-year incentive contract has just passed its first year and 
we note retention has risen 13 percent since 2008, and now stands at 80 
percent at the 4-year point for the Nurse Corps as a whole.
    Our Biomedical Sciences Corps is the most diverse Corps and 
represents 19 specific specialties. Retention appears to have improved 
for some of these professions, although as a whole, the BSC has 
significant losses in the O3 rank and O4 rank. Early indicators show 
use of the special and incentive pays under the Consolidation of Pays 
authority released in July 2009 are showing increased retention for the 
physician assistant field as attritions in this field have decreased. 
The clinical psychologist specialty has gross losses after their 
initial completion of their initial obligation in the O3 rank, with 
ripple effects throughout the specialty. The public health career field 
also has similar deficits at the O3 rank and struggles to maintain 
adequate retention to meet mission requirements. Many other biomedical 
science career fields are not authorized or funded for special and 
incentive pays, although recruitment and retention of these fields is a 
challenge.
    Retention of the Medical Service Corps is generally not an issue, 
but recently we have noticed a loss trend in O-4 and O-5 rank as 
increasing numbers of personnel with long prior service become eligible 
for retirement with only 10 years of commissioned service. Recent 
changes to the selection process should provide more stability in this 
field.
    In summary, improved recruitment and retention incentives are 
projected to stabilize the chronic manning shortfall of several 
critical health professions specialties. Educational incentives (HPSP, 
FAP, USUHS) are especially successful to fulfill out-year requirements, 
however recruiting FQ health professionals continues to be a challenge.

    17. Senator Graham. Mr. Lamont, Mr. Garcia, and Mr. Ginsberg, what 
is your Service's plan for accomplishing the difficult task of 
recruiting and retaining highly qualified and motivated health care 
professionals?
    Mr. Lamont. The Army will continue to use monetary and nonmonetary 
incentives to recruit and retain sufficient quantity of military and 
civil service behavioral health providers.
    Mr. Garcia. Navy met overall health professions recruiting goals in 
fiscal years 2008 and 2009 and is on track to meet overall Active 
medical goals in 2010. With a 43 percent increase in Reserve Component 
(RC) medical goal in 2010, an increased accession requirement of 121 
providers, we continue to experience challenges in all four RC health 
profession corps.
    We are continuing best practices learned during the past 2 years 
and are implementing several new initiatives that we expect will bear 
fruit in our shortfall areas including:

         Adjusting bonuses and incentives for fully trained 
        medical professionals.
         Participating in the Military Accessions Vital to the 
        National Interest (MAVNI) pilot program to access qualified, 
        legal non-citizen medical doctors.
         Initiating an accession process for legal permanent 
        residents who are qualified physicians or medical students.
         Offering loan repayment opportunities for critical 
        medical specialties.
         Expanding use of medical officers to inform 
        undergraduate and professional medical students across the 
        Nation of opportunities in Navy medicine.
         Adding more full time recruiters to recruiting medical 
        professionals.
         Expanding the Health Service Collegiate Program to 
        include Permanent Residents (green card) in critical student 
        specialties.
         Offering bonuses for clinical psychologists, 
        physician's assistants, and social workers.
         Continuing the Critical Wartime Skills Accession Bonus 
        to target physicians (up to $400,000) and dentists (up to 
        $300,000).

    Navy's most effective tools for retaining health care are special 
and incentive pays. Each of the four Corps (Medical, Dental, Medical 
Service and Nurse) has unique special pays designed to enhance 
retention among their respective health professionals. Other tools 
include training opportunities, age waivers and selective use of 
retired retained officers.

         Medical Corps. The retention challenge for the Medical 
        Corps is maintaining the needed inventory with the proper 
        specialty mix to meet requirements. We are addressing this 
        challenge through targeted use of direct accessions, age 
        waivers, and selective use of retaining retired officers for 
        undermanned critical medical specialties. Multi-year Special 
        Pay (MSP), Additional Special Pay and Board Certified Pay are 
        all critical retention tools the Navy uses to maintain its 
        inventory. Of these, MSP offers the greatest leverage with a 2- 
        to 4-year obligation that enables achievement of proper 
        specialty mix.
         Dental Corps. The Dental Corps is falling short of 
        meeting retention goals. Junior officers are especially 
        difficult to retain. Just as with the Medical Corps, special 
        pays are critical to Dental Corps retention efforts. The Dental 
        Corps has a Critical Skills Retention Bonus for junior 
        officers, which was recently renewed for another 3 years and a 
        multi-year retention bonus targeted at junior officer dentists. 
        Additionally, a Critical Wartime Skills Accession Bonus was 
        approved fiscal year 2010.
         Medical Service Corps (MSC). Fiscal year 2009 gains in 
        MSC exceeded losses for first time since 2002. The overall loss 
        rates are starting to stabilize at 9 percent, but still fall 
        short of meeting the 5-year retention goals. Another retention 
        challenge is retaining the proper specialty mix. MSC retention 
        bonuses were recently approved for clinical psychology and 
        physician's assistants, along with the retention special pay 
        that exists for pharmacists and optometrists. Navy is 
        addressing the retention of mental health and wartime 
        specialties through the Health Professions Loan Repayment 
        program and other special/retention pays.
         Nurse Corps. Retention of Nurse Corps junior officers 
        has been difficult due to issues around work/life balance and 
        long deployments. Navy is working to improve retention through 
        application of new special pays for critically manned and 
        undermanned specialties. Additionally, the Nurse Corps is 
        allowing junior officers to apply for funded training earlier 
        in their career and using the Health Profession Loan repayment 
        program to encourage retention of junior officers.

    Mr. Ginsberg. The specific recruiting challenges faced by the Air 
Force and our plan to overcome those challenges were described in the 
response to Senator Graham's question on the challenge of recruiting 
health professionals in the wartime environment and how we plan to meet 
this challenge. Our future members have many of the same concerns as 
our current members. Retention presents many of the same challenges as 
recruiting. As we attempt to retain our skilled health care 
professionals, the private sector and other Federal agencies, such as 
Department of Veterans Affairs (VA) and Public Health Service, are our 
strongest competitors. Private sector pays, sign-on bonuses, annual 
compensation, and retirement packages are increasing due to the growing 
demand for these skilled professionals. Once the education of our 
health care professionals is completed, the value of these individuals 
is enhanced, leading to significant pay disparities between our members 
and their private sector counterparts. This is especially true for 
those surgical specialties crucial for wartime support. Limited 
compensation packages, limited educational and leadership 
opportunities, limited family and quality of life benefits are all 
areas we hear as reasons for our health professionals leaving the Air 
Force. Similar to the approach we have for recruiting, the Air Force is 
confronting retention challenges with an aggressive three-pronged 
approach to enhance: (1) education, (2) compensation, and (3) quality 
of life.

          (1) Education: Education is an invaluable tool. We continue 
        to find great success in ``growing our own'' through civilian 
        or military-sponsored residency and subspecialty programs, with 
        over 13 percent of the Air Force Medical Service (AFMS) 
        commissioned officers in formal training programs. ``Growing 
        our own'' encompasses the spectrum from accessing new recruits, 
        developing their skills and specialties, to maintaining and 
        expanding on those capabilities for use in both state-of-the-
        art medical centers and in the deployed and austere 
        environments of wartime and humanitarian missions. Our highest 
        retention occurs when we control both the educational 
        environment and the service obligations associated with 
        advanced training programs. Our educational opportunities 
        include aggressive use of subspecialty training and post-
        baccalaureate degree programs for our Nurse Corps, Biomedical 
        Sciences Corps, and Medical Service Corps. Our surgical 
        optimization project partners with VA hospitals and other non-
        Federal facilities. The continuing education of our health care 
        professionals enhances the retention and value of these 
        military members through continuing commitments and service 
        obligations.
          (2) Direct compensation through contractual agreements is 
        another way we retain members, using all available pay 
        authorities equitably amongst the other Services and under the 
        auspices of Health Affairs. By fully funding multi-year 
        contract retention programs with our incentive pay programs, 
        the Air Force affirms its commitment to retaining long-term the 
        best skilled health care professionals. With the exception of 
        our wartime and critical surgical specialties, the total 
        enhanced pay compensation programs are helping to retain mid-
        and senior-level physician specialists. The Air Force 
        investment in health professions special incentive pays totaled 
        $194 million in fiscal year 2008 and $259 million in fiscal 
        year 2009, and $271 million for fiscal year 2010. These 
        increases are having a positive effect on retention. Retention 
        of our Dental Corps specialists has greatly improved over the 
        last 2 years; we look forward to maintaining nearly 100 percent 
        in the near future. Our best successes are with our Nurse 
        Corps, where we appear to be stabilizing after precipitous 
        losses of 11.4 percent annually from fiscal year 2005 to fiscal 
        year 2008. With increased incentives, we lost only 9.5 percent 
        of the Nurse Corps inventory in fiscal year 2009. Various 
        specialties of the Biomedical Sciences Corps, including 
        clinical psychologists and clinical social workers, have 
        recently been funded for incentive pays. Early results indicate 
        these programs are stabilizing also. Incentive packages help 
        offset some of the pay disparities between the military and 
        private sector compensation packages. Although it does not 
        reach parity, it does help ease the burden of multiple 
        deployments. Multi-year contracts under Title 37 allow some 
        stability in the health care professions, especially those with 
        high separation rates. As the incentive pay programs come 
        closer to meeting private sector compensations, we see 
        increased retention of our stressed career fields. At this 
        point, we are close to maximizing the pay authorities of Title 
        37 for many of our most critical wartime specialties, leading 
        us to utilize more of section 335 of Title 37. As we migrate 
        our compensation packages under the new pay authority of 
        section 335 of Title 37, we will finally be able to include 
        other critical specialties previously excluded from incentive 
        and retention pays. We will still be at the threshold ceiling 
        for many critical specialties for the retention bonuses and 
        board certification pay areas. We feel the eventual migration 
        of all our pay programs under section 335 of Title 37 over the 
        next several years will be of great benefit to the Air Force, 
        but we will be unable to compete with private sector 
        compensation packages for many of the critical surgical 
        specialties.
          (3) As our members grapple with decisions to remain in the 
        service, we understand the family is greatly involved. Quality 
        of life issues of family services, availability of schools, 
        frequency of moves and deployments, general base services, and 
        future opportunities are at the forefront of any discussion. We 
        have addressed many of these issues both for the new member, 
        the 20-plus year veteran, or the civil service employee. For 
        those specialties with increasing wartime deployments, we are 
        able to spread the deployment load more evenly among our bases 
        and members. By maintaining our deployments to 6-months in 
        duration, we can stabilize our force and retain more of our 
        skilled assets. Other ongoing projects include the Family 
        Health Initiative, posturing our personnel for our future 
        medical model. We are partnering among intra-AF agencies to 
        build force sustainment models, increase promotions, and 
        develop a proactive approach to retaining the numbers of 
        professionals in each specialty, providing the Air Force a 
        valued tool to reflect our future force.

    While retention of the health professions remains a challenge, we 
remain committed to exercise all available authorities in concert with 
the other Services under Health Affairs to obtain the best value in 
health care for our Nation's military and their family members.

                               pay raise
    18. Senator Graham. Dr. Stanley, the proposed pay raise for fiscal 
year 2011 is only 1.4 percent, but as you point out, matches the rise 
in the Employment Cost Index. What would be the impact on the DOD 
budget, and on the personnel accounts of each of the Services, if 
Congress directed an increase in the pay raise by 1 percent, or even a 
half percent, and did not provide a top-line increase or offsetting 
funding?
    Dr. Stanley. While the Department must and will continue to offer a 
competitive compensation package that recognizes the sacrifice of 
military members and their families, the Department must work closely 
with OMB and Congress to ensure the additional cost hinder 
recapitalization or put additional burden on the American taxpayer.
    Each time the annual pay raise is increased by an additional \1/2\ 
percent, military personnel costs are increased by roughly $0.5 billion 
in the current year and every year thereafter. Without a top-line 
increase, the Department would be forced to sacrifice other programs to 
fund the pay raise.
    The Department supports an increase in the military basic pay of 
1.4 percent, corresponding to the increase in the Employment Cost Index 
but is opposed to an increase in excess of this amount. The pay gap 
between military and private sector compensation has been closed as a 
result of congressionally mandated military basic pay increases of \1/
2\ percent above the ECI over the past decade. Currently, the 
Department believes the full compensation package provided to military 
members compares favorably with counterparts in the private sector.

                       incentives for uav pilots
    19. Senator Graham. Mr. Lamont, Mr. Garcia, and Mr. Ginsberg, the 
importance of improving our surveillance capabilities through unmanned 
aircraft is well understood. Each Service, however, seems to approach 
the issue of who controls--or pilots--such aircraft, and the 
compensation they receive--differently. Please explain how your Service 
handles this issue, and how you are doing in making this an attractive 
career path or skill.
    Mr. Lamont. All Army Unmanned Aircraft Systems (UAS) are operated 
by enlisted personnel in the Military Occupational Specialty (MOS) 15W, 
UAS Operator. MOS 15W is one of the most popular MOSs, and the Army is 
not experiencing problems filling or maintaining its ranks. The 
majority of UAS operators are assigned to maneuver Brigade Combat Teams 
(BCTs), operating the RQ-7 Shadow UAS. These personnel directly support 
ground maneuver commanders, providing intelligence, surveillance, 
reconnaissance, and target acquisition capability. Although the UAS 
community has a small population of Warrant Officers who were prior UAS 
operators, they serve as the tactical and technical UAV systems 
integrators who interface with the ground commanders, and no longer 
function as operators.
    As the Army continues to grow the UAS operator population, the 
capability of the Army to fill and maintain these positions has grown 
along with it. This is a specialty in which the Army has enjoyed 
tremendous success with its enlisted operator community. Given this 
success, there are no plans at this time to request any special or 
incentive pay for UAS operators.
    Mr. Garcia. Marine Corps Unmanned Aerial Vehicle (UAV) Operators 
are enlisted Marines, E1 through E9, assigned Primary MOS 7314. The 
Marine Corps currently reports PMOS 7314 as ``critical'' to OSD due to 
inventory shortages. While there is no Enlistment Bonus to become a UAV 
operator (the Marine Corps does not pay enlistment bonuses for specific 
MOSs), the Marine Corps currently pays high Selective Reenlistment 
Bonuses (SRB) to retain Marines with these skills. Additionally, in the 
fiscal year 2010 Retention Plan, the Marine Corps has opened up 7314 
for qualified Marines from other PMOSs to lateral move into upon 
reenlistment.

                                                                                   Fiscal Year 2010 SRB Rates
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                    Zone A (E3 and                          Zone A (E5 and      Zone B (E5 and      Zone B (E6 and                                              Zone C (E7 and
              PMOS                      Below)            Zone A (E4)           Above)              Below)              Above)            Zone C (E5)         Zone C (E6)           Above)
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
7314............................  $46,500...........  $53,000...........  $58,500...........  $36,000...........  $40,000...........  $38,000...........  $43,500...........  $48,000
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

    The decision on who will pilot Navy's UAVs has not been determined 
as the program is still in its early development phase.
    Mr. Ginsberg. Today's operational requirements for both unmanned 
and manned aircraft demand high level of aviation professionalism from 
both the rated and career enlisted aviator communities. Current 
resourcing methods of manning remotely piloted aircraft (RPA) 
authorizations with traditional undergraduate pilot trained (UPT) 
pilots from other manned weapon systems are unsustainable. As the AF 
continues to grow to 65 RPA Combat Air Patrols (CAPs) by 2013, the 
demand on a stressed inventory of undergraduate pilot trained (UPT) 
pilots competing to fill both manned and unmanned weapon systems 
requirements is falling short. As a result, the Air Force created a new 
rated officer Air Force Specialty Code (AFSC) to categorize RPA pilots 
in a distinct career field and created a unique RPA training pipeline, 
currently being refined through ``BETA Test'' classes. The RPA ``BETA 
Test'' is a potential future alternative to the current UPT method. In 
addition, the Air Force also created a new AFSC to categorize enlisted 
RPA sensor operators in a distinct career field.
    As with other aviation career fields, having the ability to attract 
and retain airmen to these new RPA career fields for a military 
aviation career is instrumental. Due to legislative language in the 
monthly Aviation Career Incentive Pay (ACIP) and Career Enlisted Flyer 
Incentive Pay (CEFIP) authorities, the Air Force is unable to pay new 
RPA pilots and sensor operators ACIP or CEFIP. As a result, by 
memorandum, I authorized implementation of the Air Force's RPA Pilot 
Incentive Pay Program effective 30 November 2009 and the RPA Sensor 
Operator Incentive Pay Program effective 29 January 2010, both 
consistent with approval provided by DUSD (P&R). RPA pilot and sensor 
operator incentive pay is paid monthly under the assignment incentive 
pay (AIP) legislative authority, 10 U.S.C., 307a, and mirrors the 
policy and dollar amounts outlined for paying and receiving ACIP or 
CEFIP. As far as annual bonuses, BETA-trained RPA pilots will not be 
eligible for a retention bonus until the expiration of their 6-year 
training ADSC in 2015. However, to initially grow the enlisted RPA 
sensor operator career field, use of the selective re-enlistment bonus 
(SRB) was deemed necessary to garner volunteers from both the enlisted 
Intelligence and Career Enlisted Aviators (CEAs) career fields.
    The Air Force will continue to evaluate monthly incentive pays and 
annual bonuses as both of the RPA career fields mature.

                               recruiting
    20. Senator Graham. Dr. Stanley and Mr. Lamont, you pointed out in 
your written statement that the Services achieved remarkable success in 
recruiting high school graduates in fiscal year 2009. You also note, 
however, that economic conditions will change and that the Services 
have to be ready to recruit the highest caliber men and women in good 
economic times or bad. The Army looked very hard a few years ago at the 
merits of individuals who wished to enlist, but did not finish high 
school. Similarly, waivers for drug use, minor--and not so minor--
civilian criminal activities and so on, were carefully administered, 
but in much greater numbers than today. What is your assessment of the 
Services' ability to identify individuals with potential for 
outstanding service despite blemishes on their records?
    Dr. Stanley. We are confident processes the Services have in place 
to screen potential recruits are sound. Each Service realizes that 
youthful indiscretions not indicative of moral turpitude are not sound 
predictors of successful service.
    The waiver process used by the Services revolves around the ``whole 
person'' concept and includes extensive screening which takes into 
account many factors, such as the time since the infraction, the actual 
events leading to the infraction, recommendations from members of the 
community (teachers, members of the clergy, neighbors, etc), and face-
to-face interviews with senior leaders. Studies have shown that 
individuals granted enlistment waivers generally perform equally or 
better than their non-waivered counter parts.
    In 2008, the Department issued policy directives that standardize 
the waiver processes and data collection procedures across the 
Services. These changes were designed to improve the process and 
provide the Department with more reliable data for analysis. We have 
recently contracted with the Center for Naval Analyses to study this 
issue further and to provide us with a more current assessment. The 
analysis will be concluded this fall.
    Mr. Lamont. The Army has an excellent process to identify 
individuals who display potential for military service despite 
blemishes on their records. Statistics clearly show there is very 
little risk involved in recruiting individuals with blemishes on their 
records.

    21. Senator Graham. Dr. Stanley and Mr. Lamont, if supply and 
demand dictates varying standards for recruitment, should we not be 
looking continually and over the long run at the metrics that will 
ensure successful recruiting of quality individuals over the long run?
    Dr. Stanley. DOD has proven, long-established Recruit Quality 
Benchmarks, developed under the guidance of the National Academy of 
Sciences. The key metrics for each fiscal year enlistment cohort are: 
90 percent high school diploma graduates (because they have lower 
attrition rates in the first 36-months of Service than other credential 
holders or dropouts); and 60 percent average or above cognitive ability 
(as measured by the Armed Forces Qualification Test because higher 
scoring recruits perform better in training and on the job than lower 
scoring recruits). That said, the Department recognizes the potential 
value of other metrics--such as temperament (personality) 
characteristics of applicants and has been encouraging Service efforts 
to explore such non-cognitive attributes that may be reliably measured 
and predictive of military performance.
    Mr. Lamont. We are experiencing a marked increase in fiscal year 
2008, 2009, and 2010 recruit quality. Part of that increase is based on 
screening metrics. The Army's attempts to screen recruits to predict 
high performance and retention continued last year as we employed the 
Tailored Adaptive Personality Assessment System, a non-cognitive test 
which can be used to predict first term attrition and other 
motivational performance aspects of applicants. Additionally, a recent 
Tier II Attrition Screen (TTAS) report completed by the United States 
Army Accessions Command indicated the TTAS screen could significantly 
reduce the Tier II (Non-High School Diploma Graduate/Alternate 
Credential Holder) 36-month attrition rate. These are two applications 
employed in an effort to sustain the Army's tremendous momentum of 
recruiting high quality individuals. We also commissioned a RAND study 
this year to develop a holistic strategy for the optimal levels and 
balance of recruiting resources that both accounts for the near-term 
recruiting environment and postures the Army for continued longer-term 
quality recruiting success as the environment changes. The results 
should assist the Army with manning the recruiting force and optimally 
employing incentives and deploying resources based on the recruiting 
mission and environment.

            educational opportunities for military children
    22. Senator Graham. Dr. Stanley, last year we received testimony 
from military spouses who were concerned about access to high quality 
education for their children, and in particular, the problem that 
military families experience in moves to remote areas or communities 
where there are few educational options. In your statement you report 
that more than half of the schools serving communities with significant 
military populations do not meet State academic standards in reading 
and math. The National Defense Authorization Act for Fiscal Year 2010 
required DOD to do a study on options to improve educational 
opportunities for military children, including the option of charter 
schools. A report on that study is due to the subcommittee on March 31, 
2010. Are we on track for that?
    Dr. Stanley. The quality of education for the children of our 
servicemembers is extremely important to the Department. I share your 
concern that some families, based on their assignment, may have fewer 
educational choices.
    To address the important question posed within the National Defense 
Authorization Act (NDAA) for Fiscal Year 2010, we are conducting a 
competitive procurement to obtain a reputable and experienced 
contractor in education and military student research. This method of 
conducting the study will provide an unbiased view and expert analysis 
to inform Congress of the Department's progress in this area.
    The procurement process for developing a solicitation which 
includes free and open competition takes approximately 4 months. This 
process began in November, and included collaboration with the U.S. 
Department of Education as the reporting requirement in the NDAA 
required. The solicitation was put out for bidding on March 26. We 
expect to have a contract awarded in May and a report to you by 
December 31, 2010.
    An interim response giving detailed accounts of the Department's 
progress is currently being reviewed and will be delivered to Congress 
in the near future.

    23. Senator Graham. Dr. Stanley, what is your opinion on the option 
of charter schools?
    Dr. Stanley. DOD welcomes parental and community efforts to develop 
and enhance the educational opportunities for all children, especially 
military connected children. These opportunities can include 
traditional public schools, private schools, home school, and charter 
schools.
    DOD supports charter school options on military installations as 
one approach to improving the public schooling of military children.
    Specific examples of DOD's support of charter schools are the three 
Charter Schools currently on military installations, Joint Reserve Base 
New Orleans, Davis Monthan Air Force Base, and Vandenberg Air Force 
Base.

    24. Senator Graham. Dr. Stanley, what would be the advantages of 
DOD looking at this type of public option on military installations?
    Dr. Stanley. An advantage of charter schools on military 
installations is to provide our families with another viable public 
school option when considering where to educate their children. 
Additionally, starting a charter school takes community investment and 
involvement, we encourage our families and leadership to be involved in 
their children's education.
    DOD does not have the authority to establish charter schools. There 
are, however 158 public schools on 68 military installations which are 
not DOD schools. The establishment of charter schools could be another 
alternative.

    25. Senator Graham. Dr. Stanley, can you envision a circumstance in 
which an opportunity scholarship program could address the concerns of 
military families regarding expanded educational options?
    Dr. Stanley. Yes, I can envision a circumstance in which 
opportunity scholarship programs could address military families' 
concerns for expanded educational options. I consider education 
opportunities for military families an important Departmental goal.

    26. Senator Graham. Mr. Ginsberg, I understand that the Air Force 
hosts two charter schools, one at Davis-Monthan in Arizona and one at 
Vandenberg Air Force Base in California. What have you learned in this 
experience; some of the best practices that could be shared, especially 
in terms of funding for facilities and capital expenses, drafting of a 
school's charter or contract, staffing, etc? What unique challenges 
does the Air Force face in establishing carter schools on military 
installations?
    Mr. Ginsberg. The initiatives at Davis-Monthan AFB and Vandenberg 
AFB have worked for those two bases. Davis-Monthan used results from a 
survey of 200 parents to identify interest in, and a need for, an on-
base middle school. The school liaison officer coordinated with base 
leadership including the Plans Office, Civil Engineering, the Legal 
Office, Contracting, and Security Forces to ensure smooth 
implementation of the charter school. The school on Davis-Monthan now 
has 114 students (5 are non-military connected) and is requesting 
future expansion (over 4 years) from grades 6-8 to grades 6-12. The 
school is housed in an existing facility that was previously leased to 
the local school district. The charter school company signed a no-fee 
lease and cares for the property and provides building maintenance.
    Davis-Monthan reports challenges do still exist, especially 
ensuring installation security procedures are communicated to and 
followed by all school personnel, students and parents. Included in 
maintaining these essential procedures is the proper coordination for 
the entrance of non-DOD personnel and school subcontractors onto the 
installation. In addition faculty members who are foreign national 
sometimes required an extended period of time for background checks.
    At Vandenberg AFB, the charter school, located on the base, 
operates as a public school with open enrollment. The base leases the 
school to the local education agency which, in turn, leases the 
building site to Manzanita Charter School. All facility maintenance, 
utilities, etc are paid by the charter school. The base does have 
jurisdiction for law enforcement and contingencies. Manzanita officials 
are very vocal about their continued desire to remain on base due to 
the outstanding relationship built with the military community. 
Military students account for approximately 100 of the 280 children 
enrolled. Parents of the military students are grateful to have the 
choice of attending a Lompoc Unified school District school or the 
Manzanita pubic charter school. Each entity operates off a different 
educational model, enabling parents to choose the best option for their 
child.
    Headquarters Air Force Services recently issued a memo to address 
the establishment of charter schools on or near Air Force 
installations. In an effort to provide standard procedures for Air 
Force base leadership in working with charter school initiatives in 
their communities, installation commanders now contact the Headquarters 
Air Force office with functional responsibility for military-connected 
student programs.

    27. Senator Graham. Dr. Stanley, Mr. Lamont, Mr. Garcia, and Mr. 
Ginsberg, how would you characterize the concerns of military families 
about the quality of education for their children?
    Dr. Stanley. The quality of K-12 education is an important factor 
for military families as they make career decisions on assignments and 
is linked to retention in the military services.
    A significant element of family readiness is an educational system 
which provides not only a quality education but recognizes and responds 
to the unique needs of children of military families.
    Children of military families face distinctive challenges 
unparalleled in the general student population. The most glaring of 
these challenges is the number of transitions military children undergo 
during their school years. Military children move on average six to 
nine times during their K-12 school years. Among the common stresses 
involved in children relocating to a new school are the differences in 
achievement standards, school protocol, course offerings, 
extracurricular activities, and academic requirements.
    These school-based transitions are exacerbated by the challenges of 
leaving a cadre of friends, educators, and caregivers the military 
child has spent months or years establishing. Additionally, one of the 
greatest difficulties military children will face, regardless of 
additional stresses of relocation and school transition, is the effect 
of being apart from one or both parents who may be deployed. All of 
these factors can result in military children suffering in areas of 
school performance and educational attainment.
    The Department offers a variety of support programs and educational 
opportunities to address these concerns.
    Mr. Lamont. Army parents care deeply that their children have 
access to quality educational opportunities despite the frequent moves 
and deployments. Recognizing this importance, one of the five tenets of 
the Army Family Covenant is our commitment to ensure excellence in 
schools. As our children move from State to State, school district to 
district, they encounter different achievement standards, school 
protocols, course offerings, extracurricular activities, and academic 
requirements that may jeopardize their educational progress to include 
high school graduation. These school-based transitions are further 
exacerbated by the challenges of leaving friends, educators, and 
caregivers that the military child has spent months or years 
establishing. Additionally, one of the greatest difficulties military 
children will face, regardless of additional stresses of relocation and 
school transition, is the effect of being apart from one or both 
parents who have been deployed. All of these factors can result in 
military children suffering in areas of school performance and 
educational attainment.
    Army has implemented several programs and initiatives to mitigate 
the effects of deployments and to help ensure smooth educational 
transitions as our children move from one installation to another. Army 
School Liaison Officers serves as advocates for military-connected 
students and assist them through school transitions and with school-
related issues. Academic support services help students compensate for 
parental absences with on-post homework centers, and 24/7 online 
tutoring support for students regardless, of where they live. The Army 
provides specialized training for school personnel to ensure they are 
prepared for the challenges our military students face when their 
parents are deployed. In addition, Military Family Life Consultants, 
licensed mental health clinicians, have been placed in many of the 
public schools that serve large populations of military children, to 
assist students to effectively handle the stress of parental 
deployment.
    Mr. Garcia. Marine Corps and Navy parents rank quality K-12 
education very high on their priorities when making decisions that 
impact their families. It also gets high consideration on their career 
decisions, on assignments, and is linked to retention. One of the first 
areas many of our families explore when notified of a Permanent Change 
of Station (PCS) is the quality of the schools near their new 
installation. A significant element of family readiness is an 
educational system that provides not only a quality education, but also 
one that recognizes and responds to the unique needs of children of 
military families.
    Military children move several times during their K-12 school 
years. Continuous transitions equate to increased difficulties 
integrating into new schools which are usually in different States; 
adjusting to differences in achievement standards, enrollment criteria, 
school policies, and course offerings; access to or eligibility for 
extracurricular activities; and academic requirements for graduation. 
The Interstate Compact for Educational Opportunity for Military 
Children, now signed by 28 States, focuses on leveling the field for 
those issues. The DoN is engaged with the DOD in supporting that 
Compact.
    Mr. Ginsberg. Air Force families across the world include 175,000 
children ages 5-18 and these children generally move more than six to 
nine times during their K-12 school years, often making multiple moves 
in high school years alone. Academic standards, promotion/graduation 
requirements, services for children with special needs, eligibility for 
sports and extracurricular activities, and transfer and acceptance for 
records vary greatly from State to State and even district to district. 
While these are not new issues, national emphasis on quality education 
(as exemplified by strong interest in the re-authorization of the 
Elementary and Secondary Education Act), and higher standards for 
admission to many post high school education and training institutions 
increase the stakes like never before. In addition, the added stress of 
family separation due to deployments (recent study indicates 37 percent 
of children worry about safety of the deployed parent) has combined 
with transition issues to increase the need for providing information 
and support to military families dealing with military child education 
issues.
    Air Force families are no different than civilian families in that 
concern for the general well-being of their children is a primary 
driver in their lives. A major part of this sense of well-being is 
availability of quality education opportunities. Most of our families 
are fortunate to be located in areas where the local school districts 
(and overseas, the DODDS schools) provide a positive educational 
experience. In areas where that is not the case, our families have 
proven very proactive and resourceful in working with school liaison 
officers, installation leadership, local education agencies and others 
to find suitable educational augments or options.

    28. Senator Graham. Dr. Stanley, Mr. Lamont, Mr Garcia, and Mr. 
Ginsberg, what thoughts do you have on ideas that could lead to better 
options, including establishing charter schools or offering opportunity 
scholarships on military installations?
    Dr. Stanley. My ideas for better educational options include 
support for charter schools, DOD partnership with Department of 
Education, and an interagency collaboration.
    DOD supports charter school options on military installations as 
one approach to improving the public schooling of military kids. Like 
all parents, military parents want quality education for their 
children. A significant element of family readiness is an educational 
system that provides not only a quality education but one that 
recognizes and responds to the unique needs of children of military 
families.
    The Department is working on a collaborative Educational 
Partnership Initiative with the Department of Education in efforts to 
ease the transition of military students and to provide resources to 
local education agencies (LEA) who educate military children. DOD 
expanded mission is a proactive approach to addressing the issue of the 
availability of quality educational opportunities for military 
children.
    The Department is represented on the National Security Council 
Military Family Interagency Policy Committee (IPC) that has been 
established as part of the President's commitment to military families. 
This administration-wide effort is essential to focus the strengths of 
the various departments and agencies toward supporting and enriching 
the lives of our military families, including transition, achievement, 
and expanding educational options for military children.
    Mr. Lamont. While Army has no authority or expertise to establish 
charter schools, we fully support charter school options on military 
installations as one avenue to improve the educational achievement of 
military students and meet their unique needs. Using another approach, 
Army is an active participant in DOD's formal partnership with the 
Department of Education in an effort to ease the transition of military 
students and provide resources to local education agencies who educate 
military children. In June 2008, the Deputy Secretaries of Defense and 
Education signed a Memorandum of Understanding (MOU) to create a formal 
partnership between the two departments to support the education of 
military students. The MOU provides a comprehensive and cohesive 
structure for collaboration between the two Federal agencies as well as 
with local, State, and other relevant entities. Through the MOU, the 
agencies can now leverage their coordinated strengths to improve the 
educational opportunities of military connected students.
    Mr. Garcia. Navy and Marine Corps parents' desire for access to a 
quality K12 education is no different than most other parents. With our 
sailors and marines already experiencing a high state of readiness, 
regular relocations, and multiple/extended deployments, it is 
particularly important that Services do all they can to support access 
to quality education for their children. It is essential that we 
explore alternatives. However, the DoN does not have the authority, nor 
the required resources, to establish charter schools.
    Through recent improvements in the provision of civilian School 
Liaison Officers (SLO) at installations, an emphasis on Exceptional 
Family Member services, better collaboration with Local Educational 
Authorities (LEAs) through the Educational Partnership Initiative, and 
connections to the military liaisons working with States on the 
Interstate Compact, we've made great strides toward smoothing 
transitions for our students. A number of parents have opted to home 
school their children. While a viable option, it adds additional 
stressors to parents who are already experiencing difficulties and can 
even add to the economic burden of the family when a spouse must leave 
paid employment to educate their children. Our SLOs are helping by 
providing home school parents with linkages to networks and resources.
    The DoN supported the 2008 Memorandum of Understanding between DOD 
and the Department of Education which created a formal partnership to 
support the needs of military children. The DoN continues to work 
closely with DOD and the Department of Defense Education Activity 
(DODEA) on collaboration between local, State, and other agencies to 
support the educational opportunities of military children.
    Both the Navy and the Marine Corps will continue to place a high 
emphasis on collaborative relationships between military families and 
their LEAs and seek to find resolutions at the local level.
    Mr. Ginsberg. Installation commanders are encouraged to support 
parental and community efforts to develop/enhance learning 
opportunities for all children and especially military connected 
students. These opportunities can include traditional public schools, 
private schools, virtual schools, home schools, and charter schools.
    Headquarters Air Force Services recently issued a memo to address 
the establishment of charter schools on or near Air Force 
installations. In an effort to provide standard procedures for Air 
Force base leadership in working with charter school initiatives in 
their communities, installation commanders now contact the Headquarters 
Air Force office with functional responsibility for military connected 
student programs. This office provides procedural guidance and 
coordinates with other headquarters offices on related issues such as 
use/lease of Air Force facilities. This policy insures a positive, 
standardized approach to support of charter schools and other 
educational options for military-connected students.
    Air Force also works closely with the DODEA Educational Partnership 
Initiative, providing input and advocating for grants and other support 
to school districts that educate military-connected students. We 
believe this proactive approach will strengthen educational options 
within local education agencies for not just Air Force children but all 
students within these districts.

                              legislation
    29. Senator Graham. Dr. Stanley, Mr. Lamont, Mr. Garcia, and Mr. 
Ginsberg, do you need any additional legislation in order for the DOD 
to move forward?
    Dr. Stanley. No, other than the fiscal year 2011 Omnibus 
legislative proposals submitted to Congress no further legislative 
adjustments for my organization, the Office of the Under Secretary of 
Defense (Personnel and Readiness), are needed at this time. If 
additional authority is required, the Department will follow the formal 
channels to work with Congress.
    Mr. Lamont. The Department is continually assessing the need for 
additional legislation. As we reach consensus as to what legislative 
changes will help DOD move forward, we will certainly communicate those 
recommendations to Congress.
    Mr. Garcia. The Department of Navy is not currently seeking new 
legislative authorities. If new legislative requirements are 
identified, we will propose their inclusion in the Defense Legislative 
Program.
    Mr. Ginsberg. Yes. Compressed Orderly Rapid Equitable Replacement
    DOD has transmitted a proposal to authorize the Secretary of 
Defense and the Air Force specifically to conduct an alternate, 
streamlined Equal Opportunity complaint processing system similar to a 
highly successful pilot program the Air Force conducted from 2005-2007 
pursuant to a congressional mandate. This system is completely optional 
for the complainant, stresses early dispute resolution, consolidates 
processes in the administrative stage and preserves the complainant's 
full right to appeal to the Equal Employment Opportunity Commission and 
to bring suit in Federal court. According to a June 2008 DOD report to 
the Government Accountability Office report, the previous pilot cut 
processing times for cases that used this alternate system by 
approximately 50 percent (from 216 calendar days to 109). We
found this to be an effective tool in addressing the chronic problem of 
excessive time to process these complaints. It saves resources and 
leads to a quicker resolution of the complainant allowing complainants, 
coworkers and managers involved to return their full focus to the 
mission. We would ask that this legislation be favorably considered.

    [Whereupon, at 12:41 p.m., the subcommittee adjourned.]


DEPARTMENT OF DEFENSE AUTHORIZATION FOR APPROPRIATIONS FOR FISCAL YEAR 
                                  2011

                              ----------                              


                       WEDNESDAY, MARCH 24, 2010

                               U.S. Senate,
                         Subcommittee on Personnel,
                               Committee on Armed Services,
                                                    Washington, DC.

       MILITARY HEALTH SYSTEM PROGRAMS, POLICIES, AND INITIATIVES

    The subcommittee met, pursuant to notice, at 10:02 a.m. in 
room SR-232A, Russell Senate Office Building, Senator Jim Webb 
(chairman of the subcommittee) presiding.
    Committee members present: Senators Webb, McCaskill, 
Begich, Graham, and Thune.
    Also present: Senator Cardin.
    Majority staff members present: Jonathan D. Clark, counsel; 
Gabriella Eisen, counsel; and Gerald J. Leeling, counsel.
    Minority staff members present: Diana G. Tabler, 
professional staff member; and Richard F. Walsh, minority 
counsel.
    Staff assistants present: Paul J. Hubbard and Jennifer R. 
Knowles.
    Committee members' assistants present: Nick Ikeda, 
assistant to Senator Akaka; Gordon I. Peterson, assistant to 
Senator Webb; Tressa Guenov, assistant to Senator McCaskill; 
Lindsay Kavanaugh, assistant to Senator Begich; and Walt Kuhn, 
assistant to Senator Graham.

        OPENING STATEMENT OF SENATOR JIM WEBB, CHAIRMAN

    Senator Webb. Good morning. The subcommittee meets today to 
receive testimony on Military Health System programs, policies, 
and initiatives in review of the National Defense Authorization 
Request for Fiscal Year 2011 and the Future Years Defense 
Program.
    The Military Health System serves a population of more than 
9.5 million eligible beneficiaries, both in military treatment 
facilities and through contracted private-sector care.
    The primary mission of the Military Health System is to 
maintain the health and readiness of our Active Duty military 
personnel, both at home and on the battlefield. The system also 
provides medical care for millions of dependents of Active Duty 
personnel, military retirees and their dependents, certain 
Guard and Reserve members and their families, and others.
    As one who's spent most of his life in and around the 
military, I note the presence of the ranking Republican.
    Senator Graham. Thanks for starting on time.
    Senator Webb. Yes.
    I care deeply about our special obligation to provide our 
military servicemembers, their families, retirees, and our 
veterans with the finest healthcare treatment available.
    For this reason, I introduced a companion bill in the 
Senate on Monday, when it was recognized that legislation was 
needed to explicitly state in the law that TRICARE and 
Department of Defense (DOD) nonappropriated-fund health plans 
meet the minimum essential coverage for individual healthcare 
insurance required by the healthcare reform bill. My bill was 
based on one introduced in the House of Representatives last 
Friday by Congressman Skelton.
    I appreciate the support demonstrated by Senator Graham and 
other members of this subcommittee for this bipartisan 
legislation. The measure was hotlined last night. I'm hopeful 
that our members will agree to pass it soon so that we can take 
this issue off the table as a matter of concern for our 
servicemembers, their families, and other beneficiaries.
    Nine years of conflict have stressed our military in ways 
that were not contemplated at the inception of the All-
Volunteer Force. As I noted 3 years ago, and again 2 weeks ago, 
during this subcommittee's initial hearing in this session, we 
are in uncharted territory as a result of past rotation cycles, 
multiple combat deployments, and an unsatisfactory deployment-
to-dwell ratio.
    Many of you will remember that I introduced what was called 
dwell time legislation 3 years ago, trying to put a safety net 
underneath our military members being deployed when the 
rotational cycles went below 1 to 1, although traditionally 
they were supposed to be, and have been, around 2 to 1--2 years 
home for every year deployed, 1 year home for every 6 months 
deployed.
    A lot of people at that time, I think, interpreted this 
legislation as politically motivated. I can say again, and 
reaffirm today, that it was not, that the well-being and proper 
leadership of our men and women in uniform is not the sole 
prerogative or the sole responsibility of our military 
commanders. The circumstances under which they serve, where, 
for how long, and under what conditions is very much the 
subject of the stewardship of Congress.
    My perspective on this issue is also shaped by 4 years 
spent as a counsel to the House Committee on Veterans' Affairs, 
when we did pioneering work in the areas of post-traumatic 
stress disorder (PTSD) and other issues posing long-term 
consequences for veterans of the Vietnam war.
    During the past 3 years, we've seen a marked improvement in 
areas such as the treatment of traumatic brain injury (TBI) and 
wounded warrior care management, but the Military Health System 
is still a work in progress. It's not enough simply to provide 
healthcare. It must also be the most appropriate and effective 
professional care given in a timely way. In this regard, I 
believe it's always important to point out our appreciation to 
the healthcare providers in each branch of the Armed Forces who 
treat and stabilize servicemembers wounded in battle. Our 
dedicated medical teams bring wounded warriors from the 
battlefield to the operating room within what is called the 
``golden hour,'' enabling our medical professionals to achieve 
the best wartime survival rates, by far, in our Nation's 
history.
    The budget request for fiscal year 2011 includes more than 
a billion dollars for research into TBI and PTSD. Last year, 
the Army established a Warrior Transition Command to oversee 
the care and management of wounded, ill, and injured soldiers. 
The Navy and Marine Corps created programs, such as the Marine 
Corps Wounded Warrior Regiments and the Navy's Safe Harbor, to 
support a full-spectrum recovery process for sailors, marines, 
and their families.
    Our most pressing concern is the health of our 
servicemembers who are deployed, and who have been deployed 
repeatedly. Despite shortages of healthcare professionals, we 
must adequately assess the medical condition of our 
servicemembers, before and after they deploy, to include 
effective mental health screenings.
    We've seen recent reports of increased prescription drug 
use that are deeply troubling. In fact, the data is stunning, 
when you look at it. According to an article published this 
month by the Military Times, at least one in six servicemembers 
is on some form of psychiatric-related drug. The newspaper 
reported that the use of such medications is estimated to have 
increased by 76 percent since combat operations began in 
Afghanistan and Iraq, with antipsychotic prescriptions more 
than tripling from 2001 to 2009. Whether these drugs are 
antidepressants, pain medications, muscle relaxants, or 
antianxiety drugs, we really do need to understand the dynamic 
of this problem. We look to today's witnesses to help us 
understand the scope of these alarming trends and to describe 
what is being done to address them.
    I would say that there is a larger issue in play here that 
I have a great deal of concern about, and that is the 
transparency of what is actually happening to our Active Duty 
military when they are deployed, whether it is in the context 
of the combat operations that they are in, the living 
circumstances that they have in these deployed areas, or issues 
such as this.
    This subcommittee is also hearing reports of increased 
substance abuse, growing numbers of servicemembers with 
emotional difficulties across the Services, and a lack of 
access to mental healthcare. It's not enough to address these 
issues piecemeal, we must approach them holistically, because 
their effects, clearly, tend to overlap.
    At a hearing held by the Personnel Subcommittee last year, 
we were told by a number of military spouses that access to 
healthcare, including access to mental healthcare and specialty 
care, was a top concern. Clearly, our servicemembers must be 
secure in the knowledge that their family members are receiving 
the medical care that they need.
    We must also be mindful of the cost of providing this care. 
Secretary Gates said last year that ``healthcare is eating the 
Department alive.'' This year, he stated his desire to ``work 
with Congress, in figuring out a way to bring some modest 
control to this program.''
    We welcome any suggestions the Department and the Services 
may have to address the steadily increasing costs of providing 
healthcare under the Military Health System.
    Our military men and women in uniform and their families 
have given much to this country. We must do everything we can 
to ensure that they continue to receive the finest healthcare 
available. We cannot achieve that goal without open 
communication with DOD and with the Services. If we are not 
aware of a problem, we cannot be a part of a solution.
    I'd like now to recognize our ranking member, Senator 
Graham, if he has any opening statement.
    Senator Graham.
    Senator Graham. Thank you, Mr. Chairman, for holding this 
hearing.
    I'll tell you what, I'll just work my comments in with the 
witnesses. I know Senator Cardin is a busy man. I look forward 
to hearing what he has to say.
    Senator Webb. Without objection, all witness written 
testimony submitted for today's hearing will be included in the 
record.
    In addition, the National Military Family Association and 
Georgetown University Medical Center's Palliative Care Program 
have submitted testimony, and, without objection, this will 
also be included in the record.
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    Senator Webb. I'm very pleased to introduce our colleague, 
Senator Ben Cardin, who is the lone witness on our first panel. 
Senator Cardin shares with me a great concern about the 
dramatic increase in the use of prescription drugs by 
servicemembers. I would like to express my appreciation to 
Senator Cardin, for having really gotten out in front of this 
issue and helped make all of us aware of the data that ended up 
being reported in USA Today. I invited him. I sought his 
testimony today. I would like to welcome you, this morning.
    Senator Cardin.

  STATEMENT OF HON. BENJAMIN L. CARDIN, U.S. SENATOR FROM THE 
                       STATE OF MARYLAND

    Senator Cardin. Chairman Webb, first of all, thank you very 
much for holding this hearing and for your interest in this 
subject.
    Senator Graham, thank you for your continued interest in 
fighting for our soldiers in so many different ways. I'm 
honored to be before your committee, and I bring to your 
attention a serious issue concerning the health of our combat 
troops and how the military is dealing with the stress of 
combat and repeated deployments.
    There are some very disturbing statistics that the chairman 
mentioned in his opening statement. Let me try to just fill in 
a few more of the details. In 2009, there were 160 Active Duty 
Army suicides. That's a 15 percent increase from the previous 
year. We have an alarming use in the increase of 
antidepressants. In 2005, there were a little over 4,000 combat 
troops using antidepressants. That's about 1 percent. By 2007, 
it grew to over 19,000, or 5 percent, of our troops on 
antidepressants. That's a huge increase in the use of 
antidepressants, and that number remained pretty constant for 
2008.
    We do know that there is information that's been made 
available to us. I can cite just one source. The Army's Fifth 
Mental Health Advisory Team tells us that the use of 
antidepressants and sleeping pills of our combat troops in Iraq 
is 12 percent, and our combat troops in Afghanistan is 17 
percent. Mr. Chairman, as you said, one out of every six. We 
know that there's a huge number of those that are using these 
types of medications.
    There's a real question as to whether they're receiving the 
proper medical supervision, the proper monitoring. This is 
particularly true during the first 6 weeks, when medications 
are taken and when your body adjusts to the medicines that 
you're taking, so that the adverse reactions are less likely.
    In combat, the antidepressant that's most likely used is 
selective serotonin reuptake inhibitors (SSRI). Since 2004, the 
Food and Drug Administration (FDA) has required a warning on 
the use of these types of antidepressants by the increased risk 
of suicidal thoughts. The vulnerable age that the FDA tells us 
is 18 to 24. Forty-one percent of those deployed in Iraq and 
Afghanistan fall within that age group, which should have all 
of us concerned.
    I want to say, I think DOD has made some strides in the 
right direction. As part of the National Defense Authorization 
Act for Fiscal Year 2010, I offered an amendment that requested 
information to be made available to our congressional 
committees on the numbers taking these drugs over the next 5-
year period. It was included in the Senate version. It was not 
included in the conference version. I did send a letter to 
Secretary Gates, and I want to compliment Secretary Gates. He 
supplied the information to my office. I have had a chance to 
talk to him personally. I think he understands the seriousness 
of this matter.
    There's been significant improvements in the predeployment 
screening for healthcare issues for our soldiers before they go 
to combat. There's been post-deployment healthcare assessment 
and treatment. I acknowledge that. But, I still think we need 
DOD's help in trying to understand what is happening, as far as 
the use of these prescribed drugs.
    We have a lot of dots, but we haven't connected the dots. I 
really do ask this committee, and I'll be asking my colleagues 
in the Senate, to help in trying to understand what is 
happening here. Why has there been such a large increase in the 
use of antidepressants? I think we need to have the answers to 
the questions. We need to know whether there is proper medical 
supervision for those who are taking prescribed 
antidepressants. We need to know what the policy is for those 
soldiers that are in combat. If they start on antidepressants, 
what is the policy of the military during those first 6 weeks? 
Are they to be sent into combat itself, again, there is a 
particular vulnerability during that 6-week period. I'm not 
aware if there is a policy, and I think this committee needs to 
know, and the U.S. Senate needs to know.
    I think we need to have a better understanding of the 
relationship between the use of antidepressants and suicide 
within the military. I would urge us to make the resources 
available for a scientific study, with peer review, so that we 
can try to connect the dots. I think we need to know whether 
there are other treatment options, rather than the use of 
prescribed medicines. I certainly would urge us to request 
relevant data be made available to Congress on the use of 
antidepressants, so that we can be part of the oversight 
responsibilities that we have as Members of the U.S. Senate.
    I look forward to working with the committee. I look 
forward to working with my two colleagues. I think this is an 
important issue, and I thank you for giving it attention.
    [The prepared statement of Senator Cardin follows:]
            Prepared Statement by Senator Benjamin L. Cardin
    Chairman Webb, Ranking Member Graham and distinguished members of 
the subcommittee: thank you for your invitation to appear before you 
this morning.
    I am pleased to have this opportunity to discuss with you the issue 
of the deteriorating mental health of so many of our combat troops. On 
behalf of the American families whose loved ones have gone into harms 
way I come before you today to discuss the strains that have been 
placed upon our All-Volunteer Force.
    In 2009, an unprecedented 160 Active-Duty Army suicides were 
reported, representing a 15 percent increase over the previous year. In 
response to this growing concern I proposed an amendment (#1475) to the 
2010 National Defense Authorization Act (NDAA) which would have 
required the Department of Defense to report to Congress annually, for 
the next 5 years, the number and percentage of servicemembers who were 
prescribed antidepressant medications while serving in Iraq and 
Afghanistan. It would have also required that a study be initiated to 
investigate the relationship between the increased number of suicides 
and attempted suicides by members of the Armed Forces and the increased 
number of antidepressants and other behavior modifying prescriptions 
being used to treat anxiety for our combat troops.
    This amendment was successfully accepted into the Senate's version 
of the NDAA, but was unfortunately removed during the conference 
process.
    As a follow-up to my amendment, I also sent a letter to Defense 
Secretary Gates last November, asking him to provide details on the 
number of troops being prescribed antidepressant medications while 
serving in Iraq and Afghanistan. The intent of this letter was to get a 
preliminary assessment of the number of troops being affected by the 
Department of Defense's (DOD) policies on mental health care in 
theater. This information, when coupled with the committee's 
requirement for the DOD to demonstrate their policies on how they 
manage patients prescribed antidepressants in-theater, would begin to 
provide insight into how the DOD was addressing this significant issue.
    As background to this discussion, I would like to first invite your 
attention to the following information. In October 2004, the Food and 
Drug Administration (FDA) directed manufacturers of a certain class of 
anti-depressants known as Selective Serotonin Reuptake Inhibitors--
commonly referred to as SSRIs--to add a black box warning that alerted 
the public to the increased risk of suicidal thoughts by children and 
adolescents. By May 2007, the FDA further directed that the warning be 
extended to include young adults from ages 18 to 24, with an emphasis 
towards the first 6 weeks of initiating treatment.
    The FDA's decision to extend the black box warning was the result 
of scientific findings that children with major depressive disorders 
showed significant increases in the risk of ``possible suicidal 
ideation and suicidal behavior.'' An additional analysis indicated a 
one-and-a-half fold increase in the potential for suicide in the 18-24 
year old age group. For the purpose of today's hearing, it is 
critically important to understand that this same age group--18-24 year 
olds--comprises about 41 percent of our young men and women currently 
deployed to Iraq and Afghanistan.
    Now, during the 2005 to 2008 time period (the last year full data 
were provided by the DOD) there was a 400 percent increase in the 
prescription of antidepressants and other drugs used to treat anxiety--
a disproportionate number of which are the SSRIs I just described. Of 
the 18,155 troops taking antidepressants while on deployment in 2008, 
98.5 percent of them initiated the use of the drug while on deployment.
    Data contained in the Army's Fifth Mental Health Advisory Team 
Report indicate that roughly 12 percent of combat troops in Iraq and 17 
percent of those in Afghanistan were taking prescription 
antidepressants or sleeping pills to help them cope with the stress of 
their deployments. While the sixth report--released in late 2009 from 
this same group of mental health professionals--shows that the suicide 
rate in Iraq had since stabilized, it more tellingly indicates that the 
suicide rate in Afghanistan doubled during the same timeframe.
    It bears repeating that military personnel, who are being called 
upon to serve in a forward deployed combat area, often for up to a 
year-long deployment, are being prescribed medications with a warning 
that indicates potential side effects which include an increased risk 
of suicide as well as aggressive, angry, or violent behavior.
    This deeply concerns me, and it should equally concern those who 
are responsible for the long-term mental health of our servicemembers.
    I submit, for your consideration, the following questions that I 
hope you will agree merit a response from those charged with caring for 
these young men and women:

         If the DOD is medicating personnel in forward deployed 
        combat areas, how are they maintaining the necessary oversight 
        of these soldiers, sailors, and marines, especially during the 
        initial 6-week window when the increased risk of suicidal 
        thoughts is said to occur?
         Are these personnel removed from combat status? (At 
        least during the first 6 weeks of medication).
         Who makes the determination of whether a servicemember 
        undergoing mental health treatment in-theatre is deemed fit-
        for-duty? Is it the physician or mental health professional, or 
        is it the servicemember's operational commander, and if so, is 
        this the right person to make that decision? Why?

    Let me in closing recognize that the DOD has made significant 
strides in addressing both its pre-deployment health care screenings 
and its post-deployment health care follow-ups and treatment when 
necessary. It has also achieved many positive steps towards 
destigmatizing the process of seeking and obtaining mental health care 
for our troops.
    In light of this, I recognize that to move forward with a review of 
DOD's procedures, great caution must be exercised so as to avoid 
undoing the progress that has been made. Due diligence, however, 
dictates that Congress utilize its oversight authority in this matter 
and investigate whether the DOD's current policies regarding the use of 
prescription antidepressant drugs--most notably those known adverse 
side effects--pose an unacceptably high risk to our troops--especially 
while they are serving in forward operating areas.
    Since the beginning of the current conflicts there has been a 
steady increase in the number of suicides and suicide attempts by 
current and past members of our Armed Forces. We have been told that 
there is no one reason for this increase, but rather a combination of 
causes and stressors. However, we cannot ignore that this has occurred 
at the same time as we have witnessed a four-fold increase in the 
number of psychiatric medications being prescribed to our men and women 
serving in combat areas.
    Admittedly, much debate continues within the scientific and mental 
healthcare communities over the potential relationship and extent 
between the use of psychiatric medication and suicide.
    Mr. Chairman, we owe it to our servicemembers--past, present, and 
future--and to their families, to do everything in our power to ensure 
that the mental healthcare they receive is the best our Nation can 
offer. For this reason, I ask that you and the rest of my Senate 
colleagues will again consider requiring the implementation of an 
annual reporting mechanism for DOD to come before Congress and disclose 
the extent to which it is employing antidepressant medications to treat 
the wartime stress and overall mental health of our service men and 
women. I would also ask that the DOD be directed and sufficiently 
funded to contract for a scientific, peer-reviewable study of the 
potential relationship between this increased use of antidepressant 
medications and the increased number of military suicides.
    I thank you again Mr. Chairman, Ranking Member Graham, and the 
distinguished members of this subcommittee. I hope that my testimony 
before you today has been truly enlightening, and will serve as a call 
to action on this important issue.

    Senator Webb. Senator Cardin, thank you very much for 
having worked so hard to bring this matter to the attention of 
the Senate and of Congress. You have our commitment that we 
will be working on it. We will actually be seeking observations 
of the witnesses that follow you today.
    Thank you for being with us.
    Senator Cardin. Thank you.
    Senator Graham. Thank you, Senator. What you're pointing 
out is very important to the country, and I appreciate your 
interest, and we'll get some answers to these real legitimate 
questions.
    Senator Cardin. Appreciate it.
    Senator Webb. I'm pleased now to welcome and introduce the 
witnesses for our second panel. They are Dr. Charles L. Rice, 
who is performing the duties of the Assistant Secretary of 
Defense for Health Affairs and Acting Director of TRICARE 
Management Activity--you could join us as we announce your 
names--Rear Admiral Christine Hunter, U.S. Navy, Deputy 
Director of TRICARE Management Activity; Lieutenant General 
Eric B. Schoomaker, U.S. Army, Surgeon General of the Army and 
Commander of U.S. Army Medical Command; Vice Admiral Adam 
Robinson, Jr., U.S. Navy, Surgeon General of the Navy, and 
Chief of the Navy Bureau of Medicine and Surgery; Lieutenant 
General Charles B. Green, U.S. Air Force, Surgeon General of 
the Air Force; and Rear Admiral Richard R. Jeffries, U.S. Navy, 
who is the Medical Officer of the U.S. Marine Corps.
    I'd like to thank all of you for joining us today to 
discuss the vital issues associated with military healthcare. I 
would like to ask Dr. Rice to begin the panel's opening 
statements. Unless there's some special protocol, maybe we 
could just work across the table.
    Senator Graham. Sounds good to me.
    Senator Webb. Welcome to you all.
    Dr. Rice, the floor is yours.

 STATEMENT OF CHARLES L. RICE, M.D., PERFORMING THE DUTIES OF 
  THE ASSISTANT SECRETARY OF DEFENSE FOR HEALTH AFFAIRS, AND 
          ACTING DIRECTOR, TRICARE MANAGEMENT ACTIVITY

    Dr. Rice. Thank you, Mr. Chairman, Senator Graham, for the 
opportunity to come before you today.
    Late February, I was asked by Dr. Stanley, the Under 
Secretary of Defense for Personnel and Readiness, to perform 
the duties of the Assistant Secretary of Defense for Health 
Affairs, stepping away from my permanent position as the 
President of the Uniformed Services University until President 
Obama's choice for this job is confirmed by the Senate and 
sworn in, whereupon I will happily return to Uniformed Services 
University.
    I'm honored to be here and to be able to represent the men 
and women who serve in our Military Health System and deeply 
appreciative of the support you have always provided military 
medicine and for your unwavering support to the University.
    I have submitted my written comments to the committee, and 
with your indulgence, I'd like to make just some very brief 
opening remarks.
    I approach my role as the senior medical advisor to 
Secretary Gates and Secretary Stanley with advantages of 
multiple perspectives. As a trauma surgeon, as an educator, as 
a retired Navy medical officer, and, like you, Mr. Chairman, as 
the father of an Active Duty servicemember, this issue is 
personal to me.
    There is much to be proud of in the Military Healthcare 
System. The performance of our military medics in combat 
remains nothing short of remarkable. In addition to the 
lifesaving care on the battlefield, we're continuously 
improving the medical readiness of the total force.
    We monitor and record the health of servicemembers in the 
most comprehensive manner ever witnessed throughout the cycle 
of deployment, before, during, and after their service in 
combat theaters. Despite the breakneck pace of combat, our 
medical personnel have responded heroically to natural 
disasters in Haiti and Chile.
    I know that you share this pride in the people who serve 
our Nation, and so, today I want to focus on those areas where 
greater attention is required from me, so that you will 
understand where I focus my energies.
    First, our deepest obligations are reserved for the 
casualties returning to the United States and to their families 
and the caregivers who support them. Substantial progress has 
been made since problems with wounded warrior support first 
came to light in 2007. This committee has played an important 
role for driving change, standing up new programs, and ensuring 
substantial new resources to address any shortcomings. We are 
grateful for that.
    More needs to happen on our end to ensure that the 
programs, services, health information, and communication are 
knitted together more tightly so that we can provide more clear 
and cohesive services to those families who continue to 
sacrifice so much.
    Second, I am intently focused on the performance and the 
perception of our electronic health record, AHLTA. My intent is 
not to micromanage the many technological issues, but to 
determine whether our proposed solutions will result in better 
capability for our providers--nurses, physicians, pharmacists--
all the key members of the healthcare team, and to deliver 
value for patients. The key test for a successful electronic 
health record is whether it leads to better quality care. If 
our current effort fails that test, we will find one that can 
deliver on that crucial expectation.
    Third, the Department continues to implement the broad 
changes required by the 2005 Base Realignment and Closure 
Commission. Our approach to the right organizational construct 
and how we build medical facilities design must result in 
better service, better quality, and better access for our 
patients. Investments in evidence-based design concepts for our 
new facilities are critically important. They offer a better 
healing environment for patients and for their families.
    The hospital at Fort Belvoir will be a showcase for this 
new approach. I was there last week with General Schoomaker and 
was truly dazzled by the design concepts that have been 
incorporated to create an unmatched healing environment. If you 
haven't been down to see it, I urge you to try to work a visit 
in to your busy schedules.
    In addition to design, we need to better integrate service 
delivery across the military branches, an effort that will 
require sustained effort in decisions in the months ahead to 
better serve our patients.
    Fourth, we're working to resolve the serious matters 
identified in the protests upheld by the Government 
Accountability Office (GAO) regarding the TRICARE system 
contract awards. While the issues that we must address are 
serious, I am reassured, and want to reassure you, that the 
internal issues affecting these awards have not affected the 
day-to-day service for our beneficiaries. Nonetheless, our 
efforts to control TRICARE cost growth are closely linked to 
the effective implementation of new contracts. It is in the 
best interests of the government and of the organizations who 
are involved in these contract decisions to move toward a 
definitive conclusion. I'm grateful to Admiral Hunter for her 
leadership in this area.
    Finally, I'd like to briefly comment on the larger issue of 
national healthcare reform that you alluded to, Mr. Chairman. 
It has been the focus of much attention this week. Although the 
Military Health System is in many ways a unique system of care, 
we do not function apart from the civilian healthcare system 
used by the American people. In fact, almost 70 percent of the 
care our beneficiaries receive is delivered by our civilian 
colleagues.
    TRICARE benefits will not be affected at all by the passage 
of reform. We know that the DOD medical benefit is, 
appropriately, one of the most comprehensive medical benefits 
of any employer. One visit to Walter Reed or Bethesda 
demonstrates why this should be so more than any words I can 
offer here.
    Yet, there are other potential benefits that will accrue to 
the Department when more Americans are covered by insurance. 
This includes a more medically fit recruiting pool, greater 
investments in comparative effectiveness research that will 
help all practitioners of care with delivering scientifically 
valid approaches to medicine, and a more secure transition for 
those members of our Armed Forces who decide to separate prior 
to full retirement.
    I will be working with my healthcare colleagues at the 
Department of Health and Human Services and elsewhere to ensure 
that we're appropriately involved in the implementation of 
healthcare reform initiatives that both reassure our 
beneficiaries and promote the goals of reform.
    Mr. Chairman, I want to thank you again for your steadfast 
support of the Military Health System. I look forward to your 
questions.
    [The joint prepared statement of Dr. Rice and Rear Admiral 
Hunter follows:]
 Joint Prepared Statement by Charles L. Rice, M.D., and RADM Christine 
                             S. Hunter, USN
    Mr. Chairman, members of the committee, thank you for the 
opportunity to discuss the Military Health System's (MHS) priorities 
and budget for fiscal year 2011.
    We have enduring obligations to the men and women of our Armed 
Forces, and to their families who serve with them, and to the millions 
of retired military personnel who have served us in the past.
    This obligation begins the moment a recruit walks through our 
doors. In our budget for the coming year, we acknowledge that lifetime 
commitment we have to those who serve today or have served in the past, 
and to their families.
    For those servicemembers who honorably conclude their service 
before reaching military retirement, we have an obligation to ensure 
their medical experience is fully captured and easily shared with the 
Department of Veterans Affairs (VA) or with their own private 
physician. For those who retire from military service, our obligation 
to them and their families often extends for a lifetime.
    For those who have borne the greatest burden, through injury or 
disease suffered in our Nation's conflicts, we have an even higher 
obligation to the wounded and their families. As Secretary Gates stated 
with the introduction of the Defense budget, ``Recognizing the strain 
that post-September 11 wars have put on so many troops and their 
families, the department will spend more than $2 billion for wounded 
warrior initiatives, with a special focus on the signature ailments of 
current conflict, such as post-traumatic stress disorder (PTSD) and 
traumatic brain injury. We will sustain health benefits and enlarge the 
pool of medical professionals. We will broaden electronic information-
sharing between the Department of Defense (DOD) and VA for wounded 
warriors making the transition out of military service.''
    The budget we are putting forward reflects our commitment to the 
broad range of responsibilities of the MHS--the medical readiness 
requirements needed for success on today's battlefield; the medical 
research and development necessary for success on tomorrow's; the 
patient-centered approach to care that is being woven through the 
fabric of the MHS; the transformative focus we are placing on the 
health of our population; the public health role we play in our 
military community and in the broader American community; the reliance 
we have on our private sector health care partners who provide 
indispensable service to our servicemembers and families; and our 
responsibility to deliver all of these services with extraordinary 
quality and service.
    As our military forces in Afghanistan are engaged in combat 
operations to expand the security, governance, and development 
environment for the people of Afghanistan; as we continue with the 
careful hand-off of responsibilities to the elected leaders of Iraq; 
and, as marines provide security and the joint medical team provides 
care for the people of Haiti, we are mindful of the trust and 
investment that the American people have made in military medicine. We 
will continue to honor that trust.
                     mhs mission and strategic plan
    The MHS overarching mission remains as in years past: to provide 
optimal health services in support of our Nation's military mission--
anytime, anywhere.
    Over the last 12 months, the Office of the Assistant Secretary of 
Defense for Health Affairs has worked with our Service Surgeons General 
and the entire Joint MHS leadership team to update and refine the MHS 
Strategic Plan.
    In the process, we sought the expertise and advice from leaders 
both within our system and external to the MHS, to include renowned 
experts at the Mayo Clinic, Kaiser Permanente, Geisinger Health System, 
the Cleveland Clinic, Intermountain Health, and the Institute for 
Healthcare Improvement.
    This effort resulted in unanimous support for adopting ``The 
Quadruple Aim'' as the foundation for our strategic plan in the coming 
years.
    The Quadruple Aim borrows liberally (and with permission) from the 
Institute for Healthcare Improvement's ``Triple Aim,'' and is further 
tailored to the unique mission of the MHS. The four core components of 
the Quadruple Aim are:

         Readiness--Ensuring that the total military force is 
        medically ready to deploy and that the medical force is ready 
        to deliver health care anytime, anywhere in support of the full 
        range of military operations, including combat support, defense 
        support to civil authorities, and humanitarian assistance/
        disaster relief missions as we witnessed most recently in 
        Haiti.
         Population Health--Improving the health of our 
        population by encouraging healthy behaviors and reducing the 
        likelihood of illness through focused prevention and the 
        development of increased resilience.
         Experience of Care--Providing a care experience that 
        is patient and family centered, compassionate, convenient, 
        equitable, safe, evidence-based, and always of the highest 
        quality.
         Cost--Creating value by focusing on measuring and 
        enhancing quality healthcare; eliminating inefficiencies; 
        reducing unwarranted variation; and emphasizing investments in 
        health that reduce the burden and associated cost of 
        preventable disease in the long term.

    The outcome of this strategic planning effort is more than the plan 
itself. The values and strategies we have articulated in our plan are 
reflected in our proposed budget.
    Whereas we take great pride in the past accomplishments of the 
joint MHS team, the overview we provide in the following pages for our 
fiscal year 2011 strategic priorities is forward-looking, not merely a 
reflection of past accomplishments. By aligning this testimony with our 
strategic plan, we link our budget proposal and priorities to our 
strategic focus inherent in the four core components of the Quadruple 
Aim.
                               readiness
    A fit, healthy, and protected force is the starting point in 
ensuring a medically ready force. We have a core set of individual 
medical readiness (IMR) measures that inform both our line commanders 
and our medical teams about the individual preparedness of a 
servicemember to deploy.
    We will continue to use our monitoring systems so that we reduce 
the rate of deployment limiting conditions. We will also focus on 
disparities between the active and Reserve Components in terms of IMR, 
and improve the medical readiness of the Total Force.
    A critical companion strategic matter for the Department is the 
psychological health of our people. Between 20-30 percent of our 
servicemembers who have deployed to Operation Iraqi Freedom or 
Operation Enduring Freedom (OIF/OEF) have reported some form of 
psychological distress. As has been widely noted, suicide rates in the 
Armed Forces have also been rising. DOD and the individual Services are 
studying every suicide or suicide attempt closely, and we have 
collectively introduced a number of new programs and initiatives to 
reduce the occurrence of suicide. We are engaging commanders, the 
medical research community and fellow servicemembers in a multi-tiered 
effort to understand and implement effective strategies to deter 
suicide; to reduce the stigma of seeking professional help and 
counseling; and to ensure there are adequate personnel resources to 
meet a clear and growing demand for mental health services.
    We remain focused on accelerating our research into and the 
adoption of evidence-based care treatments for personnel with PTSD and 
traumatic brain injury. Secretary Gates continues to be personally 
interested in seeing us move information from the research realm to the 
field in a much more rapid manner.
    We are proposing another $669 million to support our requirements 
in meeting these critical needs in support of psychological health. 
Significant funds are also directed to other critical battlefield 
medical research and development needs.
    In addition, our investments in Defense Centers of Excellence and 
the Defense and Veterans Brain Injury Center are funded and poised for 
delivering world-class care and service to our military and veteran 
populations.
    Finally, in fiscal year 2010 and fiscal year 2011, we will be 
undertaking actions to expand our measures of ``readiness.'' 
Specifically, we will be assessing how to better measure ``family 
readiness.'' There is no question that the health and resiliency of the 
entire family is tied to the readiness of the individual soldier, 
sailor, airman, and marine. Our efforts will be directed toward 
measures that help us proactively identify and address health risks 
within a family prior to deployment.
                           population health
    There are few organizations in the world that compare to the DOD in 
having the right incentives to truly invest in population health 
efforts. A significant number of military personnel and their families 
will have their health care managed by DOD or other Federal and private 
sector partners for their lifetimes. Accordingly, we will continue to 
develop and employ the best tools and programs to transform our culture 
to one focused not just on expertly treating disease and injury, but to 
one focused on sustaining the health and well-being of our population.
    There are a number of tools and programs at our disposal to improve 
overall population health. The Department will continue to invest 
deeply in our preventive service programs. We will improve our provider 
support tools so that opportunities for education or preventive 
treatment can be engaged at all patient-provider opportunities.
    We will closely track our performance in delivering preventive 
services using the Health Employer Data Information System (HEDIS) 
measures. HEDIS allows us the opportunity to compare ourselves among 
each Service or MTF, but equally importantly, to compare ourselves 
against our private sector counterparts. In 2009, we witnessed 
impressive gains in preventive service delivery as compared to both 
national norms and national benchmarks, particularly in the Army and 
Navy, after introducing pay for performance incentive programs.
    We recognize, however, that not all measures are moving in the 
right direction. For example, we are seeing continued high levels of 
tobacco usage among our youngest servicemembers. We are also seeing 
rising rates of obesity in our non-active duty population (along with 
the related morbidities, particularly diabetes).
    As an aspect of our strategic imperatives, we are seeking to more 
directly and more personally engage patients to take a more active role 
in managing their health. We will seek to influence behaviors through 
increased positive actions (better nutrition and increased physical 
activity) and reduced negative habits (tobacco use and excessive 
alcohol intake).
    Our efforts to improve the overall health status of our population 
do not operate in a vacuum. Improvements are made one patient at a 
time; one patient visit at a time. In this regard, our efforts in this 
strategic arena are directly tied to our efforts at the individual 
level with their experience with the care received--and the topic of 
the next section.
                           experience of care
    One of our foremost and sustained priorities is to improve the 
experience of care for those who are most intimately interacting with 
our MHS every day--the wounded, ill, and injured from our current 
conflicts who are moving through the joint patient evacuation system, 
from point of injury in the theater of operations, to the point of 
definitive care in the United States, where many are recovering at our 
flagship military medical centers in the National Capital Area and 
other medical centers around the country.
    We remain grateful for the support of Congress, and especially this 
committee, to ensure we have the resources to provide the very best 
health care for our forces and their families, and in particular for 
the wounded, ill, and injured.
    We propose a budget of more than $670 million to support the 
spectrum of services for the wounded, ill, and injured--services which 
include enhanced case management, improvements to our Disability 
Evaluation System, and greater data sharing with the VA and other 
private sector medical organizations.
    Central to our efforts is the obligation to expedite the 
administrative elements of our disability cases, and work to get our 
Wounded Warriors to the best possible location to facilitate their 
recovery. We are expediting our Medical Evaluation Board (MEB) process 
toward a goal of completing all MEBs within 30 days.
    We have also successfully piloted efforts with the VA to have both 
Departments' medical examination requirements completed in a single 
exam--which increases the timeliness of processing and increases 
satisfaction with the entire experience for the servicemember.
    Enhancing the care experience is not limited, however, to our 
wounded warriors. It is imperative that we offer solutions and 
improvements for our entire beneficiary population we serve.
    The overriding issue in our system has historically been and 
continues to be ``access to care.'' Simply put, access is about getting 
the right care for the right patient at the right time.
    Our efforts to improve access in the coming year will be focused on 
expanding our ``Medical Home'' initiatives. The Patient Centered 
Medical Home provides patients with a known provider or small team of 
providers, who will get to know that patient and her or his medical 
problems. The continuity of care offered by this model, when coupled 
with enhanced access to the provider through telephone messaging or 
secure electronic communication and timely appointing, will enhance the 
quality and safety of care and improve the patient experience. This 
model has been endorsed by professional medical societies (the American 
Academy of Pediatrics and the American Academy of Family Physicians, 
American College of Physicians, and American Osteopathic Association), 
several large third party payers, employers, and health plans. Its 
adoption in the MHS reflects the continuation of a journey toward 
improving patient access and satisfaction.
    We will be providing our enrolled population with clear 
communications about how to access the appropriate level of medical 
care to meet their needs at any time, 24 hours a day, 7 days a week. We 
will offer our patients with multiple modes of accessing care, to 
include expansion of telephone access, and secure, web-based patient-
provider messaging service.
                        per capita cost control
    We are proposing a fully funded budget for fiscal year 2011. The 
MHS serves 9.5 million beneficiaries, to include active duty members 
and their families, members of the Reserve Component and their 
families, and retired military personnel and their families. It is 
important to note that this number that has grown with the increased 
active duty end strength as well as the expansion of health benefits to 
members of the Reserve Component. Thus, while real cost growth will 
continue to rise, we, nonetheless, will be focused on controlling per 
capita costs within our system.
    Our primary and most strategically important bulwark against 
unmanaged cost growth for the coming year is quality. Our efforts to 
develop, proliferate and adhere to evidence-based guidelines will have 
the most dramatic effect on our costs. In this instance, we will again 
compare ourselves against each other and against private sector data 
using the Dartmouth Atlas as our guide. Our goal is to reduce 
inappropriate variation in the utilization of services.
    The urgency of addressing costs in fiscal year 2011 is clear from 
our budget request. A major increase in the budget request includes 
$1.2 billion for private sector care costs due to an increase in users 
of TRICARE and an increase in utilization of the TRICARE benefit.
    We recognize that this focus on quality and utilization does not 
diminish the need for wise and informed management actions to also 
control costs. In fiscal year 2011, we will also:

         continue implementation of Federal Ceiling Pricing of 
        retail pharmaceuticals;
         continue implementation of the Outpatient Prospective 
        Payment System, which reduces the reimbursement paid for 
        outpatient care at inpatient private sector care facilities;
         standardize medical supply chain management across the 
        full range of military health care operations;
         increase efforts to identify and detect fraud, waste, 
        abuse, and overpayments to civilian medical providers; and
         pursue the first fully integrated Joint DOD/VA 
        healthcare collaboration consisting of the North Chicago 
        Veterans Affairs Medical Center and the Navy Health Clinic, 
        Great Lakes, IL.

    Through improved access to care from the medical home initiative 
and adherence to evidence-based care guidelines, we are hoping to 
reduce the need for referrals to private sector sources wherever 
possible, and to decrease utilization of emergency room services (when 
used as a source for non-emergent primary care).
    We recognize that the MHS is not immune from the cost growth 
challenges faced by our private sector peers. The ever-increasing value 
of the TRICARE benefit against private sector plans and premiums will 
likely place additional pressure on the MHS budget. Yet, along with the 
civilian and military leadership of the Department, we are mindful of 
the trade-offs being made every day to sustain this system of care.
                          learning and growth
    Fiscal year 2011 promises to be both exciting and challenging, as 
many of the Department's most significant health efforts will be 
advanced in bold and meaningful ways. The 2005 Base Realignment and 
Closure actions, which impact medical facilities in multiple joint 
medical markets, the joint Medical Education and Training Campus, and 
co-location of medical headquarters, will come to fruition in September 
2011. Additionally, work on the Electronic Health Record (EHR) will 
continue on the trajectory toward improved system effectiveness and 
interoperability. The Department will continue to address and resolve 
governance issues related to emerging requirements to organize, 
execute, and oversee joint peacetime health care activities.
    In this dynamic environment, supporting the Quadruple Aim is an 
objective that must continue to grow and support the people who serve 
the MHS. Our major initiatives for this year center on: (1) furthering 
the MHS, contribution to medical science; (2) delivering information to 
enable better healthcare decisions; and (3) ensuring a fully capable 
workforce most prepared to support our strategic initiatives.
    Our medical research program continues to grow, with the leadership 
of Secretary Gates and the ongoing support of Congress. Significant 
funding has been dedicated to TBI and psychological health; battlefield 
medicine; threats from the full range of chemical, biological, 
radiobiological and nuclear threats. Our EHR continues to serve a vital 
function in support of our clinicians and patients. The incredibly rich 
clinical data repository is capturing care delivered throughout our 
system, to include outpatient services in the combat theaters. In each 
successive year, we are able to transfer more health information more 
easily with our counterparts in the VA.
    Yet, our EHR has not been without its technical challenges. For 
fiscal year 2011, we are proposing a total of $875 million for 
modernization efforts and to enable data interoperability with the 
Virtual Lifetime Electronic Record (VLER), being jointly led by DOD and 
the VA. VLER is an ambitious and needed undertaking to integrate 
medical, personnel benefits, and financial information in a single 
virtual record for veterans.
    Finally, vital to our ability to deliver a high quality, accessible 
and cost-effective health system is a workforce that is trained and 
ready to operate in a fast-paced environment. We are investing in 
recruitment and retention programs to sustain our system. We have 
proposed legislation that will allow us to offer post-graduate 
scholarships for MHS civilians. We are partnering with universities, 
marketing our job opportunities to their graduates. Outreach activities 
include attending job fairs, speaking at professional conferences, and 
marketing through our MHS website. Partnering with the VA has allowed 
us to share recruiting opportunities, improving our mutual ability to 
recruit scarce medical professionals. In all, our MHS human capital 
programs will continue to allow us to extol the benefits of public 
service while supporting our strategic initiatives.
    We are proud to serve with the talented, dedicated and resourceful 
team of public servants and military volunteers who comprise the MHS. 
We are committed to enhancing their professional experience in service 
to the country.
          unified medical budget request for fiscal year 2011
    The Defense Health Program (DHP), the appropriation that supports 
the MHS, is under mounting financial pressure. The DHP has more than 
doubled since 2001--from $19 billion to $50.7 billion in fiscal year 
2010.
    The majority of DOD health spending supports health care benefits 
for military retirees and their dependents, not the active force. We 
project that up to 65 percent of DOD healthcare spending will be going 
toward retirees in fiscal year 2011--up from 45 percent in fiscal year 
2001. As civilian employers' health costs are shifted to their military 
retiree employees, TRICARE is seen as a better, less costly option and 
they are likely to drop their employer's insurance. These costs are 
expected to grow from 6 percent of the Department's total budget in 
fiscal year 2001 to more than 10 percent in fiscal year 2015.
    Despite these fiscal challenges, the fiscal year 2011 budget 
request provides realistic funding for projected health care 
requirements.
    The Unified Medical Budget, the Department's total request for 
healthcare in fiscal year 2011, is $50.7 billion. This includes the DHP 
appropriation, including Wounded, Ill and Injured Care and 
Rehabilitation; Military Personnel, Military Construction, and normal 
cost contributions for the Medicare-Eligible Retiree Healthcare.
    89Defense Health Program
    The largest portion of the request, or $30.9 billion, will be used 
to fund the DHP, which is comprised of Operation & Maintenance (O&M), 
Procurement and Research, Development, Test & Evaluation (RDT&E). A 
little over $29.9 billion is for O&M, which funds most day-to-day 
operational costs of healthcare activities;
                  military personnel and construction
    For Military Personnel, the Unified Medical Budget includes $7.9 
billion to support the more than 84,000 military personnel who provide 
healthcare services in military theaters of operations and fixed health 
care facilities around the world. These services include medical and 
dental care, global aeromedical evacuation, shipboard, and undersea 
medicine, and global humanitarian assistance and response.
    Funding for medical Military Construction (MILCON) includes $1.0 
billion to improve our medical infrastructure. We are committed to 
building new hospitals using the principles of Evidence-Based Design 
(EBD). We are excited to be able to open a national showcase in EBD, 
the new Fort Belvoir Hospital, in 2011.
    MILCON funding will also be directed toward infrastructure 
enhancements at the National Interagency Biodefense Campus at Fort 
Detrick, MD--a vital resource for the Nation.
             dod medicare-eligible retiree health care fund
    The estimated normal cost of the Medicare-Eligible Retiree Health 
Care Fund in fiscal year 2010 is $10.9 billion. This funding includes 
payments for care in MTFs, to private health care providers, and to 
reimburse the Services for military labor used in the provision of 
healthcare services.
                               conclusion
    Mr. Chairman, the Military Health System continues to provide 
world-class medical care for a population that demands and deserves the 
best care anywhere. We are proud to represent the men and women who 
comprise the MHS. We are proud to submit to you and your committee 
members a budget that is fully funded and that we can successfully 
execute in the coming year.
    We are pleased that we are able to provide you a budget with a 
direct and specific link to our strategic planning efforts of the last 
year.
    Thank you again, Mr. Chairman, for the opportunity to be with you 
today. We look forward to your questions.

    Senator Webb. Thank you very much, Dr. Rice.
    Admiral Hunter, welcome.

 STATEMENT OF RADM CHRISTINE S. HUNTER, USN, DEPUTY DIRECTOR, 
                  TRICARE MANAGEMENT ACTIVITY

    Admiral Hunter. Thank you, Mr. Chairman, Senator Graham. 
I'm really honored to be able to appear before you today.
    Together with Dr. Rice, I have the responsibility for 
operating the TRICARE Management Activity (TMA) and 
administering the TRICARE benefit.
    As you said, 9.6 million Americans rely on us to ensure 
they receive high-quality healthcare whenever they need it and 
wherever they are in the world. Along with the growth in the 
Army and Marine Corps, our program has grown by over 370,000 
servicemembers, families, and retirees since 2008.
    Since assuming my responsibilities 10 months ago, I've been 
fortunate to work closely on many critical initiatives with DOD 
leaders, the Service Surgeons General, and key stakeholders who 
represent our beneficiaries.
    Initially, we focused our efforts on the care of wounded 
warriors, access to care, particularly behavioral healthcare, 
and services for families whose children have special needs.
    More recently, we introduced the construct of the Quadruple 
Aim and carefully examined how we're performing in each domain. 
The Quadruple Aim builds on the Institute for Healthcare 
Improvements Triple Aim for Health Systems, which advocates 
that we achieve excellence in population health, the patient 
experience, and responsibly manage the costs.
    In the Military Health System, our Quadruple Aim adds the 
fourth aim, a specific emphasis on our core mission of 
readiness. I'm pleased to report that we're making progress. To 
support readiness, certainly the Surgeons General will share 
many of their observations. But, at TMA we have concentrated on 
our Reserve and Guard populations, as well as behavioral 
health.
    Participation in our TRICARE Reserve Select product is 
growing, ensuring that reservists and guardsmen have coverage 
to maintain their health between mobilizations. We've also made 
it easier for physicians around the country to participate in 
this plan and receive timely payment.
    Our efforts to reduce the stigma associated with seeking 
mental healthcare have been accompanied by an increase in 
providers to meet the growing demand. Together with the 
Surgeons General and our TRICARE contractors, we've added over 
1,900 providers to the military hospitals and clinics, and more 
than 10,000 added to the networks. Visits have increased 
dramatically, with 112,000 behavioral health outpatients now 
seen every week. In addition, servicemembers and their families 
can access the TRICARE Assistance Program for supportive 
counseling via Web cam from their homes, 24 hours a day.
    To improve health overall, we're putting a priority on 
prevention, eliminating copays for preventive services under 
TRICARE standard, recently adding immunizations like flu 
vaccine to our retail pharmacy program, and tracking our 
performance. Since 2007, we can demonstrate significant 
improvement in the number of patients who receive cancer 
screening that's appropriate to their age, immunizations, and 
medications to control diabetes, asthma, and cholesterol.
    Patients are beginning to notice the difference. On 
surveys, they're telling us that they receive timely care, 
needed care, and see their assigned primary care manager more 
often. We certainly still have room to improve, but this is a 
very encouraging beginning trend.
    To address the costs of care, we're focused on ensuring 
that patients with acute minor conditions visit their primary 
care site or an urgent care clinic, rather than the emergency 
room, and choose the convenience and lower out-of-pocket cost, 
as well as lower government cost, of our mail-order pharmacy, 
rather than the retail pharmacy, whenever that's possible.
    Our partnerships at the interface between the direct care 
and private-sector care are thriving. On a regular basis, 
TRICARE regional directors engage with Army MTF commanders in 
rehearsal of capability drills. We work together to develop the 
medical capacity that's needed as the Army grows and shifts its 
population concentrations.
    When Navy medical personnel ably responded to the disaster 
in Haiti, we staffed a fusion cell to make daily adjustments to 
network referrals and assist with interservice crossleveling, 
to ensure that all patients continue to receive timely care.
    The Air Force has led the other Services to articulate the 
challenges with access to care in Alaska, and we've been able 
to stabilize reimbursement to encourage more providers to 
participate.
    We appreciate the Senate's leadership in this area, and 
we're engaged with the Veterans' Affairs (VA) Department and 
other Federal partners to develop comprehensive solutions.
    In the months ahead, we'll work diligently to address all 
concerns cited by the GAO and move forward to delivery of 
healthcare under the TRICARE third-generation contracts.
    We proudly anticipate the introduction of our TRICARE 
Reserve Retiree Program for those gray-area reservists who have 
served our Nation so honorably, and are excited by pending 
improvements to our overseas and dental programs.
    There's certainly much more to do, but my staff and I come 
to work every day mindful of all those that we serve and 
striving to make a positive difference.
    Thank you again, Mr. Chairman, for your advocacy on behalf 
of our servicemembers, and I look forward to your questions.
    Senator Webb. Thank you, Admiral Hunter.
    General Schoomaker.

 STATEMENT OF LTG ERIC B. SCHOOMAKER, USA, SURGEON GENERAL OF 
    THE U.S. ARMY, AND COMMANDER, U.S. ARMY MEDICAL COMMAND

    General Schoomaker. Chairman Webb, Senator Graham, and 
distinguished members of the Personnel Subcommittee, thank you 
for inviting us to discuss the Defense Health Program and our 
respective Service medical programs.
    Now in my third congressional hearing cycle as the Army 
Surgeon General and Commanding General of the U.S. Army Medical 
Command, I can tell you that these hearings are valuable 
opportunities for me to talk about the accomplishments and 
challenges of Army Medicine, and to hear your collective 
perspectives regarding military health promotion and 
healthcare.
    I'm pleased to tell you that the President's budget 
submission for fiscal year 2011 fully funds the Army Medical 
Department's needs. Your support of the proposed President's 
budget is greatly appreciated.
    I know, in your recent hearing with the Under Secretary of 
Defense for Personnel and Readiness and the Assistant 
Secretaries for Manpower and Reserve Affairs, that much concern 
was expressed regarding the increasing size of the defense 
health budget within the overall defense budget. I'd like to 
share with you some of the efforts that we are making in Army 
Medicine that complement what Admiral Hunter just discussed, to 
maximize the value in health services that we deliver, of our 
Army Medicine's five strategic themes.
    This theme is built on a belief that providing high-quality 
evidence-based services is not only right for soldiers and 
families, it results in the most efficient use of resources 
within the healthcare system, thus delivering value not only 
for our patients, but indeed for the Nation as a whole. In 
fact, what we really want to do is move from a healthcare 
system, one that is focused on delivering care, simply, to one 
that is a system of health and a system for health, which 
optimizes health and well-being through enhanced prevention and 
in a holistic approach.
    We've resisted simply inventing new processes and inserting 
new diagnostic tests or therapeutic options, although we are 
keeping abreast of all of the cutting-edge changes in the 
American healthcare and international healthcare terrain. Or 
we've resisted adding just more layers of bureaucracy, but 
we're really, truly adding value to the products we deliver, 
the care we provide, and the training of our people.
    This requires focusing on the clinical outcome for the 
patient and the community, and maintaining or even reducing the 
overall resource expenditure that's needed to achieve this 
objective. My own wife reminds me, she's not interested in 
sitting in waiting rooms or going through the turnstile of 
medicine, she wants to know, at the end of the day, is she 
better for what she came to seek care for? I think we can tell 
here unequivocally, and all of our patients and soldiers and 
families, that we are.
    This has occurred, for us, through adoption of evidence-
based practices, that you heard both of my colleagues here talk 
about, and reducing unwarranted variation in our practices, 
even unwarranted administrative practice variation for all the 
transactional processes that go on in our work.
    One example of this in Army Medicine is that, we are 
expanding upon a performance-based budget model that links 
resources to clinical and quality outputs. Since 2007, we've 
been providing financial incentives to our hospitals, our 
clinics, our clinical commanders, and our clinicians for 
superior compliance in key preventive measures and other 
measures of evidence-based practices.
    Currently, we track nine measures and compare our 
performance to a national benchmark. Our performance has 
improved on every measure, in one case by 63 percent. We've 
demonstrated that these incentives work to change 
organizational behavior to achieve desired outcomes in our 
health system.
    Put quite simply, our beneficiaries, our patients, and our 
communities are receiving not only better access to care, but 
for better care once they get that access, that we can 
objectively measure.
    We've undertaken major initiatives to improve both access 
and continuity of care. This is one of the Army Chief of 
Staff's and my top priorities, and it's reflected in what 
you've heard Admiral Hunter talk about. After conducting 
thorough business-case analyses, Army Medicine is expanding 
healthcare product lines in some communities, and we're 
expanding clinical space in others. In 14 locations across the 
country, we're establishing community-based primary care 
clinics by leasing and operating clinics located in off-post 
communities that are close to where our Active Duty families 
live and work and go to school. These clinics will provide a 
Patient-Centered Medical Home for families, an effort which is 
warmly embraced and resourced by all three of the medical 
services in the Military Health System and will provide a range 
of benefits, to include improved readiness for our Army and our 
Army family, improved access to and continuity of care, reduced 
emergency room visits, and improved patient satisfaction, which 
is growing.
    Both our community-based Primary Care Clinic Initiative and 
the three medical services Patient-Centered Medical Home 
implementation have been well-supported by Rear Admiral Hunter 
and the TRICARE Management Agency and the Assistant Secretary 
of Defense for Health Affairs. We are very appreciative and are 
working closely on these efforts.
    I look for 2010 to be the year that Army Medicine achieves 
what we set out to improve 2 years ago in access and 
continuity, key elements of our covenant with the Army family, 
led by our Chief of Staff and by the Secretary of the Army.
    Army leadership is also engaged in an all-out effort to 
change DOD culture regarding TBI, or mild TBI, as it's called, 
especially the milder form, or what we call concussion TBI, 
which has a very wide spectrum, from concussive injury to much 
more unusual penetrating injuries or moderate crush injuries, 
of those, we are really focusing very, very closely on 
concussive injury, the most common injury. Our goal is nothing 
less than a cultural change in the management of soldiers after 
potential concussive events in combat or, frankly, on the 
football fields or sports fields or in motor vehicle accidents.
    Every warrior requires appropriate treatment to minimize 
concussive injury and maximize recovery. To achieve this goal, 
we're educating the force so as to have a trained and prepared 
soldier, a leader, and our medical professional and personnel 
to provide early recognition, treatment, and tracking of these 
concussive injuries, ultimately designed to protect warrior 
health.
    The Army is issuing very direct standards and protocols to 
commanders and healthcare providers, similar to aviation 
incident actions. There's an automatic grounding and medical 
assessment which is required for any soldier that meets 
specified criteria. The end state of these efforts is that 
every servicemember sustaining a possible concussion will 
receive early detection, state-of-the-art treatment, and 
return-to-duty evaluations, with long-term digital health-
record tracking of their management.
    We're combining our efforts to identify and manage 
concussive brain injury as close as possible, both in time and 
geographic proximity, to the actual blast event, with more 
aggressive battlefield management of post-traumatic stress 
symptoms. Our experts tell us that the closer we can manage 
those symptoms as they emerge in combat, the more likely we are 
to reduce long-term PTSD problems.
    Treatment of concussive injuries is an emerging science. 
The Army is leading the way in implementing these new treatment 
protocols for DOD, and the DOD is leading the Nation.
    I brought with me today our Brain Injury Awareness Toolkit. 
I'd like to share this with you and your staff. If you don't 
have any other time, I'd really urge you to look at the DVD 
that we've put together with our senior leadership, because 
this is really a commanders-led program--the Chief of Staff, 
George Casey; the Vice Chief of Staff, Pete Chiarelli; and our 
Sergeant Major of the Army are very actively involved in. They 
contain patient information materials, as well as this DVD, 
which we're using to educate soldiers before they deploy 
overseas. We're training them as to what they should do, should 
they have a concussion.
    [The information referred to follows:]
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    
    
      
    General Schoomaker. I truly believe that this evidence-
based directive approach to concussive management will change 
the military culture regarding head injuries and significantly 
impact the well-being of our force.
    In closing, I'm very optimistic about the next 2 years. I 
feel very privileged to serve with the men and women of Army 
Medicine, as soldiers, as Americans, and as global citizens.
    Thank you for holding this hearing and your unwavering 
support of the Military Health System and Army Medicine.
    I look forward to answering questions. In particular, I'd 
be happy to discuss the Army's approach to pain management, to 
the treatment of post-traumatic stress, and the use of 
medications across the force, those other concerns that were 
raised by Senator Cardin.
    Thank you.
    [The prepared statement of General Schoomaker follows:]
           Prepared Statement by LTG Eric B. Schoomaker, USA
    Chairman Webb, Senator Graham, and distinguished members of the 
Personnel Subcommittee, thank you for inviting us to discuss military 
medicine and our respective Service medical programs. Now in my third 
Congressional hearing cycle as the Army Surgeon General and Commanding 
General, U.S. Army Medical Command (MEDCOM), I can tell you that these 
hearings are valuable opportunities for me to talk about the 
accomplishments and challenges of Army Medicine and to hear your 
collective perspectives regarding military healthcare. You and your 
staff members ask some difficult questions, but these questions help 
keep us focused on those we serve--the soldiers, sailors, marines, 
airmen, coastguardsmen, family members, and retirees as well as the 
American public. I hope you also find these hearings beneficial as you 
review the President's budget submission, which this year fully funds 
the Army Medical Department's needs, and determine priorities and 
funding levels for the next fiscal year.
    The U.S. Army Medical Department is a complex, globally-deployed, 
and world class team. My command element alone, the MEDCOM, is an $11 
billion international health improvement, health protection, emergency 
response and health services organization staffed by 70,000 dedicated 
Soldiers, civilians, and contractors. I am in awe at what these 
selfless servants have done over the past years--their accomplishments 
have been quietly, effectively, powerfully successful. While we have 
experienced our share of crises and even tragedies, despite 8 years of 
continuous armed conflict for which Army medicine bears a heavy load, 
every day our soldiers and their families are kept from injuries, 
illnesses, and combat wounds through our health promotion and 
prevention efforts; are treated in cutting-edge fashion when prevention 
fails; and are supported by an extraordinarily talented medical force 
to include those who serve at the side of the Warrior on the 
battlefield. We mourn the loss of 26 teammates in the Fort Hood 
shootings--6 dead and 20 wounded--but are inspired by the resolve shown 
by their units to continue their missions and the exemplary performance 
of the 467th and 1908th Medical Detachments serving in Afghanistan 
today.
    One area of special interest to Congress is our comprehensive 
effort to improve warrior care from point of injury through evacuation 
and inpatient treatment to rehabilitation and return to duty. I am 
convinced the Army has made some lasting improvements, and I was 
recently heartened to read the comments of a transitioning warrior that 
reinforced these perceptions. She commented:

          As I look back in the past I am able to see with a reflective 
        eye . . . the people that have helped me fight this battle, 
        mostly my chain of command, who have always stood beside me 
        instead of in front of me. They have gone out of their way to 
        do what was best for me and I cannot say I would be here still 
        if I hadn't had such wonderful support. . . . This is my story 
        at the WTB and all in all, I just had to make aware to everyone 
        that has helped that I am very grateful and I truly appreciate 
        all of the work you have done for me.

    There is nothing more gratifying than to care for these wounded, 
ill, and injured heroes. We in Army medicine continue to focus our 
efforts on our warriors in Transition and I want to thank Congress for 
its unwavering support. The support of this committee has allowed us to 
hire additional providers, staff our warrior transition units, conduct 
relevant medical research, and build healing campuses. In the remainder 
of my testimony today, I will discuss how we are providing optimal 
stewardship of the investment the American public and this Committee 
has made in Army medicine.
    We lead and manage Army medicine through the Kaplan & Norton 
Balanced Scorecard performance improvement framework that I introduced 
to you in last year's testimony. The Scorecard balances missions and 
resources across a broad array, while ensuring that near-term measures 
of success are aligned with longer-term, more strategic results. This 
balancing is depicted on the Scorecard's Strategy Map, which shows how 
we marshal our resources, train and develop our people, and focus our 
internal processes and efforts so as to balance competing goals. 
Ultimately our means, ways, and ends contribute toward accomplishing 
our mission and achieving our strategic vision. The five strategic 
themes that guide our daily efforts are:

         Maximize Value in Health Services
         Provide Global Operational Forces
         Build the Team
         Balance Innovation with Standardization
         Optimize Communication and Knowledge Management

    Although distinct themes, they inevitably overlap and weave 
themselves through everything we do in Army medicine.
    The first strategic theme--Maximize Value in Health Services--is 
built on the belief that providing high quality, evidence-based 
services is not only the right for our soldiers and families; it 
results in the most efficient use of resources within the healthcare 
system, thus delivering value to not only our patients, but indeed, the 
Nation. In fact, what we really want to do is move from a healthcare 
system to a system for health.
    We have resisted simply inventing a new process, inserting a new 
diagnostic test or therapeutic option in vacuo or adding more layers of 
bureaucracy but are truly adding value to the products we deliver, the 
care we provide, and the training of our people. This requires focusing 
on the clinical outcome for the patient and the community and 
maintaining or even reducing the overall resource expenditure needed to 
achieve this objective. It has occurred through adoption of evidence-
based practices and reducing unwarranted practice variation--even 
``unwarranted administrative practice variation'' for the transactional 
processes in our work. As one example of this, Army Medicine is 
expanding upon our Performance Based Budget model to link resources to 
clinical and quality outputs. The Healthcare Effectiveness and Data 
Information Set (HEDISR) is a tool used by more than 90 percent of 
America's health plans (> 400 plans) to measure performance on 
important dimensions of care, namely, the prevention of disease and 
evidence-based treatments for some of the most common and onerous 
chronic illnesses. The measures are very specifically defined, thus 
permitting comparison across health plans. Since 2007, we have been 
providing financial incentives to our hospitals, clinics and clinicians 
for superior compliance in key HEDIS measures. Currently, we track nine 
measures and compare our performance to national benchmarks. Our 
performance has improved on each measure, in one case by 63 percent. We 
have demonstrated that these incentives work to change organizational 
behavior to achieve desired outcomes in our health system. Put quite 
simply, our beneficiaries, patients and communities are receiving not 
only better access to care but better care--objectively measured.
    As the DOD budget and health-/healthcare-related costs come under 
increasing scrutiny, this element of our strategy will be even more 
critical for us. As the United States struggles to address improvements 
in health and healthcare outcomes while stabilizing or reducing costs 
of our national system of care, we in Army Medicine and the Military 
Health System will surely keep the goal of maximizing value in our 
cross-hairs . . . or we will find our budgets tightening without a way 
to measure the effects on our patients' and our communities' health and 
well-being.
    All of these remarkable achievements would be without meaning or 
importance to our soldiers, their families, and our patients if we do 
not provide access and continuity of care, especially within the direct 
care system of our medical centers, community hospitals, health 
centers, and clinics. I am looking carefully at my commanders' 
leadership and success in ensuring that their medical and dental 
treatment facilities provide timely access and optimize continuity of 
care. We have undertaken major initiatives to improve both access and 
continuity--this is one of the Army Chief of Staff's and my top 
priorities. After conducting thorough business case analyses, Army 
Medicine is expanding product lines in some markets and expanding 
clinical space in others. At 14 locations, we are establishing 
Community-Based Primary Care Clinics by leasing and operating clinics 
located in off-post communities that are close to where active duty 
families live, work, and go to school. These clinics will provide a 
patient-centered medical home for Families and will provide a range of 
benefits:

         Improve the readiness of our Army and our Army Family
         Improve access to and continuity of care
         Reduce emergency room visits
         Improve patient satisfaction
         Implement Best Practices and standardization of 
        services
         Increase physical space available in military 
        treatment facilities (MTFs)
         Improve physical and psychological health promotion 
        and prevention

    Along with the rest of the Military Health System, Army Medicine is 
embracing the Patient-Centered Medical Home concept, which is a 
recommended practice of the National Committee for Quality Assurance 
and is endorsed by a number of medical associations, several large 
third-party payers, and many employers and health plans. The Patient-
Centered Medical Home improves patient satisfaction through its 
emphasis on appropriate access, continuity and quality, and effective 
communication. The goal is simple: consult with one consistent primary 
care provider-nurse team for all your medical needs. The seven core 
features of the Medical Home are:

         Personal Primary Care Provider (primary care manager/
        team)
         Primary Care Provider Directed Medical Practice (the 
        primary care manager is team leader)
         Whole Person Orientation (patient centered, not 
        disease or provider centered)
         Care is Coordinated and/or Integrated (across all 
        levels of care)
         Quality and Safety (evidenced-based, safe medical 
        care)
         Enhanced Access (meets access standards from the 
        patient perspective)
         Payment Reform (incentivizes the development and 
        maintenance of the medical home)

    I look for 2010 to be the year Army medicine achieves what we set 
out to improve 2 years ago in access and continuity, key elements of 
our covenant with the Army Family, led by our Chief of Staff and 
Secretary of the Army.
    Unlike civilian healthcare systems that can focus all of their 
energy and resources on providing access and continuity of care, the 
Military Health System has the equally important mission to Provide 
Global Operational Forces.
    The partnership between and among the medical and line leadership 
of Operations Iraqi Freedom and Enduring Freedom, Central Command, Army 
Forces Command, U.S. Army Reserve Command, National Guard Bureau, Army 
Medical Department Center & School, Medical Research and Materiel 
Command, Army G3/5/7, and others has resulted in a dynamic 
reconfiguration of the medical formations and tactics, techniques, and 
procedures required to support the deployed Army, joint and coalition 
force. Army Medicine has never missed movement and we continue to 
achieve the highest survivability rate in the history of warfare. Army 
medicine leaders have never lost sight of the need to first and 
foremost make a difference on the battlefield.
    This will not change--it will even intensify in 2010 as the 
complexity of the missions in Afghanistan increases. This is occurring 
even while the need to sustain an Army and joint force which is 
responsibly withdrawing from Iraq puts more pressure on those medics 
continuing to provide force health protection and care in Operation 
Iraqi Freedom. This pressure on our All-Volunteer Army is 
unprecedented. Healthcare providers, in particular, are subject to 
unique strains and stressors while serving in garrison as well as in 
deployed settings. The MEDCOM has initiated a defined program to 
address provider fatigue with current efforts focused on sustaining the 
healthy force and identifying and supporting higher risk groups. MEDCOM 
has a healthy healthcare workforce as demonstrated by statistically 
significant lower provider fatigue and burnout than: The Professional 
Quality of Life Scale (ProQol) norming sample of 1187 respondents; and 
Sprang, Clark and White-Woosley's study of 222 civilian behavioral 
health (BH) providers. But as our Chief of Staff of the Army has told 
us: this is not an area where we just want to be a little better than 
the other guy--we want the healthiest and most resilient healthcare 
provider workforce possible.
    The Provider Resiliency Training (PRT) Program was originally 
designed in 2006, based on Mental Health Advisory Team findings. The 
U.S. Army Medical Department Center and School (AMEDDC&S) developed a 
military-specific model identifying ``provider fatigue'' as the 
military equivalent of compassion fatigue. In June 2008, MEDCOM 
implemented a mandated PRT program to educate and train all MTF 
personnel to include support staff on the prevention and treatment of 
signs and symptoms of provider fatigue. The stated goal of PRT is to 
mitigate the negative effects of exposure to combat, to deployment, to 
secondary trauma from caring for the casualties of war as well as the 
unremitting demand for healthcare services and from burnout. All will 
ultimately improve organizational effectiveness. The AMEDDC&S currently 
offers three courses in support of the MEDCOM PRT: the Train the 
Trainer Course; the Professional Resiliency Resident Course; and the 
PRT Mobile Training.
    None of our goals and themes would be achievable without the right 
mix of talented professionals within Army Medicine and working with 
Army Medicine; what our Balanced Scorecard refers to as Build The Team: 
a larger, more inclusive joint medical team; an adaptive and responsive 
interagency team (VA, DHS, DHHS/NIH/NIAID, CDC, USDA, etc.); an 
effective coalition team; and a military-civilian/academic-operational 
team. The teams we build must be aligned with the Army, Defense, and 
National Military Strategy and long-term goals, not based solely on 
personalities and the arcane interests of a few. My Deputy Surgeon 
General, subordinate leaders, and others have been increasingly more 
deliberate and disciplined in how we form and sustain these critical 
partnerships.
    Effective joint, interagency and coalition team-building has been a 
serious challenge for some time now. I see the emphasis on our ability 
to craft these teams grow in 2010. The arrival of September 15, 2011--
the deadline for the 2005 BRAC--will be one of the key milestones and 
tests of this skill. My regional commanding generals in San Antonio and 
Washington, DC have taken lead roles in this endeavor. Let there be no 
question among those who underestimate our collective commitment to 
working as a team and our shared vision to serve the Nation and protect 
and care for the warriors and his or her family--we are one team!
    In addition to building external teams, we need to have the right 
mix and quality of personnel internal to Army medicine. In fiscal year 
2010 and continuing into fiscal year 2011 the Army requested funding 
for programs to improve our ability to attract and retain the 
professional workforce necessary to care for our Army. Our use of 
civilian hiring incentives (Recruiting, Retention, and Relocation) 
increased in fiscal year 2010 by $90 million and should increase by an 
additional $30 million in fiscal year 2011. In fiscal year 2011, 
civilian hiring incentives will equate to 4.8 percent of total civilian 
pay. We have instituted and funded civilian recruiting programs at the 
MEDCOM, regional, and some local levels to seek qualified healthcare 
professionals. For our military workforce, we are continuing our 
successful special salary rates, civilian nurse loan repayment 
programs, and civilian education training programs. Additionally, our 
Health Professional Scholarship Program and loan repayments will 
increase in fiscal year 2010 by $26 million and continue into fiscal 
year 2011. This program supports 1,890 scholarships and 600 
participants in loan repayments--it is as healthy a program as it has 
ever been. Let me point out that our ability to educate and train from 
within the force--through physician, nursing, administrative, medic, 
and other programs in professional education--is a vital capability 
which we cannot permit to be degraded or lost altogether. In addition 
to providing essential enculturation for a military healthcare 
provider, administrator and leader, these programs have proven to be 
critical for our retention of these professionals who are willing to 
remain in uniform, to deploy in harm's way and to assume many onerous 
duties and assignments in exchange for education in some of the 
Nation's best programs. Army and Military Graduate Medical, Dental, 
Nursing, and other professional education has undoubtedly played a 
major role in our remaining a viable force this far into these 
difficult conflicts.
    The theme of evidence-based practice runs through everything we do 
in Army Medicine and is highlighted throughout our Balanced Scorecard. 
Evidence-based practices mean integrating individual clinical expertise 
with the best available external clinical evidence from systematic 
research. Typical examples of evidence-based practices include 
implementation of clinical practice guidelines and dissemination of 
best practices. I encourage my commanders and subordinate leaders to be 
innovative, but across Army medicine we Balance Innovation with 
Standardization so that all of our patients are receiving the best care 
and treatment available. Standardization efforts include:

         The MEDCOM Armed Forces Health Longitudinal Technology 
        Application (AHLTA) Provider Satisfaction (MAPS) initiative
         Care of combat casualties through the Joint Theater 
        Trauma System (JTTS), enabled by the use of a Joint Theater 
        Trauma Registry (JTTR)--both of which I will discuss further 
        below--which examines every casualty's care and outcome of that 
        care, including en route care during medical evacuation 
        (MEDEVAC) with an eye toward standardizing care around the best 
        practices
         The Virtual Behavioral Health Pilot (aka Comprehensive 
        Behavioral Health Integration) being conducted at Schofield 
        Barracks and Ft. Richardson
         Our initiative to reduce Ventilator Associated 
        Pneumonia events in our ICUs by adopting not only industry best 
        practices, but sending out an expert team of MEDCOM 
        professionals to evaluate our own best practices and barriers 
        to success
         Our standardized events-driven identification and 
        management of mild TBI/concussion on the battlefield coupled 
        with early diagnosis and treatment of Post-Traumatic Stress 
        Reactions/Acute Stress Reactions as close in time and space to 
        the events which lead to these reactions

    Programs which are in the process of maturing into best practices 
for more widespread dissemination are:

         The Confidential Alcohol Treatment and Education Pilot
         The standardized and now automated Comprehensive 
        Transition Plan for Warriors In Transition in our WTUs and 
        CBWTUs
         A standardized program to ``build trust in Army 
        Medicine'' through hospitality and patient/client/customer 
        service in our medical, dental, and veterinary treatment 
        facilities and throughout the MEDCOM
         Standardized support of our Active, National Guard, 
        and Reserve Forces engaged in the reiterative, cyclic process 
        of the Army Force Generation Model including but not restricted 
        to preparation for combat medics and medical units, Soldier 
        Readiness Processing of deploying units, ensuring full medical 
        readiness of the force, restoration of dental and behavioral 
        health upon redeployment, support of the total Army Family 
        while soldiers are deployed, and provision of healthcare for 
        mobilized and demobilizing Reserve component soldiers and their 
        families.

    These and many other standardized efforts reflect a change in how 
we do the business of Army medicine. We can no longer pride ourselves 
on engaging in a multiplicity of local ``science projects'' being 
conducted in a seemingly random manner by well-meaning and creative 
people but without a focus on added value, standard measures of 
improved outcomes, and sustainability of the product or process. Even 
the remarkably agile response to the behavioral health needs-assessment 
and ongoing requirements at Fort Hood following the tragic shooting 
were conducted in a very deliberate and effective fashion which 
emphasized unity of command and control, alignment of all efforts and 
marshalling of resources to meet a well-crafted and even exportable 
community behavioral health plan.
    The emphasis which Army Medicine leaders have placed on 
disciplining these innovative measures so as to harvest best practices, 
subject them to validation at other sites, and rapidly proliferate them 
across the MEDCOM and Army in a standard fashion has been remarkable. 
It is the essence of Optimizing Communication and Knowledge Management.
    Many of our goals, internal processes and enablers, and resource 
investments are focused on the knowledge hierarchy: collecting data; 
coalescing it into information over time and space; giving it context 
to transform it into knowledge; and applying that knowledge with 
careful outcome measures to achieve wisdom. This phenomenon of guiding 
clinical management by the emergence of new knowledge is perhaps best 
represented by Dr. Denis Cortese, former President and Chief Executive 
Officer of the Mayo Clinic. He laid out this schematic earlier this 
year after participating in a set of workshops which centered on 
healthcare reform. We participated to explore how the Federal system of 
care might contribute to these changes in health improvement and 
healthcare delivery.
    What Dr. Cortese depicted is a three-domain ideal representation of 
healthcare delivery and its drivers. We share this vision of how an 
ideal system should operate. His notion is that this system of care 
should focus on optimizing individual health and healthcare needs, 
leveraging the knowledge domain to drive optimal clinical practices. 
This transition from the knowledge domain to the care delivery domain 
now takes 17 years. The clinical practice domain then informs and 
drives the payer domain to remunerate for effective clinical outcomes. 
What occurs too often today is what I call ``widget-building'' or 
``turnstile'' medical care which chases remuneration for these 
encounters--too often independent of whether it is the best treatment 
aimed at the optimal outcome. To transform from a healthcare system to 
a system for health, we need to change the social contract. No longer 
should we be paid for building widgets (number of clinic visits or 
procedures), rather, we should be paid for preventing illness and 
promoting healthy lifestyles. When bad things happen to good people--
which severe illness and injury and war continuously challenge us 
with--we should care for these illnesses, injuries and wounds by the 
most advanced evidence-based practices available, reducing unwarranted 
variation in practice whenever possible.
    Our Military Health System is subtly different in that we have two 
practice domains--garrison and battlefield. Increasingly, we leverage 
the clinical domain to provide feedback into the knowledge domain--with 
the help of the electronic health record--AHLTA--and specialized 
databases. We do this in real time and all under the umbrella of the 
regulatory domain which sets and enforces standards.
    The reengineering of combat trauma care borne of rapid turnaround 
of new-found, data-driven knowledge to new materiel and doctrinal 
solutions is one of the premier examples of this concept. The simplest 
example is our continuous re-evaluation of materials and devices 
available to soldiers, combat life savers, combat medics and the trauma 
team at the point of injury and in initial trauma management and the 
intellectual framework for their application to rapidly improve 
outcomes from combat-injured warriors.
    After making the first major change in 40 years to the field 
medical kit--the Improved First Aid Kit--we have modified the contents 
of the kit at least three times since May 2005 based upon ongoing 
reviews of the effectiveness of the materials and head-to-head 
comparisons to competing devices or protocols. In like fashion, we have 
modified protocols for trauma management through active in-theater and 
total systemic analyses of the clinical outcomes deriving from the use 
of materials and protocols.
    The specialized system in this endeavor is a joint and interagency 
trauma system which creates the equivalent of a trauma network 
available for a major metropolitan area or geographic region in the 
U.S. but spread across three continents, 8,000 miles end-to-end--the 
JTTS. Staffed and led by members of the Army, Navy, Marine Corps, and 
Air Force, it is truly a joint process. It is centered on the U.S. Army 
Institute of Surgical Research in San Antonio, TX. The specialized 
database in this effort and an essential element of the JTTS is the 
JTTR--a near-comprehensive standardized database which has been 
developed for each casualty as soon as possible in the treatment 
evacuation chain--usually at level II or III healthcare in theater. One 
of the most important critical applications of the JTTS and JTTR at 
present is the ongoing analysis of MEDEVAC times and the casualties 
being managed during evacuation. This is our effort to minimize the 
evacuation time for casualty in a highly dispersed force which is 
subjected in Afghanistan to the ``tyranny of terrain and weather.''
    The decisions about where and how many trauma teams should be 
placed around the theater of operation as well as where to place 
MEDEVAC crews and aircraft is a delicate balancing act--one which 
balances the risk of putting care providers and MEDEVAC crews and 
helicopters at risk to the enemy and the elements with the risk of loss 
of life and limb to Warriors whose evacuation may be excessively 
prolonged. The only way to fully understand these competing risks is to 
know the outcomes of care and evacuation by injury type across a wide 
range of MEDEVAC missions. This analysis will help us understand if we 
still require a ``Golden Hour'' for every casualty between initial 
management at the point of injury and arrival at a trauma treatment 
site (like an Army Forward Surgical Team, the Marine Forward 
Resuscitative Surgical System or a Combat Support Hospital) or whether 
we now have a ``Platinum 15 Minutes'' at the point of injury which 
extends the Golden Hour.
    This methodology and these casualty data are being applied to the 
next higher level of inquiry: how do we prevent injury and death of our 
combatants from wounds and accidents at the point of potential injury? 
Can we design improved helmets, goggles, body armor, vehicles and 
aircraft to prevent serious injuries? These questions are answered not 
only through the analysis of wound data, both survivable and 
nonsurvivable, through the JTTS and data from the virtual autopsy 
program of the Office of the Armed Forces Medical Examiner, but also by 
integrating these data with information from the joint operational, 
intelligence, and materiel communities to enable the development of 
improved tactics, techniques, and procedures and materiel improvements 
to protective equipment worn by the Warriors or built into the vehicles 
or aircraft in which they were riding. This work is performed by the 
Joint Trauma Analysis and Prevention of Injury in Combat program, a 
component of the DOD Blast Injury Research Program directed by the 
National Defense Authorization Act for 2006. To date it has been an 
effective means of improving the protection of warriors and preventing 
serious injury and death even as the enemy devises more lethal and 
adaptive weapons and battlefield tactics, techniques, and procedures.
    We in Army Medicine are applying these knowledge management tools 
and approaches to the improvement of health and the delivery of 
healthcare back home as well. We are coupling these knowledge 
management processes with a funding strategy which incentivizes our 
commanders and clinicians to balance productivity--providing episodes 
of care--with optimal outcome: the right kind of prevention and care.
    Among our greatest team achievements in 2009 was our effort to 
better understand how we communicate effectively with our internal and 
external stakeholders, patients, clients and customers. We adopted a 
formal plan to align our messages--ultimately all tied to Army goals 
and those on our Balanced Scorecard. Our creation of a Strategic 
Communications Directorate to ensure alignment of our key messages, to 
better understand and use social media, to expedite cross-talk and 
learning among such diverse groups as the Office of Congressional 
Liaison, Public Affairs, Protocol, Medical History, the Borden 
Institute, the AMEDD Regiment and others speaks directly to these 
efforts.
    While we are still in the ``advanced crawl/early walk'' phase of 
knowledge management, we know from examples such as the JTTS and the 
Performance Based Budget Model that we can move best practices and 
newly found evidence-based approaches into common or widespread use if 
we aggressively coordinate and manage our efforts and promote 
transparency of data and information and the knowledge which derives 
from it. We have begun a formal process under the Strategy and 
Innovation Directorate to move the best ideas in both clinical and 
transactional processes into standard practices across the MEDCOM in a 
timely way. This will be achieved through a process to identify, 
validate, and transfer best practices. We endeavor to be more agile and 
adaptive in response to a rapidly changing terrain of U.S. and Federal 
healthcare and operational requirements for a Nation at war.
    In closing, I am very optimistic about the next 2 years. We have 
weathered some serious challenges to trust in Army Medicine. Logic 
would not predict that we would be doing as well as we are in 
attracting, retaining and career developing such a talented team of 
uniformed and civilian medical professionals. However, we continue to 
do so year after year--a tribute to all our Officer Corps, the 
leadership of our noncommissioned officers, and our military and 
civilian workforce. The results of our latest Medical Corps Graduate 
Medical Education Selection Board and the Human Capital Distribution 
Plan show continued strength and even improvements over past years. The 
continued leadership and dedicated service of officers, noncommissioned 
officers, and civilian employees are essential for Army Medicine to 
remain strong, for the Army to remain healthy and strong, and for the 
Nation to endure. I feel very privileged to serve with the men and 
women of Army medicine during this historic period as Army medics, as 
soldiers, as Americans and as global citizens.
    Thank you for holding this hearing and your unwavering support of 
the Military Health System and Army Medicine. I look forward to working 
with you and your staff and addressing any of your concerns or 
questions.

    Senator Webb. Thank you, General Schoomaker.
    Let me just very quickly thank you for those comments about 
TBI and concussive injuries. This really is a different 
phenomenon from, I think, anything we've ever seen, because of 
the echo effect of so many of these actually occurring inside 
vehicles. It's almost like shaped charge. So, you can't even 
directly compare this with football injuries----
    General Schoomaker. No, sir.
    Senator Webb.--or any of these others.
    We have a great program down at Virginia Tech that's 
examining this concept, and I thank you for that detailed 
analysis.
    General Schoomaker. This has been a great collaborative 
effort with my colleagues here, too, sir.
    Thank you.
    Senator Webb. Admiral Robinson, welcome.

 STATEMENT OF VADM ADAM M. ROBINSON, JR., USN, SURGEON GENERAL 
   OF THE U.S. NAVY, AND CHIEF, NAVY BUREAU OF MEDICINE AND 
                            SURGERY

    Admiral Robinson. Good morning, Chairman Webb, Senator 
Graham, distinguished members of the subcommittee.
    I want to thank you for your unwavering support of Navy 
Medicine, particularly as we continue to care for those who go 
into harm's way, our Marine Corps, our Navy, their families, 
and all beneficiaries.
    I am honored to be with you today to provide an update of 
the state of Navy Medicine, including some of our 
accomplishments, our challenges, and strategic priorities.
    Navy Medicine: World-Class Care, Anytime, Anywhere. This 
poignant phrase is arguably the most telling description of 
Navy Medicine's accomplishments in 2009 and continues to drive 
our operational tempo and priorities for the coming year and 
beyond.
    Throughout the last year, we saw challenges and 
opportunities. Moving forward, I anticipate the pace of 
operations and demands will continue to increase. We have been 
stretched in our ability to meet our increasing operational and 
humanitarian assistance requirements, as well as maintain our 
commitment to provide care to a growing number of 
beneficiaries. However, I am proud to say that we are 
responding to this demand with more flexibility and agility 
than ever before.
    The foundation of Navy Medicine is force-health protection; 
it's what we do and why we exist. Nowhere is our commitment 
more evident than in Iraq and Afghanistan. During my October 
2009 trip to theater, I again saw the outstanding work of our 
medical personnel. The Navy Medicine team is working side-by-
side with Army and Air Force medical personnel and coalition 
forces to deliver outstanding healthcare to our troops and 
civilians alike.
    As our wounded warriors return from combat and begin the 
healing process, they deserve a seamless and comprehensive 
approach to their recovery. We want them to mend in body, mind, 
and spirit. Our patient- and family-centered approach brings 
together medical treatment providers, social workers, care 
managers, behavioral health providers, and chaplains. We are 
working closely with our line counterparts in the Marine Corps 
Wounded Warrior Regiments, and the Navy's Safe Harbor, to 
support the full-spectrum recovery process for sailors, 
marines, and for their families.
    We must act with a sense of urgency to continue to help 
build resiliency among our sailors and marines, as well as the 
caregivers who support them. We are aggressively working to 
reduce the stigma surrounding psychological health and 
operational stress concerns, which can be a significant barrier 
to seeking mental health services.
    Programs such as Navy Operational Stress Control, Marine 
Corps Combat Operational Stress Control, Families OverComing 
Under Stress (FOCUS)--Caregiver Occupational Stress Control, 
and our Suicide Prevention Program are in place and maturing to 
provide support to personnel and to their families.
    An important focus for all of us continues to be caring for 
our warriors suffering from TBIs. We are expanding TBI training 
to healthcare providers throughout the fleet and the Marine 
Corps. We are also implementing a new in-theater TBI 
surveillance system and conducting important research. This is 
in collaboration with our sister Services and medical 
colleagues.
    We are also employing a strategy that is both collaborative 
and integrative by actively partnering with other Services, the 
Defense Centers of Excellence for Psychological Health and 
Traumatic Brain Injury, the Department of Veterans Affairs, and 
leading academic, medical, and research centers, to make the 
best care available to our warriors.
    We must continue to recognize the occupational stress on 
our caregivers. They are subject to the psychological demands 
of exposure to trauma, loss, fatigue, and inner conflict. This 
is why our Caregiver Occupational Stress Control programs are 
so important to building and sustaining the resiliency of our 
providers. Mental health specialists are being placed in 
operational environments and forward deployed to provide 
services where and when they are needed. The Marine Corps is 
sending more mental health teams to the front lines, with the 
goal of better treating an emotionally strained force. 
Operational Stress Control and Readiness teams known as OSCAR 
will soon be expanded to include the battalion level. This will 
put mental health support services much closer to combat 
troops. A mobile care team of Navy Medicine mental health 
professionals is currently deployed to Afghanistan, conducting 
mental health surveillance, command leadership consultation, 
and coordinate mental health care for sailors throughout the 
AOR.
    An integral part of the Navy's Maritime Strategy is 
humanitarian assistance and disaster relief. In support of 
Operation Unified Response Haiti, Navy Medicine answered the 
call. We deployed the Hospital Ship Comfort from her homeport 
in Baltimore within 77 hours of the order and ahead of 
schedule.
    Senator Webb. Admiral?
    Admiral Robinson. Yes, sir?
    Senator Webb. Just making an announcement, here.
    Apparently, the Republicans are objecting to all hearings 
after 11:00 this morning, except for one. Senator Graham is 
going to try to see----
    Senator Graham. Yes, I would like to----
    Senator Webb.--if we can't get ours also excluded, but----
    Senator Graham. Yes, I want to hear what you have to say, 
if I can.
    Senator Webb. How do we do this, Senator?
    Senator Graham. They're checking on it, now. Let's just 
keep going, and we'll figure out what the rules are.
    Senator Begich. Mr. Chairman?
    Senator Webb. Yes?
    Senator Begich. With or without it, can we just continue on 
and just have it as a non-hearing hearing?
    Make the rules as we go, is my rule. [Laughter.]
    Why not?
    I mean these guys have come----
    Senator Webb. I suppose we could go into informal 
conversation, if they cancel the hearing at 11 a.m. I don't 
know what that would do to the official transcript of the 
hearing, or that sort of thing. But, I----
    Senator Begich. I think this is an important issue.
    Senator Graham. I want to hear what they have to say.
    Senator Webb. Okay.
    Senator Graham.--we'll figure out----
    Senator Webb. Let's proceed.
    Senator Begich. I don't think you have support, bipartisan, 
for this effort, Mr. Chairman. [Laughter.]
    Admiral Robinson. Thank you very much, sir.
    An integral part of Navy's Maritime Strategy is 
humanitarian assistance and disaster response. In support of 
Operation Unified Response Haiti, Navy Medicine answered the 
call. We deployed Naval Hospital Ship Comfort within 77 hours 
of the order and ahead of schedule. She was on station in Port-
au-Prince 5 days later. From the beginning, the operational 
tempo on board Comfort was high and our personnel were 
challenged, both professionally and personally. For many, this 
was a career-defining experience, and I was proud to welcome 
the crew home last week and congratulate them for their 
outstanding performance. The men and women of Comfort and all 
involved in this mission saved lives, alleviated suffering, and 
brought hope in the midst of devastation.
    I'm also encouraged with our recruiting efforts within Navy 
Medicine, and we are starting to see the results of new 
incentive programs. But, while overall manning levels for both 
officer and enlisted personnel are relatively high, ensuring we 
have the proper specialty mix continues to be a challenge in 
both the Active and Reserve components. Several wartime 
critical specialties, as well as advanced practice nursing and 
physicians' assistants are undermanned. We are also facing 
shortfall for general dentists, oral maxilla facial surgeons, 
and many of our mental health specialists, including clinical 
psychologists and social workers. We continue to work hard to 
meet this demand, but fulfilling the requirements among these 
specialties is expected to present a continuing challenge.
    Research and development is critical to Navy Medicine's 
success and our ability to remain agile to meet the evolving 
needs of our warfighters. It is where we find solutions to our 
most challenging problems and, at the same time, provide some 
of medicine's most significant innovations and discoveries. 
Research efforts targeted at wound management, including 
enhanced wound repair and reconstruction, as well as extremity 
and internal hemorrhage control and phantom limb pain in 
amputees, present definitive benefits. These efforts support 
our emerging expeditionary medical operations and aid in 
support of our wounded warriors.
    Clearly, one of the most important priorities for 
leadership of all the Services is the successful transition to 
the Walter Reed National Military Medical Center on board the 
campus of the National Naval Medical Center in Bethesda. We are 
working diligently with the lead DOD organization, Joint Task 
Force National Capital Region Medical, to ensure that this 
significant and ambitious project is executed properly and 
without disruption of services to our wounded warrior, our 
sailors, marines, and their families, and all other 
beneficiaries that we are privileged to serve.
    In summary, I believe we are at an important crossroads for 
military medicine. How we respond to challenges facing us today 
will likely set the stage for decades to come. Commitment to 
our wounded warriors and their families must never waver, and 
our programs of support and hope must be built and sustained 
for the long haul. The long haul is the rest of the century, 
when the young wounded warriors of today mature into aging 
heroes in the years to come. They will need our care and 
support, as will their families, for a lifetime.
    On behalf of the men and women of Navy Medicine, I want to 
thank the committee for your tremendous support, your 
confidence, and your leadership. It has been my pleasure to 
speak before you today, and I look forward to your questions.
    [The prepared statement of Admiral Robinson follows:]
       Prepared Statement by VADM Adam M. Robinson, Jr., MC, USN
                              introduction
    Chairman Webb, Senator Graham, distinguished members of the 
subcommittee, I am honored to be with you today to provide an update on 
the state of Navy Medicine, including some of our accomplishments, 
challenges and strategic priorities. I want to thank the committee 
members for your unwavering support of Navy Medicine, particularly as 
we continue to care for those who go in harm's way, their families and 
all beneficiaries.
    Navy Medicine-World Class Care . . . Anytime, Anywhere. This 
poignant phrase is arguably the most telling description of Navy 
Medicine's accomplishments in 2009 and continues to drive our 
operational tempo and priorities for the coming year and beyond. 
Throughout the last year we saw challenges and opportunities; and 
moving forward, I anticipate the pace of operations and demands placed 
upon us will continue to increase. Make no mistake: We have been 
stretched in our ability to meet our increasing operational and 
humanitarian assistance requirements, as well as maintain our 
commitment to provide Patient and Family-Centered care to a growing 
number of beneficiaries. However, I am proud to say to that we are 
responding to this demand with more flexibility and agility than ever 
before. We are a vibrant, world-wide health care system fully engaged 
and integrated in carrying out the core capabilities of the Maritime 
Strategy around the globe. Regardless of the challenges ahead, I am 
confident that we are well-positioned for the future.
    Since becoming the Navy Surgeon General in 2007, I have invested 
heavily in our strategic planning process. How we accomplish our 
mission is rooted in sound planning, sharp execution and constructive 
self-assessment at all levels of our organization. I challenged our 
leadership to create momentum and establish a solid foundation of 
measurable progress. It's paying dividends. We are seeing improved and 
sustained performance in our strategic objectives. Just as importantly, 
our planning process supports alignment with the Department of Navy's 
Strategic Plan and Operations Guidance.
    Navy Medicine's commitment to Patient and Family-Centered Care is 
also reflected in our resourcing processes. An integral component of 
our Strategic Plan is providing performance incentives that promote 
quality and directly link back to workload and resources. We are 
evolving from a fiscal planning and execution process rooted in 
historical data, to a system which links requirements, resources and 
performance goals. This transformation to Performance Based Budgeting 
properly aligns authority, accountability, and financial responsibility 
with the delivery of quality, cost-effective health care.
    The President's budget for fiscal year 2011 adequately funds Navy 
Medicine to meet its medical mission for the Navy and Marine Corps. The 
budget also provides for the maintenance of our facilities. We 
appreciate the committee's strong support of our resource requirements.
                        force health protection
    The foundation of Navy Medicine is Force Health Protection. It's 
what we do and why we exist. In executing our Force Health Protection 
mission, the men and women of Navy Medicine are engaged in all aspects 
of expeditionary medical operations in support of our warfighters. The 
continuum of care we provide includes all dimensions of physical and 
psychological well-being. This is our center of gravity and we have and 
will continue to ensure our sailors and marines are medically and 
mentally prepared to meet their world-wide missions.
    Nowhere is our commitment to Force Health Protection more evident 
than in our active engagement in military operations in Iraq and 
Afghanistan. As these overseas contingency operations evolve, and in 
many respects become increasingly more dangerous, we are seeing 
burgeoning demand for expeditionary combat casualty care in support of 
joint operations. I recently returned from a trip to Afghanistan and I 
again saw the outstanding work of our medical personnel. The Navy 
Medicine team is working side-by-side with Army and Air Force medical 
personnel and coalition forces to deliver outstanding health care to 
our troops and civilians alike.
    We must continue to be innovative and responsive at the deckplates 
and on the battlefield. Since the start of Operation Enduring Freedom 
and Operation Iraqi Freedom, the Marine Corps has fielded new combat 
casualty care capabilities which include: updated individual first aid 
kits with combat gauze, advanced tourniquets, use of Tactical Combat 
Casualty Care principles, troop training in Combat Lifesaver, and the 
use of Factor VII--a blood clotting agent used in trauma settings. In 
addition, Navy Fleet Hospital transformation has redesigned 
expeditionary medical facilities that are lighter, modular, more 
mobile, and interoperable with other Services' facilities.
    Our progress is also evident in the innovative work undertaken by a 
Shock Trauma Platoon 2 years ago in Afghanistan. This team, comprised 
of 2 physicians, 2 nurses, 1 physician assistant, and 14 corpsmen, 
essentially created a mobile emergency room--a 7-ton truck with a Conex 
container and welded steel plates--that went into combat to administer 
more expedient and effective care in austere settings. This prototype 
led to the creation of the Mobile Trauma Bay (MTB), a capability that 
both Marine Corps and Navy Medicine leadership immediately recognized 
as vital to the warfighter and an unquestionable lifesaver on the 
battlefield. MTB use has already been incorporated into our Afghanistan 
shock trauma platoon operations, and they are already positively 
impacting forward resuscitative and stabilization care. We understand 
that the Marine Corps has fully embraced the MTB concept and is 
planning to add additional units in future POM submissions.
Humanitarian Assistance and Disaster Response
    An integral part of the Navy's Maritime Strategy is humanitarian 
assistance and disaster response. In the wake of the devastating 
earthquake in Haiti earlier this year, our Nation moved forward with 
one of the largest relief efforts in our history to save lives, deliver 
critically needed supplies and provide much-needed hope. The response 
was rapid, as Navy deployed ships and expeditionary forces, comprised 
of more than 10,000 personnel, to provide immediate relief and support 
for the Haitian people. In support of Operation Unified Response, Navy 
Medicine answered the call. We deployed USNS Comfort (T-AH 20) from her 
homeport in Baltimore within 77 hours and ahead of schedule--going from 
an industrial shipboard site to a ready afloat naval hospital, fully 
staffed and equipped. She was on station in Port-au-Prince 5 days later 
and treating patients right away. From the beginning, the operational 
tempo onboard USNS Comfort has been high with a significant trauma and 
surgical caseload. Medical teams from the ship are also ashore to help 
in casualty evaluation, triage crush wounds, burn injuries and other 
health issues. Providing care around the clock, our personnel were 
challenged both professionally and personally. For many, this was a 
career-defining experience and certainly reflects the Navy's commitment 
as a ``Global Force for Good.'' I spoke to the crew as they were 
preparing to get underway, and personally related just how important 
this mission is and why it is a vital part of the Navy's Maritime 
Strategy.
    Navy Medicine provided additional support that included the 
deployment of a Forward Deployed Preventive Medicine Unit and augmented 
Casualty Receiving and Treatment Ship medical staff capabilities 
onboard USS Bataan (LHD 5). We also recognized the potential 
psychological health impact on our medical personnel involved in this 
humanitarian assistance mission and ensured we had trained Caregiver 
Occupational Stress Control (CgOSC) staff onboard.
    The ship departed Haiti on 10 March 2010. Prior to getting 
underway, the crew gathered for a memorial ceremony in honor of the 
people of Haiti. The men and women of USNS Comfort, and all involved in 
this mission, saved lives, alleviated suffering, and brought hope in 
the midst of devastation. Their performance and spirit of caring was 
exemplary.
    Navy Medicine is inherently flexible and capable of meeting the 
call to support multiple missions. I am proud of the manner in which 
the men and women of Navy Medicine leaned forward in response to the 
call for help. In support of coordination efforts led by the Department 
of State and the U.S. Agency for International Development, and in 
collaboration with nongovernmental organizations, both domestic and 
international, our response demonstrated how the expeditionary 
character of our Naval and Marine forces is uniquely suited to provide 
assistance during interagency and multinational efforts.
                            concept of care
    Navy Medicine's Concept of Care is Patient and Family-Centered 
Care. It is at the epicenter of everything we do. This concept is 
elegant in its simplicity yet extraordinarily powerful. It identifies 
each patient as a participant in his or her own health care and 
recognizes the vital importance of the family, military culture and the 
military chain of command in supporting our patients. My goal is for 
this Concept of Care--this commitment to our patients and their 
families--to resonate throughout our system and guide all our actions. 
It is enabled by our primary mission to deliver force health protection 
and a fully ready force; mutually supported by the force multipliers of 
world class research and development, and medical education. It also 
leverages our emphasis on the health and wellness of our patients 
through an active focus on population health.
                         caring for our heroes
    When our Warriors go into harm's way, we in Navy Medicine go with 
them. At sea or on the ground, sailors and marines know that the men 
and women of Navy Medicine are by their side ready to care for them. 
There is a bond of trust that has been earned over years of service 
together, and make no mistake, today that bond is stronger than ever. 
Our mission is to care for our wounded, ill, and injured, as well as 
their families. That's our job and it is our honor to have this 
opportunity.
    As our Wounded Warriors return from combat and begin the healing 
process, they deserve a seamless and comprehensive approach to their 
recovery. We want them to mend in body, mind and spirit. Our focus is 
multidisciplinary-based care, bringing together medical treatment 
providers, social workers, case managers, behavioral health providers 
and chaplains. We are working closely with our line counterparts with 
programs like the Marine Corps' Wounded Warrior Regiments and the 
Navy's Safe Harbor to support the full-spectrum recovery process for 
sailors, marines, and their families.
    Based on the types of injuries that we see returning from war, Navy 
Medicine continues to adapt our capabilities to best treat these 
conditions. When we saw a need on the west coast to provide expanded 
care for returning Wounded Warriors with amputations, we established 
the Comprehensive Combat and Complex Casualty Care (C5) Program at 
Naval Medical Center, San Diego, in 2007. C5 manages severely injured 
or ill patients from medical evacuation through inpatient care, 
outpatient rehabilitation, and their eventual return to active duty or 
transition from the military. We are now working to expand utilization 
of Project C.A.R.E - Comprehensive Aesthetic Recovery Effort. This 
initiative follows the C5 model by ensuring a multidisciplinary 
approach to care, yet focuses on providing state-of-the-art plastic and 
reconstructive surgery for our Wounded Warriors at both Naval Medical 
Center San Diego and Naval Medical Center Portsmouth, with potential 
future opportunities at other treatment facilities.
    We have also significantly refocused our efforts in the important 
area of clinical case management at our military treatment facilities 
and major clinics serving Wounded Warriors to ensure appropriate case 
management services are available to all who need them. The Clinical 
Case Management Program assists patients and families with clinical and 
non-clinical needs, facilitating communication between patient, family 
and multi-disciplinary care team. Our clinical case managers 
collaborate with Navy and Marine Corps Recovery Care Coordinators, 
Federal Recovery Coordinators, Non-Medical Care Managers and other 
stakeholders to address sailor and marine issues in developing Recovery 
Care Plans. As of January 2010, 192 Clinical Case Managers are assigned 
to Military Treatment Facilities and ambulatory care clinics caring for 
over 2,900 sailors, marines, and coastguardsmen.
             psychological health and post-traumatic stress
    We must act with a sense of urgency to help build resiliency among 
our sailors and marines, as well as the caregivers who support them. We 
recognize that operational tempo, including the number and length of 
deployments, has the potential to impact the psychological health of 
servicemembers and their family members. We are aggressively working to 
reduce the stigma surrounding psychological health and operational 
stress concerns which can be a significant barrier to seeking mental 
health services for both military personnel and civilians. Programs 
such as Navy Operational Stress Control, Marine Corps Combat 
Operational Stress Control, Families Overcoming Under Stress (FOCUS), 
CgOSC, and our suicide prevention programs (A-C-T Ask-Treat-Care) are 
in place and maturing to provide support to personnel and their 
families.
    The Navy Operational Stress Control program and Marine Corps Combat 
Operational Stress Control program are the cornerstones of the 
Department of the Navy's approach to early detection of stress injuries 
in sailors and marines and are comprised of:

         Line led programs which focus on leadership's role in 
        monitoring the health of their people.
         Tools leaders may employ when sailors and marines are 
        experiencing mild to moderate symptoms.
         Multidisciplinary expertise (medical, chaplains, and 
        other support services) for more affected members.

    Decreasing the stigma associated with seeking psychological health 
care requires a culture change throughout the Navy and Marine Corps. 
Confronting an ingrained culture will take time and active leadership 
support. Stigma reducing interventions span three major fronts: (1) 
education and training for individual sailors and marines that 
normalizes mental health care; (2) leadership training to improve 
command climate support for seeking mental health care; and (3) 
encouragement of care outreach to individual sailors, marines, and 
their commands. This past year saw wide-spread dissemination of 
Operational Stress Control (OSC) doctrine as well as a Navy-wide 
education and training program that includes mandatory Navy Knowledge 
Online courses, instructor led and web-based training.
    Navy Medicine ensures a continuum of psychological health care is 
available to servicemembers throughout the deployment cycle--pre-
deployment, during deployment, and post-deployment. We are working to 
improve screening and surveillance using instruments such as the 
Behavior Health Needs Assessment Survey (BHNAS) and Post-Deployment 
Health Assessment (PDHA) and Post-Deployment Health Reassessment 
(PDHRA).
    Our mental health specialists are being placed in operational 
environments and forward deployed to provide services where and when 
they are needed. The Marine Corps is sending more mental health teams 
to the front lines with the goal of better treating an emotionally 
strained force. Operational Stress Control and Readiness (OSCAR) teams 
will soon be expanded to include the battalion level, putting mental 
health support services much closer to combat troops. A Mobile Care 
Team (MCT) of Navy Medicine mental health professionals is currently 
deployed to Afghanistan to conduct mental health surveillance, command 
leadership consultation, and coordinate mental health care for sailors 
throughout the AOR. In addition to collecting important near real-time 
surveillance data, the MCT is furthering our efforts to decrease stigma 
and build resilience.
    We are also making mental health services available to family 
members who may be affected by the psychological consequences of combat 
and deployment through our efforts with Project FOCUS, our military 
treatment facilities and our TRICARE network partners. Project FOCUS 
continues to be successful and we are encouraged that both the Army and 
Air Force are considering implementing this program. We also recognize 
the importance of the counseling and support services provided through 
the Fleet and Family Support Centers and Marine Corps Community 
Services.
    Beginning in 2007, Navy Medicine established Deployment Health 
Centers (DHCs) as non-stigmatizing portals of care for servicemembers 
staffed with primary care and psychological health providers. We now 
have 17 DHCs operational. Our health care delivery model supports early 
recognition and treatment of deployment-related psychological health 
issues within the primary care setting. Psychological health services 
account for approximately 30 percent of all DHC encounters. We have 
also increased mental health training in primary care, and have 
actively partnered with Line leaders and the Chaplain Corps to develop 
combat and operational stress control training resources. Awareness and 
training are keys to our surveillance efforts. Over 4,000 Navy Medicine 
providers, mental health professionals, chaplains and support personnel 
have been trained to detect, screen, and refer personnel who may be 
struggling with mental health issues.
    We must continue to recognize the occupational stress on our 
caregivers. They are subject to the psychological demands of exposure 
to trauma, loss, fatigue, and inner conflict. This is why our Caregiver 
Occupational Stress Control programs are so important to building and 
sustaining the resiliency of our providers. We cannot overlook the 
impact on these professionals and I have directed Navy Medicine 
leadership to be particularly attuned to this issue within their 
commands.
                         traumatic brain injury
    While there are many significant injury patterns in theatre, an 
important focus area for all of us remains Traumatic Brain Injury 
(TBI). Blast is the signature injury of OEF and OIF--and from blast 
injury comes TBI. The majority of TBI injuries are categorized as mild, 
or in other words, a concussion. Yet, there is much we do not yet know 
about these injuries and their long-term impacts on the lives of our 
servicemembers.
    The relative lack of knowledge about mild TBI amongst 
servicemembers and health care personnel represents an important gap 
that Navy Medicine is seriously addressing. We are providing TBI 
training to health care providers from multiple disciplines throughout 
the fleet and the Marine Corps. This training is designed to educate 
personnel about TBI, introduce the Military Acute Concussion Exam 
(MACE) as a screening tool for mild TBI, inform providers about the 
Automated Neurocognitive Assessment Metric (ANAM) test, and identify a 
follow-up for assessment including use of a repeatable test battery for 
identification of cognitive status. We have recently established and 
are now expanding our TBI program office to manage the implementation 
of the ANAM as a pre-deployment test for servicemembers in accordance 
with DOD policy. This office will further develop models of assessment 
and care as well as support research and evaluation programs.
    All the Services expect to begin implementation of a new in-theater 
TBI surveillance system which will be based upon incident event 
tracking. Promulgated guidelines will mandate medical evaluation for 
all servicemembers exposed within a set radius of an explosive blast, 
with the goal to identify any servicemember with subtle cognitive 
deficits who may not be able to return to duty immediately.
    Navy Medicine has begun implementing the ANAM assessment at the 
DHCs and within deploying units as part of an assistant Secretary of 
Defense (Health Affairs) mandate. We have also partnered with line 
leadership, or operational commanders, to identify populations at risk 
for brain injury (e.g., front-line units, SEAL units, and Navy 
Explosive Ordinance Disposal units). In addition, an in-theater 
clinical trial for the treatment of vestibular symptoms of blast-
exposure/TBI was completed at the USMC mTBI Center in Al Taqqadum, 
Iraq.
    Both our Naval Health Research Center and Navy-Marine Corps Public 
Health Center are engaged with tracking TBI data through ongoing 
epidemiology programs. Goals this year include the establishment of a 
restoration center in-theatre to allow injured sailors and marines a 
chance to recover near their units and return to the fight.
    Additionally, the National Naval Medical Center's Traumatic Stress 
and Brain Injury Program provides care to all blast-exposed or head-
injured casualties returning from theatre to include patients with an 
actual brain injury and traumatic stress. Navy Medicine currently has 
TBI clinics at San Diego, Portsmouth, Camp Pendleton, and Camp Lejeune 
with plans for further expansion reflecting our commitment to the 
treatment of this increasingly prevalent injury.
    We are employing a strategy that is both collaborative and 
integrative by actively partnering with the other Services, Defense 
Center of Excellence for Psychological Health and Traumatic Brain 
Injury, the Veterans Administration, and leading academic medical and 
research centers to make the best care available to our Warriors 
afflicted with TBI.
                 excellence in research and development
    Research and development is critical to Navy Medicine's success and 
our ability to remain agile to meet the evolving needs of our 
warfighters. It is where we find solutions to our most challenging 
problems and, at the same time, provide some of medicine's most 
significant innovations and discoveries. Our research and development 
programs are truly force-multipliers and enable us to provide world-
class health care to our beneficiaries.
    The approach at our research centers and laboratories around the 
world is straightforward: Conduct health and medical research, 
development, testing, evaluation and surveillance to enhance deployment 
readiness. Each year, we see more accomplishments which have a direct 
impact on improving force health protection. The contributions are many 
and varied, ranging from our confirmatory work in the early stages of 
the H1N1 pandemic, to the exciting progress in the development of a 
malaria vaccine. Research efforts targeted at wound management, 
including enhanced wound repair and reconstruction as well as extremity 
and internal hemorrhage control, and phantom limb pain in amputees, 
present definitive benefits. These efforts also support our emerging 
expeditionary medical operations and aid in support to our Wounded 
Warriors.
                         the navy medicine team
    Navy Medicine is comprised of compassionate and talented 
professionals who continue to make significant contributions and 
personal sacrifices to our global community. Our team includes our 
officers, enlisted personnel, government civilian employees, contract 
workers and volunteers working together in a vibrant health care 
community. All have a vital role in the success of our enterprise. Our 
priority is to maintain the right workforce to deliver the required 
medical capabilities across the enterprise, while using the appropriate 
mix of accession, retention, education and training incentives.
    Overall, I am encouraged with our recruiting efforts within Navy 
Medicine and we are starting to see the results of new incentive 
programs. But while overall manning levels for both officer and 
enlisted personnel are relatively high, ensuring we have the proper 
specialty mix continues to be a challenge. Several wartime critical 
specialties including psychiatry, family medicine, general surgery, 
emergency medicine, critical care and perioperative nursing, as well as 
advanced practice nursing and physician assistants, are undermanned. We 
are also facing shortfalls for general dentists, oral maxillofacial 
surgeons, and many of our mental health specialists including clinical 
psychologists and social workers. We have increasing requirements for 
mental health professionals as well as for Reserve Component Medical 
Corps, Dental Corps, Medical Service Corps, and Nurse Corps officers. 
We continue to work hard to meet this demand, but fulfilling the 
requirements among these specialties is expected to present a 
continuing challenge.
    I want to also reemphasize the priority we place on diversity. We 
are setting the standard for building a diverse, robust, innovative 
health care workforce, but we can do more in this important area. Navy 
Medicine is stronger and more effective as a result of our diversity at 
all levels. Our people are our most important resource, and their 
dignity and worth are maintained through an atmosphere of service, 
professionalism, trust and respect.
                     partnerships and collaboration
    Navy Medicine continues to focus on improving interoperability with 
the Army, Air Force, Veterans Administration (VA), as well other 
Federal and civilian partners to bring operational efficiencies, 
optimal technology and training together in support of our patients and 
their families, our missions, and the national interests. Never has 
this collaborative approach been more important, particularly as we 
improve our approaches to ensuring seamless transitions for our 
veterans.
    We remain committed to resource sharing agreements with the VA and 
our joint efforts in support of improving the Disability Evaluation 
System (DES) through the ongoing pilot program at several MTFs. The 
goal of this pilot is to improve the disability evaluation process for 
servicemembers and help simplify their transitions. Together with the 
VA and the other Services, we are examining opportunities to expand 
this pilot to additional military treatment facilities. Additionally, 
in partnership with the VA, we will be opening the James A. Lovell 
Federal Health Care Center in Great Lakes, IL--a uniquely integrated 
Navy/VA medical facility.
    We also look forward to leveraging our inter-service education and 
training capabilities with the opening of the Medical Education and 
Training Campus in San Antonio in 2010. This new tri-service command 
will oversee the largest consolidation of service training in DOD 
history. I am committed to an inter-service education and training 
system that optimizes the assets and capabilities of all DOD health 
care practitioners yet maintains the unique skills and capabilities 
that our hospital corpsmen bring to the Navy and Marine Corps--in 
hospitals, clinics at sea and on the battlefield.
    Clearly one of the most important priorities for the leadership of 
all the Services is the successful transition to the Walter Reed 
National Military Medical Center onboard the campus of the National 
Naval Medical Center, Bethesda. We are working diligently with the lead 
DOD organization, Joint Task Force--National Capital Region Medical, to 
ensure that this significant and ambitious project is executed properly 
and without any disruption of services to our sailors, marines, their 
families, and all our beneficiaries for whom we are privileged to 
serve.
                            the way forward
    I believe we are at an important crossroads for military medicine. 
How we respond to the challenges facing us today will likely set the 
stage for decades to come. Commitment to our Wounded Warriors and their 
families must never waver and our programs of support and hope must be 
built and sustained for the long-haul--and the long-haul is the rest of 
this century when the young Wounded Warriors of today mature into our 
aging heroes in the years to come. They will need our care and support 
as will their families for a lifetime. Likewise, our missions of 
cooperative engagement, through humanitarian assistance and disaster 
response, bring opportunities for us, our military, and the Nation. It 
is indeed a critical time in which to demonstrate that the U.S. Navy is 
truly a ``Global Force for Good.''
    Navy Medicine is a vibrant, world-wide health care system comprised 
of compassionate and talented professionals who are willing to make 
contributions and personal sacrifices. This team--our team--including 
officer, enlisted, civilians, contractors, and volunteers work together 
as a dynamic health care family. We are all essential to success.
    Navy Medicine will continue to meet the challenges ahead and 
perform our missions with outstanding skill and commitment. On behalf 
of the men and women of Navy Medicine, I want to thank the committee 
for your tremendous support, confidence, and leadership. It has been my 
pleasure to testify before you today and I look forward to your 
questions.

    Senator Webb. Thank you very much, Admiral Robinson.
    General Green, welcome.

 STATEMENT OF LT. GEN. CHARLES B. GREEN, USAF, SURGEON GENERAL 
                     OF THE U.S. AIR FORCE

    General Green. Thank you, sir.
    Chairman Webb, Senator Graham, and distinguished members of 
the committee, it's an honor and a privilege to appear before 
you, representing the Air Force Medical Service.
    I look forward to working with you and pledge to do all in 
my power to support the men and women or our Armed Forces and 
this great country. Thank you for your immeasurable 
contributions to the success of our mission.
    ``Trusted Care Anywhere'' is our vision for 2010 and 
beyond. Our nearly 60,000 total-force medics contribute world-
class medical capabilities to Air Force, joint, and coalition 
teams around the world. Seventeen hundred Air Force medics are 
currently deployed to 40 locations in 20 countries, delivering 
state-of-the-art preventive medicine, rapid lifesaving care, 
and critical air evacuation. Since November 2001, we've air-
evac'd over 70,000 patients from Afghanistan and Iraq, and have 
lost only 4 patients during evacuation.
    Air Force medics are responding globally in humanitarian 
missions, as well as on the battlefield, and in just the last 6 
months, we contributed significant support to Indonesia, Haiti, 
and the Chilean earthquake victims.
    This is a year of firsts. The first known successful air 
evacuation of a patient with traumatic lung removal was done 
last July. The patient is doing well in Birmingham, England, 
today.
    In January 2010, a U.S. marine sustained dislocation of 
both knees, with loss of blood flow to his lower legs, 
following an IED attack in the Helmand Province. Air Force 
surgeons performed definitive vascular reconstruction within 
hours of the injury, and the marine is now recovering in the 
National Naval Medical Center in Bethesda, and is expected to 
have fully functional limbs.
    An airman shot three times in the back will not be a 
diabetic, despite the absence of his pancreas, because surgeons 
across three continents harvested and grew his pancreatic cells 
then implanted the cells into his liver at Walter Reed.
    These success stories are possible only because of tireless 
efforts of Air Force, Army, Navy, and coalition medics to 
continuously improve our care.
    At home, our healthcare teams provide patient-centered 
full-spectrum healthcare to our beneficiaries. We're improving 
patient and provider satisfaction through our Patient-Centered 
Medical Home by building strong partnerships between patients 
and their healthcare teams. Our Family Health Initiative and 
Surgical Care Optimization Initiatives are improving healthcare 
continuity, quality, access, and patient satisfaction.
    Our Air Force Suicide Prevention Program, implemented in 
1997, continues to be effective, but we have noted a slowly 
increasing rate of suicides since 2007. We are enhancing our 
prevention programs to further decrease suicides by targeting 
the most stressed by our high operations tempo. We now target 
more indepth interventions and training to Air Force security 
forces and intelligence career fields, whom we have identified 
as having double the incidence of suicide, compared to the rest 
of the Air Force.
    We continue training the entire force on suicide prevention 
and coping skills, to improve both airmen and family 
resilience. We adapted new concepts rapidly, such as ``Ask, 
Care, and Escort'' and collaborative care, wherein mental 
health providers are now embedded in the majority of our family 
health clinics.
    We have also studied and targeted interventions for our 
civilian workforce identified at high risk. Collaborative care, 
online help, mandatory post-deployment surveys, and family-life 
counselors at our Airman and Family Readiness centers, have 
decreased stigma and allowed those in need to get help earlier.
    We're encouraged by the continued low indicators for stress 
in the Air Force. Alcohol abuse remains low and stable, as does 
illegal and prescription drug abuse. We target programs to 
further reduce underage drinking and enhance safety. Our 
numbers in domestic violence are trending downward. We continue 
to monitor these indicators carefully to target effective 
interventions.
    To achieve our vision of ``Trusted Care Anywhere,'' we 
require highly-trained, current, and qualified providers, and 
we're extremely grateful to this committee for your many 
efforts to strengthen our recruiting and retention programs.
    The Air Force Medical Service is committed to the health 
and wellness of all entrusted to our care. We are, indeed, all 
in to meet our Nation's call, and will achieve our vision 
through determined, continuous improvement. We could not 
achieve our goals of better readiness, better health, better 
care, and best value for our heroes and their families without 
your support, and we thank you.
    I stand ready for your questions, sir.
    [The prepared statement of General Green follows:]
      Prepared Statement by Lt. Gen. (Dr.) Charles B. Green, USAF
    Chairman Webb, Senator Graham, and distinguished members of the 
subcommittee, it is an honor and a privilege to appear before you 
representing the Air Force Medical Service and our 60,000 Total Force 
medics. I'm looking forward to working with you during my tenure as Air 
Force Surgeon General. I pledge to do all in my power to support the 
men and women of the Armed Forces and this great country. Thank you for 
your immeasurable contributions to the success of our mission.
    ``Trusted Care Anywhere'' is the Air Force Medical Service's vision 
for 2010 and beyond. In the domain of Air, Space and Cyberspace, our 
medics contribute to the Air Force, Joint, and coalition team with 
world class medical capabilities. Our 60,000 high performing Total 
Force medics around the globe are trained and ready for mission 
success. Over 1,600 Air Force medics are now deployed to 40 locations 
in 20 countries, building partnership capability and delivering state 
of the art preventive medicine, rapid lifesaving care, and critical air 
evacuation. In all cases, these efforts are conducted with joint and 
coalition partners. At home, our health care teams assure patient-
centered care to produce healthy and resilient airmen, and provide our 
families and retirees with full spectrum health care.
    Today's focus is on world-class health care delivery systems across 
the full spectrum of our operations. From theater hospitals in Balad 
and Bagram, to the efforts of humanitarian assistance response teams, 
to the care of our families at home, we put patients first. We are 
transforming deployable capabilities, building patient-centered care 
platforms, and investing in our people, the foundation of our success. 
We are expanding collaboration with joint and coalition partners to 
collectively strengthen rapid response capabilities. Globally, Air 
Force medics are diligently working to balance the complex demands of 
multiple missions in current and expanding areas of operations.
    We are committed to advancing capabilities through education and 
training, research, and infrastructure recapitalization. Recent efforts 
in these areas have paid huge dividends, establishing new standards in 
virtually every major category of full spectrum care including 
humanitarian assistance. The strategic investments assure a trained, 
current, and deployable medical force today and tomorrow. They 
reinforce a culture of learning to quickly adapt medical systems and 
implement agile organizations to produce healthier outcomes in diverse 
mission areas.
    While we've earned our Nation's trust with our unique capabilities 
and the expertise of our people, we constantly seek to do better! I 
would like to highlight our areas of strategic focus and share some 
captivating examples of Air Force medics in action.
    transforming expeditionary medicine and aeromedical evacuation 
                              capabilities
    Our success on the battlefield underscores our ability to provide 
``Trusted Care, Anywhere.'' The joint and coalition medical teams bring 
wounded warriors from the battlefield to an operating room within an 
unprecedented 20 to 40 minutes! This rapid transfer rate enables medics 
to achieve a less than 10 percent died-of-wounds rate, the best 
survival rate ever seen in war.
    In late July, a British soldier sustained multiple gunshot wounds 
in Afghanistan. After being stabilized by medical teams on the ground, 
who replaced his blood supply more than 10 times, doctors determined 
the patient had to be moved to higher levels of care in Germany. It 
took two airplanes to get the medical team and equipment in place, 
another aircraft to fly the patient to Germany, three aircrews and many 
more personnel coordinating on the ground to get this patient to the 
next level of care. Every member of the joint casualty care and 
aeromedical evacuation teams selflessly gave their all to ensure this 
soldier received the compassionate care he deserved. After landing 
safely at Ramstein Air Base in Germany, the soldier was flown to 
further medical care at a university hospital by helicopter. This case 
highlights the dedication and compassion our personnel deliver in the 
complex but seamless care continuum. This tremendous effort contributes 
to our unprecedented survival rate.
    As evidenced in this story, our aeromedical evacuation system (AE) 
and critical care air transport teams are world-class. We mobilize 
specially trained flight crews and medical teams on a moment's notice 
to transport the most critical patients across oceans. Since November 
2001, we have transported more than 70,000 patients from Afghanistan 
and Iraq.
    We are proud of our accomplishments to date, but strive for further 
innovation. As a result of battlefield lessons learned, we have 
recently implemented a device to improve spinal immobilization for AE 
patients that maximizes patient comfort and reduces skin pressure. We 
are working toward an improved detection mechanism for compartment 
syndrome in trauma patients. The early detection and prevention of 
excess compartment pressure could eliminate irreversible tissue damage 
for patients. In February 2010, a joint Air Force and Army team will 
begin testing equipment packages designed to improve ventilation, 
oxygen, fluid resuscitation, physiological monitoring, hemodynamic 
monitoring and intervention in critical care air transport.
             information management/information technology
    Our Theater Medical Information Program Air Force (TMIP AF) is a 
software suite that automates and integrates clinical care 
documentation, medical supplies, equipment, and patient movement. It 
provides the unique capabilities for in-transit visibility and 
consolidated medical information to improve command and control and 
allow better preventive surveillance at all Air Force deployed 
locations. This is a historic first for the TMIP AF program.
    Critical information is gathered on every patient, then entered 
into the Air Force Medical Service (AFMS) deployed system. Within 24 
hours, records are moved and safely stored at secure consolidated 
databases in the United States. During the first part of 2010, TMIP AF 
will be utilized in Aeromedical Evacuation and Air Force Special 
Operations areas.
           expeditionary medicine and humanitarian assistance
    We have also creatively developed our Humanitarian Assistance Rapid 
Response Team (HARRT), a Pacific Command (PACOM) initiative, to 
integrate expeditionary medical systems and support functions. The 
HARRT provides the PACOM Commander with a rapid response package that 
can deploy in less than 24 hours, requires only two C-17s for transport 
and can be fully operational within hours of arrival at the disaster 
site. This unique capability augments host nation efforts during the 
initial stages of rescue/recovery, thus saving lives, reducing 
suffering, and preventing the spread of disease. So far, HARRT 
successfully deployed on two occasions in the Pacific. Efforts are 
underway to incorporate this humanitarian assistance and disaster 
relief response capability into all AFMS Expeditionary Medical System 
(EMEDS) assets.
    Air Force medics contribute significant support to the treatment 
and evacuation of Haiti earthquake victims. The Air Force Special 
Operations Command sent 47 medics to support Air Force Special 
Operations Command troops on the ground within 12 hours following the 
disaster to perform site assessments, establish preventive public 
health measures, and deliver lifesaving trauma care to include surgical 
and critical care support. This team was also instrumental in working 
with Southern Command and Transportation Command to establish a patient 
movement bridge evacuating individuals from Haiti via air transport.
    As part of the U.S. Air Force's total force effort, we sent our 
EMEDS platform into Haiti and rapidly established a 10-bed hospital to 
link the hospital ship to ground operations. The new EMEDS includes 
capabilities for pediatrics, OB/GYN and mental health. Personnel from 
five Air Force medical treatment facilities are supporting Operation 
Unified Response, as well as volunteers from the Air Reserve Forces.
 build patient-centered care and focus on prevention to optimize health
    We are committed to achieving the same high level of trust with our 
patients at home through our medical home concept. Medical home 
includes initiatives to personalize care, and to improve health and 
resilience. We are also working hard to optimize our operations, reduce 
costs and improve patient access. We partner with our Federal and 
civilian colleagues to continuously improve care to all our 
beneficiaries.
Family Health Initiative
    To achieve better health outcomes for our patients, we implemented 
the Family Health Initiative (FHI). FHI mirrors the American Academy of 
Family Physicians' ``Patient Centered Medical Home'' concept and is 
built on the team-approach for effective care delivery. The partnership 
between our patients and their health care teams is critical to create 
better health and better care via improved continuity, and reduce per 
capita cost.
    Our providers are given full clinical oversight of their care teams 
and are expected to practice to the full scope of their training. We 
believe the results will be high quality care and improved professional 
satisfaction. Two of our pilot sites, Edwards Air Force Base (AFB), CA, 
and Ellsworth AFB, SD, have dramatically improved their national 
standings in continuity, quality, access to care, and patient 
satisfaction. Eleven other bases are implementing Medical Home, with an 
additional 20 bases scheduled to come on-line in 2010.
    We are particularly encouraged by the results of our patient 
continuity data in Medical Home. Previous metrics showed our patients 
only saw their assigned provider approximately 50 percent of the time. 
At Edwards and Ellsworth AFBs, provider continuity is now in the 80-90 
percent range.
    We still have work to do, such as developing improved decision 
support tools, case management support, and improved training. 
Implementing change of this size and scope requires broad commitment. 
The Air Force Medical Service has the commitment and is confident that 
by focusing on patient-centered care through Medical Home, we will 
deliver exceptional care in the years ahead.
    The Military Health System's Quadruple Aim of medical readiness, 
population health, experience of care and per capita cost serves us 
well. Patient safety remains central to everything we do. By focusing 
on lessons learned and sharing information, we continually strive to 
enhance the safety and quality of our care. We share our clinical 
lessons learned with the Department of Defense (DOD) Patient Safety 
Center and sister Services. We integrate clinical scenarios and lessons 
learned into our simulation training. We securely share de-identified 
patient safety information across the Services through DOD's web-based 
Patient Safety Learning Center to continuously improve safety.
Improving Resilience and Safeguarding the Mental Health of Our Airmen
    Trusted care for our beneficiaries includes improving resilience 
and safeguarding their mental health and well-being. We are engaged in 
several initiatives to optimize mental health access and support.
    Air Force post-deployment health assessment and post-deployment 
health re-assessment data indicates a relatively low level of self-
reported stress. However, about 20-30 percent of servicemembers 
returning from Operation Iraqi Freedom/Operation Enduring Freedom 
deployments report some form of psychological distress. The number of 
personnel referred for further evaluation or treatment has increased 
from 25 percent to 50 percent over the past 4 years, possibly 
reflecting success in reducing stigma of seeking mental health support. 
We have identified our high-risk groups and can now provide targeted 
intervention and training.
    We recently unveiled ``Defenders Edge,'' which is tailored to 
security forces airmen who are deploying to the most hostile 
environments. This training is intended to improve airmen mental 
resiliency to combat-related stressors. Unlike conventional techniques, 
which adopt a one-on-one approach focusing on emotional vulnerability, 
``DEFED'' brings the mental health professional into the group 
environment, assimilating them into the security forces culture as 
skills are taught.
    Airmen who are at higher risk for post traumatic stress are closely 
screened and monitored for psychological concerns post-deployment. If 
treatment is required, these individuals receive referrals to the 
appropriate providers. In addition to standard treatment protocols for 
post-traumatic stress disorder (PTSD), Air Force mental health 
professionals are capitalizing on state-of-the-art treatment options 
using Virtual Reality. The use of a computer-generated virtual Iraq in 
combination with goggles, headphones, and a scent machine allow 
servicemembers to receive enhanced prolonged exposure therapy in a safe 
setting. In January 2009, 32 Air Force Medical Service therapists 
received Tri-Service training in collaboration with the Defense Center 
of Excellence at Madigan Army Medical Center. The system was deployed 
to eight Air Force sites in February 2009 and is assisting 
servicemembers in the treatment of PTSD.
    Future applications of technology employing avatars and virtual 
worlds may have multiple applications. Servicemember and family 
resiliency will be enhanced by providing pre- and post-deployment 
education; new parent support programs may offer virtual parent 
training; and family advocacy and addiction treatment programs may 
provide anger management, social skills training, and emotional and 
behavioral regulation.
Rebuilding Our Capabilities by Recapturing Care and Reducing Costs
    Our patients appropriately expect AFMS facilities and equipment 
will be state-of-the art and our medical teams clinically current. They 
trust we will give them the best care possible. We are upgrading our 
medical facilities and rebuilding our capabilities to give patients 
more choice and increase provider satisfaction with a more complex case 
load. In our larger facilities, we launched the Surgical Optimization 
Initiative, which includes process improvement evaluations to improve 
operating room efficiency, enhance surgical teamwork, and eliminate 
waste and redundancy. This initiative resulted in a 30 percent increase 
in operative cases at Elmendorf AFB, AK, and 118 percent increase in 
neurosurgery at Travis AFB, CA.
    We are engaged in an extensive modernization of Wright-Patterson 
Air Force Base Medical Center in Ohio with particular focus on surgical 
care and mental health services. We are continuing investment in a 
state-of-the-art new medical campus for SAMMC at Lackland AFB, TX. Our 
ambulatory care center at Andrews AFB, MD, will provide a key 
capability for the delivery of world-class health care in the National 
Capital Region's multi-service market.
    By increasing volume, complexity and diversity of care provided in 
Air Force hospitals, we make more care available to our patients; and 
we provide our clinicians with a robust clinical practice to ensure 
they are prepared for deployed operations, humanitarian assistance, and 
disaster response.
Partnering With Our Private Sector and Federal Partners
    Now more than ever, collaboration and cooperation with our private 
sector and Federal partners is key to maximizing resources, leveraging 
capabilities and sustaining clinical currency. Initiatives to build 
strong academic partnerships with St. Louis University, Wright State 
University (Ohio); University of Maryland; University of Mississippi; 
University of Nebraska-Lincoln; University of California-Davis and 
University of Texas-San Antonio, among others, bolster research and 
training platforms and ultimately, ensures a pipeline of current, 
deployable medics to sustain Air Force medicine.
    Our long history of collaborating with the Veterans Administration 
(VA) also enhances clinical currency for our providers, saves valuable 
resources, and provides a more seamless transition for our airmen as 
they move from active duty to veteran status. The Air Force currently 
has five joint ventures with the VA, including the most recent at 
Keesler AFB, MS. Additional efforts are underway for Buckley AFB, CO, 
to share space with the Denver VA Medical Center, which is now under 
construction.
    The new joint Department of Defense-Veterans Affairs disability 
evaluation system pilot started at Malcolm Grow Medical Center at 
Andrews AFB, MD in November 2007. It was expanded to include Elmendorf 
AFB, AK; Travis AFB, CA and Vance AFB, OK; and MacDill AFB, FL, in May 
2009. Lessons learned are streamlining and expediting disability 
recovery and processing, and creating improved treatment, evaluation 
and delivery of compensation and benefits. The introduction of a single 
comprehensive medical examination and single-sourced disability rating 
was instrumental to improving the process and increasing the 
transparency. Services now allow members to see proposed VA disability 
ratings before separation.
    We continue to work toward advances in the interoperability of the 
electronic health record. Recent updates allow near real-time data 
sharing between DOD and Veterans Affairs providers. Malcolm Grow 
Medical Center, Wright-Patterson Medical Center, and David Grant 
Medical Center are now using this technology, with 12 additional Air 
Force military treatment facilities slated to come online. New system 
updates will enhance capabilities to share images, assessment reports, 
and data. All updates are geared toward producing a virtual lifetime 
electronic record and a nationwide health information network.
                      year of the air force family
    This is the ``Year of the Air Force Family,'' and we are working 
hand in hand with Air Force personnel and force management to ensure 
our Exceptional Family Member Program beneficiaries receive the 
assistance they need.
    In September 2009, the Air Force sponsored an Autism Summit where 
educational, medical, and community support personnel discussed 
challenges and best practices. In December 2009, the Air Force Medical 
Service provided all Air Force treatment facilities with an autism tool 
kit. The kit provided educational information to providers on diagnosis 
and treatment. Also, Wright-Patterson AFB, OH is partnering with 
Children's Hospital of Ohio in a research project to develop a 
comprehensive registry for autism spectrum disorders, behavioral 
therapies, and gene mapping.
    The Air Force actively collaborates with sister Services and the 
Defense Center of Excellence for Psychological Health and Traumatic 
Brain injury to offer a variety of programs and services to meet the 
needs of children of wounded warriors. One recent initiative was the 
``Family Connections'' website with Sesame Street-themed resources to 
help children cope with deployments and injured parents. In addition, 
DOD-funded websites, such as afterdeployment.org, providing specific 
information and guidance for parents/caregivers to understand and help 
kids deal with issues related to deployment and its aftermath.
    Parents and caregivers also consult with their child's primary care 
manager, who can help identify issues and refer the child for care when 
necessary. Other resources available to families include counseling 
through Military OneSource, Airman and Family Readiness Centers, 
Chaplains, and Military Family Life Consultants--all of whom may refer 
the family to seek more formal mental health treatment through 
consultation with their primary care manager or by contacting a TRICARE 
mental health provider directly.
       investing in our people: education, training, and research
Increased Focus on Recruiting and Retention Initiatives
    To gain and hold the trust of our patients, we must have highly 
trained, current, and qualified providers. To attract those high 
quality providers in the future, we have numerous efforts underway to 
improve recruiting and retention.
    We've changed our marketing efforts to better target recruits, such 
as providing Corps-specific DVDs to recruiters. The Health Profession 
Scholarship Program remains vital to attracting doctors and dentists, 
accounting for 75 percent of these two Corps' accessions. The Air Force 
International Health Specialist program is another successful program, 
providing Air Force Medical Service personnel with opportunities to 
leverage their foreign language and cultural knowledge to effectively 
execute and lead global health engagements, each designed to build 
international partnerships and sustainable capacity.
    The Nursing Enlisted Commissioning Program (NECP) is a terrific 
opportunity for airmen. Several airmen have been accepted to the NECP, 
completed degrees, and have been commissioned as Second Lieutenant 
within a year. To quote a recent graduate, 2nd Lt. April C. Barr, ``The 
NECP was an excellent way for me to finish my degree and gave me an 
opportunity to fulfill a goal I set as a young airman . . . to be 
commissioned as an Air Force nurse.''
    For our enlisted personnel, targeted Selective Reenlistment 
Bonuses, combined with continued emphasis on quality of life, generous 
benefits, and job satisfaction have positively impacted enlisted 
recruiting and retention efforts.
Increasing Synergy to Strengthen GME and Officer/Enlisted Training
    We foster excellence in clinical, operational, joint and coalition 
partner roles for all Air Force Medical Service personnel. We are 
increasing opportunities for advanced education in general dentistry 
and establishing more formalized, tiered approaches to Medical Corps 
faculty development. Senior officer and enlisted efforts in the 
National Capital Region and the San Antonio Military Medical Center are 
fostering Tri-Service collaboration, enlightening the Services to each 
others' capabilities and qualifications, and establishing opportunities 
to develop and hone readiness skills.
    The Medical Education and Training Campus (METC) at Fort Sam 
Houston, TX, will have a monumental impact on the Department of Defense 
and all Military Services. We anticipate a smooth transition with our 
moves completed by summer 2011. METC will train future enlisted medics 
to take care of our servicemembers and their families and will 
establish San Antonio as a medical training center of excellence.
    Our Centers for the Sustainment of Trauma and Readiness Skills at 
St. Louis University, University of Maryland-Baltimore Shock Trauma and 
University of Cincinnati College of Medicine remain important and 
evolving training platforms for our doctors, nurses and medical 
technicians preparing to deploy. We recently expanded our St. Louis 
University training program to include pediatric trauma. Tragically, 
this training became necessary, as our deployed medics treat hundreds 
of children due to war-related violence.
    Partnerships with the University Hospital Cincinnati and 
Scottsdale, AZ, trauma hospitals allow the Air Force's nurse transition 
programs to provide newly graduated registered nurses 11 weeks of 
rotations in emergency care, cardiovascular intensive care, burn unit, 
endoscopy, same-day surgery, and respiratory therapy. These advanced 
clinical and deployment readiness skills prepare them for success in 
Air Force hospitals and deployed medical facilities, vital to the care 
of our patients and joint warfighters.
Setting Clear Research Requirements and Integrating Technology
    Trusted care is not static. To sustain this trust, we must remain 
agile and adaptive, seeking innovative solutions to shape our future. 
Our ongoing research in procedures, technology, and equipment will 
ensure our patients and warfighters always benefit from the latest 
medical technologies and clinical advancements.
    Air Force Medical Service vascular surgeons, Lieutenant Colonels 
Todd Rasmussen and William ``Darrin'' Clouse, have completed 17 
research papers since 2005 and edited the vascular surgery handbook. On 
January 10, 2009 a U.S. Marine sustained bilateral posterior knee 
dislocations with subsequent loss of blood flow to his lower legs 
following an improvised explosive device attack in the Helmand 
Province. Casualty evacuation delivered the marine to our British 
partners at Camp Bastion, a level II surgical unit within an hour. At 
Bastion, British surgeons applied knowledge gained from combat casualty 
care research and restored blood flow to both legs using temporary 
vascular shunts. Medical evacuation then delivered the casualty to the 
455th Expeditionary Medical Group at Bagram. Upon arrival, our surgeons 
at Bagram performed definitive vascular reconstruction and protected 
the fragile soft tissue with negative pressure wound therapy. The 
Marine is currently recovering at the National Military Medical Center 
in Bethesda and is expected to have functional limbs.
    In another example, a 21-year-old airman underwent a rare 
pancreatic autotransplantation surgery at Walter Reed Army Medical 
Center (WRAMC) to salvage his body's ability to produce insulin. The 
airman was shot in the back three times by an insurgent at a remote 
outpost in Afghanistan. The patient underwent two procedures in 
Afghanistan to stop the bleeding, was flown to Germany, then to WRAMC. 
Army surgeons consulted with University of Miami's Miller School of 
Medicine researchers on transplantation experiments. The surgeons 
decided to attempt a rare autotransplantation surgery to save the 
remaining pancreas cells. WRAMC Surgeons removed his remaining pancreas 
cells and flew them over 1,000 miles to the University of Miami Miller 
School of Medicine. The University of Miami team worked through the 
night to isolate and preserve the islet cells. The cells were flown 
back to WRAMC the next day and successfully implanted in the patient. 
The surgery was a miraculous success, as the cells are producing 
insulin.
    These two cases best illustrate the outcome of our collaborations, 
culture of research, international teamwork, innovation, and 
excellence.
Shaping the Future Today Through Partnerships and Training
    Under a new partnership with the University of Illinois at Chicago, 
we are researching directed energy force protection, which focuses on 
detection, diagnosis and treatment of directed energy devices. We are 
exploring the discovery of biomarkers related to laser eye injuries, 
development of films for laser eye protection and the development of a 
``tricorder'' prototype capable of laser detection and biomarker 
assessment. Additional efforts focus on the use and safety of laser 
scalpels and the development of a hand-held battery operated laser tool 
to treat wounds on the battlefield.
    We continue our 7-year partnership with the University of 
Pittsburgh Medical Center to develop Type II diabetes prevention and 
treatment programs for rural and Air Force communities. Successful 
program efforts in the San Antonio area include the establishment of a 
Diabetes Center of Excellence, ``Diabetes Day'' outreach specialty 
care, and efforts to establish a National Diabetes Model for diabetic 
care.
    Another partnership, with the University of Maryland Medical Center 
and the Center for the Sustainment of Trauma and Readiness Skills (C-
STARS) in Baltimore is developing advanced training for Air Force 
trauma teams. The project goal is to develop a multi-patient trauma 
simulation capability using high fidelity trauma simulators to 
challenge trauma teams in rapid assessment, task management, and 
critical skills necessary for the survival of our wounded warriors. A 
debriefing model is being developed to assist with after action reviews 
for trauma team members.
    Radiofrequency technology is contributing to medical process 
improvements at Keesler AFB, MS. Currently, Keesler AFB is analyzing 
the use of automatic identification and data capture (AIDC) in AFMS 
business processes. The AIDC evaluation focuses on four main areas: 
patient tracking, medication administration, specimen tracking, and 
asset management. Further system evaluation and data collection is 
ongoing in 2010 with an expansion of AIDC use in tracking automated 
data processing equipment.
                               conclusion
    As a unique health system, we are committed to success across the 
spectrum of military operations through rapid deployability and 
patient-centered care. We are partnering for better outcomes and 
increasing clinical capacity. We are strengthening our education and 
training platforms through partnerships and scanning the environment 
for new research and development opportunities to keep Air Force 
medicine on the cutting edge.
    We will enhance our facilities and the quality of health care to 
ensure health and wellness of all entrusted to our care. We do all this 
with a focus on patient safety and sound fiscal stewardship. We could 
not achieve our goals of better readiness, better health, better care 
and reduced cost without your support, and so again, I thank you.
    In closing, I share a quote from our Air Force Chief of Staff, Gen. 
Norton A. Schwartz, who said, ``I see evidence every day the Medical 
Service is ``All In,'' faithfully executing its mission in the heat of 
the fight, in direct support of the warfighter, and of families back 
home as well.'' I know you would agree that ``All in'' is the right 
place to be.

    Senator Webb. Thank you, General Green.
    Admiral Jeffries, welcome.

STATEMENT OF RADM RICHARD R. JEFFRIES, USN, MEDICAL OFFICER OF 
                     THE U.S. MARINE CORPS

    Admiral Jeffries. Chairman Webb, Senator Graham, 
distinguished members of the subcommittee, good morning.
    I'm honored to be with you, the Senate Armed Services 
Personnel Subcommittee, today to discuss the state of Navy 
Medicine as it pertains to the health services support to the 
U.S. Marine Corps.
    I want to thank the committee members for your unwavering 
support of Navy Medicine and the U.S. Marine Corps, 
particularly as it relates to our healthcare advances and 
continuum of quality care for marines and sailors. Our warriors 
who go into harm's way for this great Nation, their families, 
and those who have gone before in service to our country 
deserve the very best in care and support that we can provide.
    Marine Medicine is all about a special bond--the one of 
complete trust between a marine and a doctor. They know that 
all will be given, each for the other, when the Nation's 
mission calls for their total commitment and potential 
sacrifice to the defense of our country. Corpsmen up with 
lifesaving skills, and yet, the potential risk of injury or 
death is just as real today as it was over 50 years ago.
    Navy Medicine is a dedicated, fully integrated worldwide 
healthcare system meeting the needs of our marines and sailors, 
their families, retirees, and, at times, those whose fortunes 
are beset with a disaster. We specialize in health, prevention, 
and readiness, and, when called upon, casualty and humanitarian 
lifesaving care to all we touch.
    Marine Medicine lives first and foremost at the point of 
injury, but is founded in primary care, prevention, wellness, 
and resilience, skills that are the hallmark of readiness. When 
called upon to deploy, they are ready to provide the best in 
damage control, resuscitation, and stabilization, with 
evacuation to a higher level of care anywhere, anytime.
    The numbers speak for themselves, even now, in Afghanistan. 
In the toughest battle, with single-digit percentages in 
ultimate sacrifices, astonishing mass transfusion, lives saved, 
and the lowest disease/nonbattle injury levels in history.
    Yes, we continue to research and advance the latest in tip-
of-the-spear advances in healthcare. We focus on equipment, 
like tourniquets and blood-clotting combat gauze, techniques in 
traumatic combat casualty care, and forward-resuscitate 
surgical and nonsurgical care, and the skills of embedded 
resilient and post-traumatic stress teams, plus early treatment 
protocols for mild TBI.
    Last year, the Commandant of the Marine Corps directed 
immediate development and fielding of the Mobile Trauma Bay, 
mini emergency rooms in protected vehicles from lessons learned 
in the field, and by the end of the year, several prototypes 
were already deployed to Afghanistan, where they're saving 
lives and mitigating injuries at the tip-of-the-spear today.
    We continue to push for solutions to some of medicine's 
toughest challenges. We are fully engaged partners with our 
``sister scissors,'' the VA, and civilian experts, to advance 
research rapidly and PTSD treatment, casualty care, recovery, 
and rehabilitation for the return of our wounded warriors.
    Collaboration with new innovative research consortia, like 
under the Armed Forces Institute for Regenerative Medicine, 
AFIRM, and early transitional enablers, like the DOD's Office 
for Technological Transition, that can quickly navigate through 
our complex bureaucratic systems and policies, can and are 
making a difference to those in the front lines, getting the 
latest advancements in medicine quickly to our providers and 
casualties.
    As we all know now, today's irregular warfare in this 
complex, protracted war is adversely affecting our forces in 
many devastating ways. Most blast injuries and horrors 
witnessed on the battlefield are putting astonishing stresses 
on our warriors--mentally, emotionally, physically, and 
spiritually. We are seeing severe amputations, burns, traumatic 
stresses, and brain injuries on an unbelievable scale.
    Our greatness in saving lives has a significant cost in the 
degree of injury and loss our warriors have suffered. Navy/
Marine Corps Medicine has been a leader in changing the way our 
military engages the mental health challenges of this war with 
providers embedded in front-line units under the Marine Corps 
Operational Stress Control and Readiness Program begun at the 
beginning of the war. The three Marine Expeditionary Force 
commanders demanded a Total Force Combat Operational Stress 
Control Program to combat stigma, mitigate suicides, and 
properly address stress. A Total Marine Corps Family Response 
has been initiated. Last year, Total Force trained suicide 
prevention with video vignettes, group discussions, 
identification and referral tools, took place in a new Marine 
Corps program involving a total team engaged leadership concept 
with OSCAR Extenders is being instituted.
    The 1st Marine Expeditionary Force (1MEF) ground combat 
units going to Afghanistan with this current surge will have 
trained OSCAR Extender peer and senior mentors, besides primary 
care mental health embed specialists. With this patient-
centered Marine and Navy Medicine team effort, stigma will be 
further challenged, and seeking and receiving help will become 
a normal part of the ever-improving Marine culture. For TBI, 
the Assistant Commandant of the Marine Corps and the current 
Marine Expeditionary Brigade commander in Afghanistan have led 
the advancement of a revolutionary concept in prevention and 
care. They have a ``three strikes and you're out'' policy. You 
will stay inside the wire if you've had three major concussions 
until you get a comprehensive health evaluation.
    Plans have been developed for an event-driven reporting, 
all-involved identification, medical evaluation and recovery 
timeout program to enhance early identification care of TBI, 
protecting our warriors with care of TBI, protecting our 
warriors at the front, and decreasing long-term sequelae.
    1MEF Forward will also be piloting a new restoration center 
concept for earlier recovery, rehabilitation, and care at the 
forward operating bases later this year.
    Many challenges remain. One concern has been the high 
demand on many of our healthcare provider areas. The Surgeons 
General have identified shortfalls in key specialties and 
supporters that could adversely affect our abilities to care 
and support our forces. More demands will come as we improve 
TBI restorative care, enhance en route casualty care, expand 
OSCAR Extender, add Medical Home Patient-Centered Care 
initiatives, and initiate other discovered advances in 
healthcare.
    Marine Corps is working closely with Navy Medicine and 
Health Affairs to address current and future needs. In the end, 
that special bond between marine and doctors propels us to do 
our very best for our warriors.
    On behalf of the men and women of Navy Medicine working 
inside the U.S. Marine Corps, I want to thank the committee for 
your exceptional leadership, help, and support. We appreciate 
your continuing confidence in our abilities to meet mission and 
to show you how we continue to address and succeed in meeting 
the healthcare needs of our marines and sailors.
    I look forward to your questions, sir.
    Senator Webb. Thank you very much, Admiral.
    I appreciate all of the testimony this morning.
    I assume we're going to continue.
    Senator Graham. Yes, Mr. Chairman. I'll take responsibility 
for not informing our leadership about this hearing. 
[Laughter.]
    So, they obviously are letting a TSA nomination go forward, 
and I'm sure every member of the Senate would like to continue 
this hearing. If I need to--because the rules do matter--I'll 
be glad to go over to the floor, take 5 minutes, and make a 
unanimous consent request to continue the hearing, if that's 
necessary. But, I'm very much committed to allowing you to stay 
here to answer questions because there are a lot of things 
hanging in the air----
    Senator Webb. I appreciate that very much.
    Senator Graham.--and I want to know the outcome of where 
are folks at? What do we need to do here?
    Senator Webb. We'll assume we're fine, unless told 
otherwise.
    Senator Graham. Sure.
    Senator Webb. I will start with a question, and then, I 
suppose, among the three of us, we can rotate through 
questions.
    Senator Graham. Sure.
    Senator Webb. I would like to get into this data that I 
mentioned in my opening statement, with respect to prescription 
drug use. Let me review what I said in my statement.
    From a recent Military Times article, ``One-in-six 
servicemembers is on some form of psychiatric drug.'' That's a 
quote, ``17 percent of the Active-Duty Force, and as much as 6 
percent of deployed troops, are on antidepressants.'' That's a 
quote. ``The use of psychiatric medications has increased about 
76 percent overall since the start of the current wars.''
    Now, I have some other data here. I'm going to ask 
unanimous consent to put this chart into the record at this 
point, as well.
    [The information referred to follows:]
      
    
    
      
    Senator Webb. I have data here from DOD that goes from 2001 
to 2009, in terms of a breakdown of different prescription drug 
uses. I'm going to start with 2002, just to put this in front 
of the panel.
    I want to lay this out, because we all know that we have to 
be careful with statistics. I'm not going to make a judgment 
based simply on these statistics. There are a number of 
potential answers to this. I don't want to answer them. I want 
to hear the answers of the panel. One is, in terms of these 
numbers in the charts, maybe there is a larger pool of people 
who are receiving prescriptions. I don't know. Maybe there is a 
different approach that's being used in medicine over the last 
8 years, in terms of people with difficulties, or maybe this is 
the stress of the force. But, if you go from 2002 to 2009, 
barbituate usage--or prescriptions increased from 7,600 to 
almost 27,000; that's three and a half times. Muscle relaxers 
increased from 139,000 to 312,000; that's two and a half times. 
Pain relievers, from 2 million to 3.8 million, that's almost 
twice. Tranquilizers, from 131,000 to 517,000, which is about 
four times. On its face, it's pretty astounding and also very 
troubling.
    Dr. Rice, I would like your thoughts on what this means.
    Dr. Rice. Yes, sir. Thank you, Mr. Chairman.
    First, let me echo your concern about the statistics. Most 
of the data here come from the Pharmacy Data Transaction 
Service (PDTS) that the TMA runs. This is a claims tracking 
system. Up until April 2007, the PDTS, the tracking system, did 
not lock the beneficiary's status in time. So, the last time a 
transaction was recorded reflected whatever the servicemember's 
status was at that time. So, you could have somebody who was 
taking an antidepressant in 2005, got another one in 2007. In 
2005, we would not have known that he was Active Duty. So, the 
underlying denominator here that leads to the substantial 
increase that you talked about results from a problem that we 
had with the way we were tracking the data and not locking it 
down.
    The second point I would make is, I think it's important to 
keep in mind that the men and women of our military are drawn 
from the population of the United States, and the use of 
psychotropic medications in the Nation as a whole has 
increased. It's difficult to turn on the television without 
becoming convinced that you're bipolar or have some other 
problem for which there is a drug ready made for you.
    With respect to pain medications, we have placed great 
emphasis on dealing with pain. The Joint Commission for the 
Accreditation of Healthcare Organizations has had a substantial 
effort, in the last several years, to make sure that we 
recognize pain among our patients, and that we treat it 
appropriately.
    I think there are a number of factors that enter into this 
apparent increase in usage that we're seeing.
    But, I would defer to my colleagues for their particular 
perspectives on this issue, as well.
    Senator Webb. When you say ``apparent,'' you mean apparent 
from the data or that the data really isn't speaking correctly 
to reality?
    Dr. Rice. No, there's no question that there is substantial 
usage. What I'm referring to is that we don't know how many of 
the people who were getting the drug in 2005 were actually on 
Active Duty. So, the denominator may be a problem, since we 
didn't lock down their status at that time, but used the last 
time they were in the system to reflect what their status was 
at any previous time.
    Senator Webb. Are these numbers reflective of Active Duty 
use in the later years? They are not?
    General, I see your shaking your head.
    General Schoomaker.
    General Schoomaker. No, sir. I think, as Dr. Rice was 
pointing out, until the last 2 years or so, the last entry that 
the soldier--in our case, soldier--would have been--say, a 
retiree--would have characterized everything we had in the 
database before that. So, it was artificially lower than the 
actual use in 2001.
    Senator Webb. Which was artificially lower?
    General Schoomaker. The use of drugs.
    Senator Webb. The use of drugs----
    General Schoomaker. If a soldier is on----
    Senator Webb.--among Active Duty----
    General Schoomaker. Yes, sir.
    Senator Webb.--in the data? That's what----
    General Schoomaker. If a soldier was on Active Duty----
    Senator Webb. Right.
    General Schoomaker.--in 2001, and was on ongoing sleep 
medicines or using a SSRI for depression or something, or for 
pain relief, and then retired in a retirement physical or 
retirement setting, in a clinical setting, got turned into a 
retiree, that was then used to characterize all of the record 
before then. So, everything attributed to his or her Active 
Duty time would have disappeared from the Active Duty roster. 
So, it appeared much lower in use in 2001, 2002, 2003 than 
actually was being used by the Active Duty.
    One of the things that you all have discussed here that is 
quite startling is the very marked increase from 2001 to 2009. 
Some of that, as Dr. Rice has explained----
    Senator Webb. What is the year that this adjustment was 
made?
    General Schoomaker. 2006, 2007.
    Dr. Rice. It was locked in April 2007.
    Senator Webb. April 2007?
    Dr. Rice. Yes, sir.
    General Schoomaker. So, we're looking at trends from 2007 
and beyond as being much more accurately reflecting the trends 
in use. There's no question, sir, as Dr. Rice has said, we're 
all concerned about the amount of use of drugs and the stress 
on the force that this reflects. But, the increase is not quite 
as marked as the data would suggest there.
    Senator Webb. Okay. We will come back to you on this to try 
to get what your view of accurate data is.
    What about the comment that ``1 in 6 servicemembers is on 
some form of psychiatric drug''?
    General Schoomaker. Sir, we have three intersecting sources 
of data--independent, somewhat--that all corroborate roughly 
the same number. The Mental Health Advisory Team 6, which I 
think you referred to, or Senator Cardin referred to, that was 
conducted in 2009--through direct surveys--scientifically 
credible surveys of the force deployed, found that, in Iraq and 
Afghanistan, so between 3 and 6 percent of soldiers were on a 
drug for mental health or stress-related, so between 3 and 6 
percent. At about the same time, or in the last year, we've had 
the release of the DOD Health-Related Behaviors Among Active 
Duty Military Personnel. As I recall, that's a triannual event 
that the Research Triangle Institute conducts for us. That's 
confidential and anonymous, so you get a much better, probably 
confidential, report on all of the Services. They report 8.6 
percent being treated for depression, anxiety, or sleep. So, 
that's a combined----
    Senator Webb. Of the deployed.
    General Schoomaker. No, sir. The total force deployed and 
nondeployed.
    We're looking at 3 to 6 percent of the deployed force. 
Roughly 8 percent of the total force.
    Then, the last thing is this PDTS snapshot of the Army. We 
have, in February of this year--last month--done a snapshot of 
550,000 Active Duty soldiers, deployed and nondeployed, and we 
find there a similar number of about 6 percent.
    I'm looking at the range of between 3 and 6 percent--at 
most, 8 percent--of being on some sort of medication related to 
mental health or stress.
    Now, admittedly, sleep medicines are being used in a 
variety of settings as an adjunct. Sleep medicines, short-term, 
are frequently used for problems of sleep in combat, problems--
--
    Senator Webb. The----
    General Schoomaker.--of sleep at home.
    Senator Webb. Excuse me. The data you're talking about is 
Army data?
    General Schoomaker. Yes, sir. It's Army data. The Mental 
Health Advisory Team 6--the second study I mentioned, the DOD 
Health Related Behaviors Among Active Duty, actually----
    Senator Webb. Right.
    General Schoomaker.--is all Services. The last----
    Senator Webb. The data from Military Times article, again, 
is 1 in 6 servicemembers. They did say 6 percent of those 
deployed.
    General Schoomaker. Yes, sir.
    Senator Webb. That number fairly well comports----
    General Schoomaker. Yes, sir.
    Senator Webb.--with what you're saying. The other number 
seems higher.
    General Schoomaker. I said, for sleep, I think that there's 
a broader group of people using sleep medications. Some of them 
are also on active drugs for stress or mental health. Frankly, 
sir, I probably, myself, appeared in that database, because 
every time I go overseas, I take a prescription for Ambien.
    Senator Webb. Right.
    General Schoomaker. I think many of us do that. It's a 
sleeper that we use transiently, and it's a prescription drug.
    That's a little broader, but I think the implication that 
we have 1 in 6 with a serious mental disorder, I think, is a 
reach.
    Senator Webb. I would like to express my appreciation to 
Senator Graham. The cloakroom is now advised that we are legal 
again in our hearing. [Laughter.]
    We have permission to meet.
    Admiral, you wanted to say something?
    Admiral Robinson. There's one more data source, and that's 
BHNAS, which is the Behavioral Health Needs Assessment Survey, 
which is very similar to the MHAT, which is Army, but the BHNAS 
is done by Navy Medicine. The numbers that General Schoomaker 
gives are approximately correct, we were looking at 2010--we're 
talking about men and women in theater--so, this is in the 
combat zone--with a 3.2 percent mental health psychotropic 
medication usage, and probably about a 20 percent--22 percent, 
actually--of sleeping medication. I think that corroborates, at 
different points, to be about that. That's all that I wanted to 
add.
    Senator Webb. Okay. We will work with you to see if we 
can't scrub this data. I think it's an extremely troubling 
piece of information here.
    Admiral Robinson. The other point, which is off the data, 
but it's to the point, I think. It's not about the data. In the 
attempt, at least in the last 3 years, as my tenure as Surgeon 
General of the Navy, to decrease stigma--we've made a huge 
drive throughout the military--Navy, Army, Marine Corps--we've 
done it independently, but we've been together. We've tried to 
increase, in the Navy, Marine Corps, as an example--and I think 
the Army has done this, too, to a degree--to increase mental 
health professionals forward deployed--and the Air Force has 
done this, also--but, we're trying to--forward-deployed mental 
health experts--psychologists, psychiatrists, social workers, 
psychiatric nurses--those people and also our medics and 
corpsmen, and our primary care providers--who can, in fact, 
intervene in mental illnesses and emotional distress amongst 
our troops, no matter where they may be.
    In concert with that is also the utilization of 
psychotropic medication. But, my point is simply that we're 
really making a huge desire and a huge effort to destigmatize 
mental health issues and their treatment and stop--and taking 
it out of the closet or suppressing it so that it's not coming 
to light, and bringing it to light, so that we can get 
effective treatments.
    Senator Webb. Well said. In that respect, it probably goes 
back to one of the possibilities that I was raising here, and 
that is that this is an indicator of the long-term stress of 
the force and also different medical practices, or more open 
medical practices.
    Admiral Robinson. I think that there is stress on the 
force. But, I also think that there is an acknowledgment by 
medical professionals--by medicine and the Services that mental 
illnesses exist and have to be treated. We have, for a long 
time, as a society----
    Senator Webb. I agree. That's the second point that I was 
making, in terms of medical practice. So, I don't want to 
dominate all the time here.
    Admiral Robinson. Yes, sir.
    Senator Webb. I appreciate your answers.
    Senator Graham, do you want to----
    Senator Graham. Thank you, Mr. Chairman.
    I think the numbers you brought up are very important, 
because I think most Americans want to make sure that our men 
and women are functioning as well as possible and getting the 
help they need. I know we have a shortage of mental health 
professionals in the military, and we're trying to address 
that.
    But, it goes back to this--being away from your home in a 
combat arena is a stressful environment that--if you're not 
depressed at some times, you're not normal. It's just a 
depressing situation to have to be away from your home.
    What Senator Webb indicates is very important. We want to 
make sure that we're tracking the health of the force. So, if 
each Service could provide us a breakdown of the percentage of 
the force, in theater and outside the theater, that's on 
psychotropic drugs, and break that out, versus sleep aids, 
because--I'm supposed to do my Reserve duty next week, 
overseas, and I've already ordered some Ambien. So, I feel 
guilty already. I'm spiking up the numbers. [Laughter.]
    Senator Webb. Messing up the database. [Laughter.]
    Senator Graham. Yes. The database.
    I just literally ordered it from the Navy physician.
    Senator Webb. Actually, if I may, if we're going to get a 
breakdown of this, perhaps you could clean up the timeline for 
us.
    Senator Graham. That's a great idea. What are the real 
numbers?--so we can judge apples to apples, and because this is 
anecdotal evidence, quite frankly, of what Senator Webb's been 
concerned about a long time. We have to make sure that we're 
not wearing these folks out beyond their ability to respond to 
the Nation's call. At the same time, you do have this counter-
competing idea that we want to make sure that every member of 
the military gets the treatment they need. There's nothing 
wrong with going to the mental health professionals in your 
unit, or the doctor or the surgeon, and saying, ``Hey, Doc, you 
know, I need a little help here. I've had a bad experience. 
Help me through it.'' That is exactly what we want to have 
happen. So, having that concept validated, that it's okay to do 
this, but, at the same time, understand how widespread these 
problems are, I think, will help us make some intelligent 
decisions.
    If each Service could give us a breakdown in your Service, 
that would be much appreciated.
    Dr. Rice. Yes, sir.
    [The information referred to follows:]

    Utilization of automated systems to record medications dispensed at 
both inpatient and outpatient theater medical facilities was not 
broadly available until 2008. Prior to this period, data retrieval 
required extensive paper reviews.
    To provide a more complete picture, using current electronic 
systems, dispensed psychiatric and sleep aid medications were queried 
starting from 2008, to most current data received. This is not a 
standard report and requires an ad hoc query for the specific drugs. 
Approximately 5 million medical records were searched for these 
specific medications and computer processing was extensive.
    The attached table provides available theater psychotropic/hypnotic 
prescription drug data through June 8, 2010.
      
    
    
      
    
    
      
    
    
      
    
    

    Senator Graham. About sustainability, I know we don't have 
all the teams in place yet, but as we look at the budget over 
time, the healthcare portion of the DOD budget is growing 
exponentially. In 2007, I had a meeting with some associations 
representing the retired community in different branches of the 
Services, as well as people who manage TRICARE. We came up with 
a list of a dozen or more things that we could do to make the 
system more efficient. Is anybody aware of that meeting? Is 
there any effort to implement those ideas? Where do we stand 
with the concept, before we ask more money from retirees, in 
terms of premiums increases? What have we done to make the 
system more efficient?
    Dr. Rice. Sir, we constantly strive to find efficiencies in 
the system. The challenges are, as I mentioned, with respect to 
the use of psychotropic drugs, we exist in a system in the 
larger national healthcare context. I know you've been having 
some conversations about that issue recently, so you know 
what's happening on the national scene. I think it was a few 
years ago that Stewart Altman appeared before your committee 
and said that if present trends continued, healthcare costs as 
a fraction of the national economy would continue to grow, but 
he was pretty sure they could not exceed 100 percent of the 
gross domestic product.
    We have more people in the force, we have more 
beneficiaries, we have more people who have been added to the 
beneficiary list. Seventy percent of the costs are incurred 
outside the direct care system, where we have less direct 
ability to control----
    Senator Graham. We haven't had a premium increase in 
TRICARE since, what?
    Admiral Hunter. 1995.
    Dr. Rice. 1995. Right.
    Senator Graham. I want to be generous and fair to all those 
who serve, but there's a cost-containment problem within DOD's 
budget. Before we ask for premium increases, I think we need to 
try to make sure that we're telling the force, ``We've done 
everything we can within reason to make it more efficient and 
to lower the cost, through efficiency, best practices, 
preventive healthcare.''
    Mr. Chairman, I don't see how we can sustain this forever, 
where TRICARE is never subject to adjustment, in terms of the 
premiums to be paid. If we're going to do that, we're going to 
have to come up with a lot more money for DOD, because it's 
going to eat away at readiness and the other things you need to 
run the military.
    What's your view of that, Admiral Hunter and Dr. Rice? What 
do we do, long term?
    Dr. Rice. I think there are a number of efforts that we can 
take to try to reduce--General Schoomaker talked about unwanted 
variation, and that is seen to be a major driver of the 
increase in healthcare costs. I think we have to focus on that. 
We have to focus on improving the quality of care. There's no 
question that better quality care tends to be less expensive 
care. Focusing on things like patient safety, I think, is an 
important dimension.
    We think that the full deployment and wide utilization of 
the Electronic Health Record will be an important aid to us in 
developing that capability. A number of steps we can take.
    Your comment about the TRICARE premium is exactly right; 
there has not been an increase since 1995, while the cost of 
healthcare insurance in the rest of the world has continued to 
rise. I would be happy to work with you on that.
    Let me ask Admiral Hunter if she has anything to add to 
that.
    Admiral Hunter. Yes, Senator, let me add a little bit, in 
terms of what we're doing internally.
    I appreciate all the comments about variation. We've looked 
very carefully, for example, at technology variation and our 
use of technology throughout military medicine, both in direct 
care and private-sector care, so that it's appropriately 
applied. I talked earlier about preventive measures.
    I'd also like to talk a little bit about utilization of 
care. In the last several years, we've seen a dramatic rise in 
our patients using the emergency room or emergency department 
as a site of care. Initially, we were concerned that that meant 
that they didn't have access to care, that they couldn't reach 
their primary care provider or perhaps they didn't have one 
assigned. But, as we looked at the data more carefully, we see 
that the graph is going up in exactly the same way for people 
who are enrolled to private sector--have a stable primary care 
relationship, where the provider isn't deploying or those sorts 
of things, as it is in our direct care systems.
    To address that, we've looked at all of the different 
quadrants of our Quadruple Aim that I talked about. First of 
all, have we maximized the relationship between provider and 
patient? All of the surgeons talked about the Medical Home. 
Second of all, have we made resources available to patients so 
that they know where else they can go if it's after hours? Do 
we reach out? Do you have the right refrigerator magnet, or 
information that says, ``This is the urgent care''? How do we 
help them get to that relationship?
    Our contractors are working with us. Many have even added 
what we call ``convenience clinics,'' the types of clinics that 
are in drug stores and things like that, to some of their 
networks so that we are working to add more and more 
convenient, but lower-cost, after-hours settings of care that 
would be appropriate for the earache, the respiratory 
infection, the sore throat, the backache that really doesn't 
require an emergency room.
    Working with all our partners to get to that effective 
Medical Home, and then measuring and holding accountable for 
continuity on our side, is important.
    In our contracting area, if I may shift, working hard on 
the business processes. General Schoomaker also talked about 
administrative variation. The business processes that bring our 
processes of care--our back office--to be as efficient as it 
can: electronic funds transfer, not manual processes, 
automating payments and claims and all of those things to the 
greatest extent possible, so that the administrative dollars on 
the contracts are minimized. Bringing multiple contracts 
together into single ones. Overseas we've just combined six 
contracts into one, where we'll be getting streamlined 
services. That's better for our patients--they deal with one 
overseas contractor--and better for us, because we get a better 
deal.
    Then the last thing I'd point out is fraud prevention. We 
know that in all major programs we need to be vigilant for 
others that may take advantage of the system, and how that 
might happen. So, we have a program integrity group that works 
carefully with our contractors, with others in the Federal 
Government--Department of Justice, Centers for Medicare and 
Medicard Services--and also with private providers to look for 
trends in claims that may suggest behavior that we need to more 
fully investigate.
    In addition, our explanations of benefits that are mailed 
to patients each time they have a health encounter. We just 
started mailing them, even with pharmacy encounters. Patients 
are great policemen on behalf of the Services. They call us and 
say--just like a credit card bill--``There's something on my 
explanation of benefits''----
    Senator Graham. That's good. That's very good.
    Admiral Hunter.--``that I didn't get and can you look at 
it?''
    Senator Graham. Yes, I think that is a terrific idea, 
because all of us, now, are worried about the cost to the 
country and to--beyond ourselves, which is good, because we all 
bear these costs.
    Mr. Chairman, I don't have any more questions. I'll make 
one brief comment to the Surgeons General and those under your 
command.
    I think one of the unsung heroes of this war are the 
medical personnel on the front lines. As Senator Webb said, 
``the golden hour.'' There are people surviving attacks in this 
war that would never have survived in any other war. I am just 
amazed and just astonished at what's been able to be done in 
theater and at Landstuhl and other places.
    There was a young man--who was a marine, who lost both 
legs. He's had 60-something surgeries. He is now at Harvard Law 
School. He just was medically discharged from the Marine Corps, 
I think, last year. He was a Congressional Fellow with me in my 
office. I think he's a testament of what people under your 
command have done for those who put themselves in harm's way. I 
just want to thank you all for your service.
    Senator Webb. Thank you very much, Senator Graham.
    Also, again, I appreciate your having gone to the floor to 
allow us to be able to continue our hearing.
    Senator Graham. It's very important.
    Senator Webb. Senator Begich.
    Senator Begich. Thank you very much, Mr. Chairman.
    I have a couple of followup comments and questions.
    First, with regards to painkillers and pain management and 
so forth, once a patient wants to try to get off of those 
painkillers, what are the services you have available for them? 
Because I do hear complaints that they don't think they're 
adequate, or where they have to go if they've become addicted 
to the painkillers. Could someone elaborate on that?
    General Schoomaker. Yes. Maybe I could take that one, if 
you don't mind.
    Senator Begich. Sure.
    General Schoomaker. Sir, I would say that to follow on a 
lot of what we've been saying up here--one of the nonstandard 
areas of care right now is in pain management.
    Senator Begich. Right.
    General Schoomaker. This is not a problem just for the 
military, it's a problem across the Nation.
    I stood up a task force last year, a Pain Management Task 
Force, to look at practices across the Army, and, frankly, the 
VA has been very active in helping with this. The other 
Services have joined, as well as support from TRICARE 
Management Agency on this. I got the latest in-progress review 
this week. It's going very well, and I expect the formal report 
to be out in the next 2 weeks.
    I'm trained as an internist and a hematologist, and I can 
tell you that caring for acute pain and chronic pain is a 
problem across the country, in terms of how we standardize it, 
how we transition from one phase to the other. We're looking at 
this in a very holistic way, so that we're employing all of the 
tools that we have available.
    Specifically within the Warrior Transition Units of the 
Army, we have a very good, comprehensive program which is 
increasingly more seamless between the inpatient to the 
outpatient and then to life beyond, even being within the 
medical system, and it addresses the issues that you're talking 
about.
    Senator Begich. If I can make sure I understand what you're 
saying, there. Not only is it the pain management program, but 
it's when they get addicted on these painkillers and they want 
to get clean. What do you do for them? I understand you're 
working through it. But, what are the services that are 
available that they can tap into to move from being addicted to 
the painkillers?
    General Schoomaker. All the Services have substance abuse 
programs for those who get addicted to addicting narcotics and 
the like. Quite honestly, sir, most of the problems with 
addictions to narcotics--and I'll go out on a limb on this--are 
attributed to social uses, rather than those associated with 
painkillers for surgical pain and the like.
    Senator Begich. We don't have to debate this much further--
I would ask you to provide me, if you can at some point, some 
of the data that shows that, because what I'm starting to hear 
from are individuals who experienced an incident during their 
deployment, have then been prescribed painkillers and may they 
misuse them or excessive use, now are addicted to them. I just 
want to know--understand that, as you're trying to develop pain 
management, another step to this.
    General Schoomaker. Yes, sir.
    Senator Begich. The step is, some of these are very strong 
prescription drugs that turn into addictive drugs. I want to 
get a better understanding of how you come to that conclusion 
so we are not missing that boat. In other words, may they no 
longer be in the DOD system because they've exited out or 
whatever, but yet, they're addicted, that our relationship with 
them has to continue in some way to make sure we clean them. 
So, that's what I want to understand.
    General Schoomaker. Yes, sir. My comments, quite frankly, 
are driven by the fear that everybody who prescribes pain 
medicines, and every patient who receives them, especially for 
surgical pain----
    Senator Begich. Right.
    General Schoomaker.--and for short-term uses is concerned 
about addiction. We don't want to do anything that drives 
people into having pain and avoiding what's appropriate 
treatment.
    Senator Begich. Excellent.
    One thing I'll mention. I'm going to go to a very Alaskan 
item here. But, you were talking about the emergency room 
increases.
    Admiral Hunter. Yes, Senator.
    Senator Begich. Admiral, thank you--I wasn't here at the 
beginning, but I know you mentioned Alaska, and I appreciate 
that.
    There's a really interesting program that Indian Health 
Services does within Alaska called the ``Nuka model''--N-U-K-A. 
They saw the exact same thing that you were describing. 
Significant increases in emergency room care, even though they 
had clinics----
    Admiral Hunter. Yes.
    Senator Begich.--all around and available in the villages 
and so forth. But, they were seeing spikes in emergency care.
    They created a demonstration project under Indian Health 
Services, and it's managed by South Central Foundation. They 
have reduced their emergency care access by 68 percent in the 
last 2\1/2\ to 3 years, and many other things. They have 
developed a model that--when you were describing the situation 
you were laying out, it was very similar to what they had 
described about 5 to 10 years ago, that they were 
experiencing--and they couldn't understand why, when they were 
building these clinics in their facilities--but they went 
through a whole process, and they saw a huge decrease in the 
last 2 or 3 years, I'd say, at least, maybe longer, on 
emergency entries, which, of course, is a huge savings, when 
you don't have to deal with that process.
    General Schoomaker. Yes, sir, we're seeing this. As we 
stand up the Patient-Centered, Family-Centered Medical Home 
concept across the Services--all of my clinic and hospital 
commanders track emergency room use, and in those places, like 
Fort Benning, where these are standing up--Fort Polk--we see 
emergency room use drop.
    Senator Begich. That's great.
    General Schoomaker. It's a chaotic, episodic kind of care 
that people are tapped into.
    Senator Begich. Right. Emergency care is expensive and, the 
last thing you want.
    General Schoomaker. Yes, sir.
    Senator Begich. Doctor, did you have a comment?
    Dr. Rice. Yes, Senator. One of the things that I think we 
hold out a lot of hope for is--with our Electronic Health 
Record--is providing patients access to their own record 
online. The experience of several healthcare systems has been 
that, as patients are able to go online, find out for 
themselves particular aspects that might influence their care, 
or get answers to questions, their use of the emergency room 
and their seeking appointments with their physicians drops off 
dramatically.
    Senator Begich. Very good.
    Mr. Chairman, I just have two quick, final comments, one 
for Dr. Rice or Admiral Hunter. Again, thank you for mentioning 
Alaska. I know we've had a conversation about this.
    Admiral Hunter. Yes, Senator.
    Senator Begich. In the healthcare reform bill that the 
President signed yesterday, we have within there a task force, 
as we've already started the process of trying to deal with 
healthcare costs in Alaska. It now sets it up formally. I just 
want to see if you have any comment for the record, while we're 
here, on the idea of the task force and how you see that moving 
forward.
    Admiral Hunter. Thank you, Senator. We absolutely 
appreciate your leadership in this area and bringing all the 
parties together. Our TRICARE Regional West Director, Admiral 
Niemyer, was up in Alaska recently and visibly engaged and 
actively engaged all of the Federal health partners in coming 
together around trying to stabilize the rate schedule.
    In addition, we're working to improve what we call the 
``back offices of care'' to make it easier for us to manage the 
relationships with providers and to bring providers on board 
for TRICARE. You will see some changes to the TRICARE manual 
soon that reflect that change. We appreciate the opportunity to 
work with you and your staff in that endeavor.
    Senator Begich. Excellent.
    Then, the last question. I appreciate--you actually 
mentioned it, and that was on the whole issue of the 
reimbursement rate. We have a differential up there because of 
some of the high costs and capacity for certain specialties and 
so forth. Do you have any additional further comment you want 
to make on that? I know we're anxious to make that more 
permanent. I know you're going through a process right now.
    Admiral Hunter. Yes.
    Senator Begich. Can you elaborate a bit on that, at this 
point?
    Admiral Hunter. Yes, Senator. But for the other members, we 
have a demonstration project in progress that allows us to pay 
a little bit more than the standard TRICARE rates up in Alaska, 
because of the difficulty in obtaining care. Primary care is 
obtained in the military medical treatment facilities, and 
specialty care goes out. For some specialties, there is truly a 
provider shortage, and it's difficult to get all the care that 
we need. Air Force has partnered with us, particularly Chief of 
Staff of the Air Force--an interest item for him--and Army--
also Coast Guard--in looking at these issues for, what do we 
need and where do we need it? So, what we did for an interim, 
we extended the demonstration project, and then we put in what 
we call locality-based waivers for certain specialties, where 
we had to go even higher--orthopedics, ENT, rheumatology, where 
some of the specialties for which we have location-specific 
waivers.
    With the other Federal partners, we're looking long-term 
solution to move to a Federal rate schedule, so that we don't 
compete with one another. We hope to at least have some interim 
progress on that this summer, so that we don't have to--we see 
extending the demo as, perhaps, a concern that we aren't 
committed.
    Senator Begich. Right.
    Admiral Hunter. We want to move forward very deliberately 
in this area.
    Thank you.
    Senator Begich. Thank you very much.
    Mr. Chairman, thank you very much.
    Senator Webb. Thank you, Senator Begich.
    Senator McCaskill.
    Senator McCaskill. Thank you, Mr. Chairman.
    I had to rush down here, because the rumor all over the 
Hill is that Webb and Graham have gone rogue. [Laughter.]
    Senator Webb. We're getting it done.
    Senator Graham. We're getting it done, yes.
    Senator McCaskill. Getting it done.
    In fact, if I'd known that this could have happened--I had 
a hearing this afternoon on Afghanistan police training 
contracting in my Contracting Subcommittee--I would have asked 
you guys to come out with me at 2:30 so we could have gotten 
that hearing done.
    Senator Webb. Senator Graham has certain connections.
    Senator McCaskill. Yes. I don't get it. I would have loved 
to have that hearing this afternoon. I'm trying to figure out 
what the point is of not being able to have a hearing this 
afternoon.
    But, I admire you all for forging ahead, in spite of what 
the rules say. I think it's great we're talking about this. I 
think you all know that there are many things that I'm very 
concerned about in this particular portfolio.
    Let me start with stigma about getting help, and how that 
stigma is such a particular problem because of the training and 
the appropriate peer pressure that makes our military so 
successful.
    I know that we're doing a confidentiality study at Fort 
Leonard Wood, on the heels of a scandal there, where we had 
some problems with the substance abuse program. General 
Schoomaker, I'd like to know, do you have anything you can tell 
this committee today about the pilot program to look at a 
program where soldiers can come forward and say, ``I need 
help,'' without it getting reported up the chain of command?
    General Schoomaker. Yes, ma'am. We identified, some time 
ago, that the soldiers would tell us, confidentially, that they 
had problems, say, with alcohol, and yet, would not be formally 
referred, because there was an automatic notification of their 
commanders. So, we started a pilot program in Hawaii and 
Alaska, in Fort Lewis. I know, ma'am, that you're aware of this 
in Fort Leonard Wood. Many other camps, posting stations, have 
signed on to the desire to have the program generalized. We 
call this the Confidential Alcohol Treatment and Education 
Program and what we find is, a much larger group of soldiers is 
now coming forward and getting treatment at an earlier stage, 
before the misconduct has been performed, before there's family 
violence, before they have a DUI or some other problem. The 
other thing that's very, very encouraging is that we're getting 
a spectrum of older soldiers, noncommissioned officers (NCO), 
and officers that are coming forward.
    The interesting part of that is that--and we expected that 
this would happen--a part of any treatment of an alcohol or 
drug problem, but certainly alcohol, is that it's a chronic-
disease model. You're going to have this as a problem for life. 
If you're really going to beat this, it's because you get your 
support system, to include your chain of command, involved in 
how to stay out of trouble. So that a large number of soldiers, 
even after they enter confidentially, come back later and 
inform their chain of command and say, ``Look, I've had the 
treatment. I've been informed. I've been counseled. I know that 
I'm going to have to get more people involved in keeping me 
sober.'' So far, it's been very successful. We have great 
support from the rest of the Army and the Army leadership to 
generalize this across the force.
    Senator McCaskill. I know that the report's due in 
September, and I'll be looking forward to seeing what's put on 
paper, because then I think it's a situation--we can look at 
all the branches----
    General Schoomaker. Yes, ma'am.
    Senator McCaskill.--and talk about confidentiality and 
stigma and how we can work around the culture of the military 
to get us to a point that folks can get help, because many, 
many times, if they feel like it's going to impact their 
career, they wait until it's too late, and it really impacts 
their career. I think those are men and women that we can't 
afford to lose in the service of our country.
    Let's talk a little bit about counselors. Does anybody have 
a number of how many counselors we're short right now, in terms 
of substance abuse counselors? I know--speaking of chronic--
this is a chronic problem, having the right number of 
counselors available.
    General Schoomaker. We have the exact numbers. What we're 
trying to do is keep abreast of the demand. Programs like the 
KTAP program--the confidential--is generating more need. So, 
the attempt is to--we've reengineered the Alcohol and Substance 
Abuse Program so that it's horizontally integrated from the 
assessment, education----
    Senator McCaskill. That's good.
    General Schoomaker.--targeted at an early intervention to 
full treatment. In doing that, we're beginning to see what the 
bow wave is, and anticipate that. We're doing, centrally, 
hiring of counselors. But, I can tell you, ma'am, just as in 
behavioral health in general, across the Army, we remain with 
shortages, because it's very hard, in some locations, to find 
counsels. It's not a money issue. It's not a problem of 
bureaucracy. It's a problem, quite frankly, of finding, in a 
Nation which is already strained for having an appropriate 
number of trained counselors, it's finding people willing to go 
to some of our locations.
    Senator McCaskill. Has there been any thought given to some 
kind of pilot program to internalize this function without 
contractors, to have military people get the substance abuse 
training, so that it's peer-to-peer, as opposed to an outside 
contractor that you're going to and talking to about your 
substance abuse issues?
    General Schoomaker. Ma'am, I think part of the program of 
horizontal integration is to start employing peer-to-peer 
counselors and even groups like former NCOs who want to come in 
and participate in this, well before the need for formal 
counseling for treatment. If we can do targeted intervention 
and education early on, the intent is to obviate the need to 
have people fall off the cliff before they're approached.
    Senator McCaskill. Let me talk a little bit about a 
specific drug, OxyContin. This is a highly addictive drug. In 
fact, it is not uncommon in many places in the country right 
now. The street value of OxyContin exceeds heroine. Let me just 
say that again. The street value of OxyContin exceeds heroine. 
As high as $80 a pill, on the street. This has really become a 
drug of choice that is a huge problem in this Nation. I 
listened to some of the testimony before I got here, and I want 
to make sure that everyone is aware that this is a growth 
industry right now, in terms of pain meds. It is something 
that--in fact, too late--we're beginning to get a handle on the 
addictive nature of this drug.
    Can you tell me, General, or can any of you tell me--I know 
that there was some diminishing of the data because of sleeping 
pills, but I have to tell you, if you guys aren't on top of 
this----
    General Schoomaker. Yes, ma'am.
    Senator McCaskill.--I guarantee you, if you plot a graph of 
how much OxyContin is being prescribed, if you all had that 
number right now, I think it would scare the bejesus out of 
you.
    General Schoomaker. Yes, ma'am. We do track that pretty 
closely.
    Senator McCaskill. What is it, in the Army?
    General Schoomaker. I can give you--I can take it for the 
record and give you the numbers. But OxyContin's been with us 
for almost 100 years. It's a derivative of----
    Senator McCaskill. Morphine.
    General Schoomaker.--many of the drugs that are related to 
one another--morphine, codeine, heroin, methadone. These are 
all related to one another, cross-react with one another, have 
variations in their absorption or how they're administered and 
how long they last.
    OxyContin is a component of a long-acting--or is a long-
acting form of Oxycodone that is mixed in other formulations 
with nonsteroidal anti-inflammatories, like acetaminophen or 
Motrin or Ibuprofen. So, we use the components of that in many, 
many different applications for pain management. But, as I said 
earlier, I think one of our problems here is that prescription 
drugs have become increasingly used in social environments for 
recreational use, and have resulted in addictions that are 
related to morphine and heroin addictions. We're tracking them 
very closely in the Army, especially in that population of 
wounded, ill, and injured soldiers for whom we know there's a 
very high use. We have sole provider programs. That is, a 
single provider prescribes all psychotropic and potentially 
addictive drugs, and watches and tracks those. Those go on in 
our hospitals and clinics for other nonwounded, ill, and 
injured soldiers, where there is high use of pain medicine.
    Frankly, ma'am, I go back to what I said earlier about our 
Pain Management Task Force. That's one of the reasons we stood 
it up, is we need a far more holistic and even nonpharmacologic 
approach to pain management.
    Senator McCaskill. Thank you very much.
    I know I'm out of time.
    I would like to put one question on the record, though, 
about a young man, Lance Corporal Lopez, from Missouri, who had 
a severe adverse reaction to a vaccine when he was deployed, 
and he was not allowed the one-time benefit on the Traumatic 
Servicemember Group Life Insurance policy, even though he was 
in a coma and, in a wheelchair for a while and has ongoing 
problems. For the record, I want to put it in and get your 
reaction as to whether or not that should be a loophole in that 
coverage.
    It seems to me that his injury has been as traumatic as any 
battlefield injury, and it doesn't seem fair to me that he's 
denied that benefit because it's an adverse reaction to a 
vaccine that he had to take for deployment, as opposed to an 
injury on the battlefield.
    General Schoomaker. This was a soldier?
    Senator McCaskill. No. It was a marine.
    Thanks.
    Senator Webb. Thank you, Senator McCaskill.
    I have two semi-technical questions, here, I want to ask.
    Then, Senator Begich, did you want another round?
    Senator Begich. No, I'm good.
    Senator Webb. Okay.
    First is--I've been trying to follow--and I think, Dr. 
Rice, I'd like to ask you to start on the answer--this ongoing 
evaluation of the disability evaluation system--the pilot 
program that's in place. I'm very familiar with the two 
different disability systems, having worked as counsel on the 
House Veterans Committee years ago, where traditionally DOD 
would be rating people based on whether they were fit for duty 
in a DOD environment, and then giving a percentage of 
disability as of the moment they left the military. VA was 
known as lifetime reevaluation. Whatever disability you 
incurred on Active Duty could be aggravated, and your VA 
percentage actually could go up over the rest of your life.
    They're basically two totally different concepts, and the 
compensation amounts pretty much reflected that. Now we have 
been exploring ways, since the Dole-Shalala Commission, to see 
if we can merge the process. Could you bring us up to date on 
how that's working?
    Dr. Rice. Senator, this issue has been a challenge. It's 
been a challenge since the early 1950s. It's been the subject 
of a number of panels and congressional hearings. The 
challenges that you mention are--that's exactly right, the--we 
have the Medical Evaluation Board, which determines whether or 
not somebody can continue on Active Duty, and then the VA has 
its own separate process.
    In all candor, it--from my vantage point at the Uniformed 
Services University, I didn't deal with that issue on a day-to-
day basis, and I'm just beginning to get up to speed. Perhaps I 
can ask one of my colleagues----
    Senator Webb. Okay.
    Dr. Rice.--who could--General Schoomaker, I expect, is a 
lot more conversant with it than am I.
    Senator Webb. If there are others who would like to be in 
that, as well.
    General Schoomaker. I feel very strongly about this topic, 
because, of course, this surfaced with the problems that we had 
at Walter Reed, roughly 3 years ago this month.
    We have a highly adversarial, highly bureaucratized program 
in which two systems are trying to intersect with one another--
the DOD system that determines fitness and then begins an 
adjudication process of disability and I focus on disability--
physical disability--for the single unfitting--most unfitting 
condition, and then hands it off to the VA, who adjudicates, 
based upon a whole-person concept, what problems that soldier, 
sailor, airman, marine may have. The fact remains that there 
are major benefits derivative from certain thresholds, like 30 
percent, where you accrue, for yourself and family, TRICARE 
benefits. The system, in 3 years, in my view, although we've 
tried in every way we can to streamline the bureaucracy and to 
improve the handoff of the VA, continues to be problematic. 
We're tweaking the edges, and I think Admiral Robinson has used 
language to that effect. We're nibbling at the edges of a 
system and a process which is inherently and intrinsically 
antiquated and adversarial.
    I say to my soldiers, it's one of the tragedies that the 
very people who saved you on the battlefield, that evacuated 
you successfully back through two or three continents, across 
8,000 miles, toward the end of your processing, becomes your 
enemy. The same people that you looked to, to get you recovered 
and rehabilitated, now you look upon as not supporting your 
successful transition into private life. It needs to be 
fundamentally changed.
    We need to focus on ability. We need a system that focuses 
on ability, that's aspirational in its focus, much like our 
most successfully transitioning soldiers, soldiers who have--
amputees, much as has already been discussed here, sir. Some of 
our most----
    Senator Webb. We also need to----
    General Schoomaker.--severely injured soldiers----
    Senator Webb.--to focus on properly compensating people who 
incur lifetime----
    General Schoomaker. Absolutely.
    Senator Webb.--difficulties, as a result of their military 
service. That's how the----
    General Schoomaker. Absolutely.
    Senator Webb.--the whole compensation system began. At one 
time in our history, if someone were to suffer an amputation on 
a battlefield, have to introduce a private bill in Congress in 
order to get relief from the government. Nobody could sue--
either that or you would want to sue--you can't sue the 
government for your disability, so we put this system into 
place. The intention, I think, was to try to make people whole 
as--in as much as you can.
    General Schoomaker. To go back to what Dr. Rice said, this 
was a system that developed during an industrial economy, that 
focused on physical disability. In an information age economy, 
we need a far different and better system that allows the 
Services to adjudicate--or to decide upon unfitness, and an 
adjudication of disability and compensation, but also assesses 
ability and gives people the tools and the bridging support----
    Senator Webb. I've heard that argument. I heard it when the 
Dole-Shalala Commission came in, and from my perspective, it's 
more akin to compensation from a tort claim or an injury, 
rather than fitting someone to a particular profession in an 
industrialized economy, other than the military profession. 
Each Service has been very different over the years in terms of 
how they've evaluated people when they left.
    I used an example 3 years ago when you were testifying, of 
two brothers, both of whom are good friends of mine in the 
Marine Corps, both of whom were badly wounded and returned to 
Active Duty. One had his patella blown off and had a really bad 
back injury. Went back to Vietnam and did a tour. These are the 
famous McKay brothers, if anyone is looking for historical 
documentation. Jim McKay finished his enlistment and said, 
``All right, I'm ready to get my disability and go on with my 
life.'' The Marine Corps said, ``No, you return to duty. Your 
disability is zero.'' He went across the street to the VA, and 
I think he got 60 percent.
    John McKay--a classmate of mine in the Naval Academy--got 
his eye shot out and broke a piece of the bone up here 
[indicating], so he couldn't even wear an artificial eye, 
stayed on Active Duty for 26 years, retired as a colonel, and 
the Marine Corps said, ``You're zero disability.'' He had the 
anatomical loss of an eye, busted sinus, busted jaw where the 
bullet went through, and they gave him a zero. I went and 
testified at his appeal hearing, saying it should have--the VA 
immediately gave him 90 percent, probably more. But, when you 
say ``an adversarial system,'' those are two pretty good 
examples of people who just wanted to give more and the 
injuries, the wounds that they suffered, even though they were 
able to do their job, related more to, I think, tort law--how 
we've formalized tort law through statute. That's really what 
the disability system is supposed to be.
    But, Admiral, I'd like to hear from you. We're going to 
wrap this up fairly soon here.
    Admiral Robinson. Just one addition, and I'm not sure it's 
going to be that helpful, but I think that what you and General 
Schoomaker are talking about is correct. I think, also, that 
there is--and, by the way, I'm not a lawyer, so the tort part, 
I'll have to ask exactly how you're working that.
    VA: systematic rehabilitative care, generally. DOD: acute 
care, generally. What's happened is, that's intermixing now. 
So, how we've done business in the past is not what we're doing 
today. Men and women who are injured today, who would normally 
never be kept in the Service, because you wouldn't stay in the 
Service with an amputation or with all sorts of different 
things, are being kept in the Service now. Men and women who 
are amputees, as an example, who would normally have moved to 
the VA system, but now we have, led by Army, a huge, major, and 
an excellent amputation program. But, again, that's a 
systematic rehab type of condition.
    So, you have DOD, and then you have the VA that's funded 
for the systematic rehab. We need to try to blend those two 
together. I think a great deal of what we're doing in the 
disability evaluation system is the two mammoth organizations 
that are coming to grips with: Who is going to fund this now? 
How is this going to get done? It has to be done, and it has to 
be done correctly, because the men and women who we're taking 
care of--I'm not thinking of 2010 and 2011, I'm thinking of 
2022 and 2025--need to know how they're going to continue that 
amputation care, whatever care that they need to have, and how 
they can actually get their lives back online.
    Senator Webb. I'm really concerned that this whole process 
is bogged down, and we have people waiting around. We have 
people waiting around to get evaluated as the pilot programs 
move forward. I've heard a number of stories from the Wounded 
Warrior Program down at Camp Lejeune, for instance, with 
marines getting frustrated because they're waiting to have 
their cases adjudicated, and then getting in trouble because 
they're going stir-crazy down there, et cetera. So, we need to 
somehow come to a conclusion on this.
    Senator Graham. Along those lines, you have two systems 
that have never been melded together before, and we need to do 
that, and you're well on your way to doing it. Again, you have 
competing interests. A lot of wounded warriors want to stay in. 
So, their first goal at that hearing is to convince the 
military, ``Hey, keep me on Active Duty.'' Sometimes that 
doesn't work out, and then you have to evaluate how much 
disability did the person have.
    The other problem we have is that, when people are 
discharged from DOD to the VA, we have to make that as seamless 
as possible, and that's what Senator Webb's talking about, 
having a joint board, where everybody sits at the same time and 
the same place to evaluate these disabilities without having 
redundancy, is great.
    But, here's just a problem. When you're discharged to rural 
South Carolina with a major injury, healthcare services are 
going to be limited. How we connect people in rural America to 
these services is a challenge for the country. I know your 
heart's right, but these are just logistical obstacles that 
have to be overcome, because when you go into a military 
treatment facility for amputation, like Walter Reed--I know 
you've been out there. It's amazing what you all are doing out 
there to get these folks back up and prosthetics and TBI. So, 
you get world-class care, then you may be sent to some rural 
place in South Carolina, where there's just not capacity. We're 
trying to connect people up to the best provider possible, with 
the least amount of logistical problems.
    Another problem that we've looked at, Mr. Chairman, is the 
spouse, their life changes dramatically. Their hopes and dreams 
basically take a back seat to this traumatic injury. Not just 
the spouse, but the entire family. So, I want to keep pushing 
to create a reimbursement system that we're honoring that 
spouse's service by having a reimbursement system to pay them, 
quite frankly, because they don't have the ability to go back 
to school, some amount of money that would otherwise go to some 
professional service to help that family, who are the primary 
care providers in the emotional front, particularly.
    So, I look forward to working with you, Mr. Chairman, to 
get this process moving. People are waiting way too long. But, 
the sad news is, there are just a lot of people affected by 
this war, and we were overwhelmed a few years ago; that's what 
happened at Walter Reed. We just didn't have the capacity 
built, and we're now building it out. I want to be your partner 
in building it out.
    As to this hearing, I'm glad we're able to conduct it. I 
called my leadership. It was an easy lift to allow the hearing 
to go forward.
    My views on healthcare will be known this afternoon. You're 
welcome to come listen. [Laughter.]
    Business as usual hasn't been done, in many ways, on both 
sides of the aisle, and I don't want to get into a healthcare 
debate, so I won't tell you my views on healthcare, but I'm 
glad we're able to conduct this hearing.
    I hope and pray the Senate, one day, can get back to doing 
business as usual. We're not there yet, but maybe we will be.
    So, thank you, Mr. Chairman.
    Senator Webb. I appreciate your saying that, Senator 
Graham. We do have people who are working on both sides of the 
aisle trying to solve problems, and you're one of them. I hope 
I'm one of them. I think Senator McCaskill is one of them.
    I would like to request all of you to give me your 
evaluation of something before I close this hearing--not at 
this hearing. But, I'd like you to look at--we've talked a lot 
about the electronic data management records and this sort of 
thing. I'm a little curious about your basic software programs 
that you use in your hospitals, whether you believe you have 
the best programs that are available. I say that from personal 
experience, having looked at a really fine software program at 
the Naval Hospital in Bethesda, which I've used for many, many 
years, about 6 or 7 years ago, in seeing that it was replaced 
by something it was less than good, according to the medical 
people that I was talking to. Just tell us whether you need 
better software systems in order to manage all your product, 
and we'd like to get your advice on that.
    [The information referred to follows:]

    Our Military Health System hospitals currently use AHLTA, the 
Department of Defense's (DOD) current electronic health record (EHR) 
capability, as part of a family of systems. AHLTA generates, maintains, 
stores, and provides secure online access to comprehensive patient 
records. The DOD EHR family of systems forms one of the largest 
ambulatory records systems in the world, with documentation of an 
average of 140,000 patient encounters each day. However, the current 
suite of applications and underlying infrastructure do not support the 
challenges of the rapid evolution of today's health care practices, the 
ever-increasing need to transact and share data across the continuum of 
care, and the timely fielding of new capabilities.
    The Military Health System is executing the multi-year plan 
developed in the fall of 2009 to redesign the EHR supporting 
infrastructure and incrementally deliver key functionality. At the 
threshold, the system must stabilize current record capabilities so 
that users may efficiently perform their duties in a timely manner, 
regardless of location, time of day, or network issues. It is 
imperative that DOD address known shortfalls and key challenges with 
functional applications and core infrastructure, including critical 
user concerns with system speed, operational availability, and the user 
interface. This will allow DOD to meet providers' near-term needs and 
better prepare for the transition of applications and supporting 
infrastructure. Further, stabilization efforts will mitigate potential 
risks prior to increasing reliance on these systems for achieving 
expanded interoperability through the virtual lifetime electronic 
record.

    Senator Webb. Any other questions for the record by anyone 
on this subcommittee will be welcome by close of business 
today, which is going to be very late.
    Senator McCaskill, you have anything?
    Senator McCaskill. I don't.
    Senator Webb. Okay.
    Again, I appreciate the incredible work that all of you are 
doing on behalf of the people who are serving, and who have 
served. I appreciate your coming today.
    This hearing is adjourned.
    [Questions for the record with answers supplied follow:]
            Questions Submitted by Senator Claire McCaskill
              traumatic servicemember group life insurance
    1. Senator McCaskill. Dr. Rice, Admiral Hunter, General Schoomaker, 
Admiral Robinson, General Green, and Admiral Jeffries, in September 
2006 Lance Corporal Josef Lopez took a Department of Defense (DOD) 
administered smallpox vaccination prior to a deployment to Iraq and 
then suffered a severe adverse reaction resulting in temporary 
paralysis, coma, bladder damage, severe leg spasms, memory loss, and 
other conditions that require daily medication and care. At the time of 
his injuries from the vaccine, Lance Corporal Lopez applied for the 
Traumatic Servicemember Group Life Insurance (TSGLI) benefit, which was 
enacted by Congress in 2005 to provide a one-time benefit of up to 
$100,000 to servicemembers who endured a traumatic injury, whether in a 
combat or non-combat environment. The benefit is intended to help 
servicemembers and their families with immediate expenses related to 
the servicemember's injury and convalescence period. Due to a loophole 
in title 38, section 1980A(b)(3), Lance Corporal Lopez was denied the 
TSGLI benefit by the Department of Veterans Affairs (VA), even though 
by all measures his injuries from the vaccine were traumatic enough to 
affect key activities of daily living, including incontinence and 
walking. Although his condition has improved to some degree, Lance 
Corporal Lopez had to be medically retired from the Marine Corps in 
June 2009 and now undergoes long-term care management through the VA. 
He cannot drive, hold a normal job, and must take extensive medication 
to prevent spasms in his legs. What is DOD's current policy in handling 
adverse reactions incurred by mandatory DOD-administered vaccines?
    Dr. Rice and Admiral Hunter. The Department's policy concerning 
reactions to vaccines is to follow best available medical practices to 
screen for potential adverse reactions and avoid unnecessary risks. 
Unfortunately, screening methods cannot prevent all adverse vaccine 
events.
    The Services administer specific vaccines based upon disease risk 
and where the servicemember will serve. If anyone receiving a vaccine 
has a negative reaction, providers monitor the patient and determine 
the severity of the reaction. DOD medical providers are required to 
report and file a Vaccine Adverse Event Reporting System (VAERS) Report 
with the Centers for Disease Control (CDC) and Food and Drug 
Administration (FDA).
    In addition, DOD has four vaccine health care centers to provide 
consultative support to providers, serve as patient advocates, support 
research to enhance vaccine safety, and provide long-term follow-up for 
patients.
    General Schoomaker. DOD is committed to providing our 
servicemembers the highest quality of health care and support. If a 
potential vaccine-related adverse event is suspected from a mandatory 
DOD-administered vaccine, the attending healthcare provider is required 
to file a VAERS report. VAERS is a national reporting and surveillance 
system to identify adverse events and promote vaccine safety, and is 
administered by the CDC and the FDA. Additionally, the attending 
healthcare provider will refer the patient to the DOD's Vaccine 
Healthcare Centers (VHC) network for further consultation, treatment, 
and follow-up. The VHC's role is to prevent, identify, and treat 
vaccine-related adverse events. It offers a 24-hour clinical call 
center and a web-based digital photo-sharing system that allows for 
easier diagnosis from remote sites. Following service discharge, 
ongoing medical care becomes the responsibility of the VA. However, the 
VHC will provide the healthcare providers at the VA clinical 
consultative follow-up care on our veterans being treated.
    Admiral Robinson. The Military Vaccine Agency (MILVAX) is the DOD 
lead agent for all vaccine-related issues. If a potential vaccine-
related adverse event is suspected from a mandatory DOD-administered 
vaccine, the attending healthcare provider will file a VAERS report. 
VAERS is administered by the CDC and the FDA. Additionally, the 
attending healthcare provider would refer the patient to the DOD's VHC 
network for further consultation, treatment, and follow-up based upon 
the clinical diagnosis.
    General Green. TSGLI is not administered through the Air Force 
Surgeon General's office, but through the Air Force Office of the 
Deputy Chief of Staff for Manpower and Personnel (AF/A1).
    If a potential vaccine-related adverse event is suspected from a 
mandatory DOD-administered vaccine, the attending healthcare provider 
will file a VAERS report in accordance with Air Force Joint Instruction 
48-110, section 2-10. VAERS is administered jointly by the CDC and the 
FDA, with occasional assistance in the analysis by the Immunization 
Safety Office at the National Center for Immunization and Respiratory 
Diseases of the CDC. Any person--not just healthcare providers--may 
submit a VAERS report to the FDA.
    Admiral Jeffries. The MILVAX is the DOD lead agent for all vaccine-
related issues. If a potential vaccine-related adverse event is 
suspected from a mandatory DOD-administered vaccine, the attending 
healthcare provider will file a VAERS report. VAERS is administered by 
the CDC and the FDA. Additionally, the attending healthcare provider 
would refer the patient to the DOD's VHC network for further 
consultation, treatment, and follow-up based upon the clinical 
diagnosis.

    2. Senator McCaskill. Dr. Rice, Admiral Hunter, General Schoomaker, 
Admiral Robinson, General Green, and Admiral Jeffries, how many 
servicemembers have had adverse reactions to mandatory DOD-administered 
vaccines over the past 5 years?
    Dr. Rice and Admiral Hunter. The Department reports 3,798 
servicemembers have had adverse reactions to mandatory DOD-administered 
vaccines over the past 5 years.
    General Schoomaker. DOD requires the attending healthcare provider 
to submit a VAERS report if a potential adverse event is suspected. 
Additionally, anyone can submit a VAERS report if they feel that they 
have had an adverse reaction to a vaccine. From January 2005 to 
December 2009, DOD personnel filed 3,798 reports to VAERS.
    Admiral Robinson. According to the MILVAX, DOD requires the 
attending healthcare provider to submit a VAERS report if a potential 
adverse event is suspected. Additionally, anyone can submit a VAERS 
report if they feel that they have had an adverse reaction to a 
vaccine. From January 2005 through December 2009, there were 3,798 
reports filed by DOD personnel to VAERS.


2005.......................................................        352
2006.......................................................        525
2007.......................................................        794
2008.......................................................      1,080
2009.......................................................      1,047
                                                            ------------
  Total:...................................................      3,798


    General Green. From January 2005 to December 2009, there were 3,798 
reports filed by DOD personnel to VAERS. As the VAERS form does not 
require the specification of the Service, it is not possible to 
determine how many of these reports were from or about Air Force 
members. DOD requires the attending healthcare provider to submit a 
VAERS report if a potential adverse event is suspected. Additionally, 
anyone may submit a VAERS report if they feel that they or a family 
member have had an adverse reaction to a vaccine.
    Admiral Jeffries. According to the MILVAX, DOD requires the 
attending healthcare provider to submit a VAERS report if a potential 
adverse event is suspected. Additionally, anyone can submit a VAERS 
report if they feel that they have had an adverse reaction to a 
vaccine. From January 2005 through December 2009, there were 3,798 
reports filed by DOD personnel to VAERS.


2005.......................................................        352
2006.......................................................        525
2007.......................................................        794
2008.......................................................      1,080
2009.......................................................      1,047
                                                            ------------
  Total....................................................      3,798



    3. Senator McCaskill. Dr. Rice, Admiral Hunter, General Schoomaker, 
Admiral Robinson, General Green, and Admiral Jeffries, how are these 
numbers tracked? Please provide specific numbers.
    Dr. Rice and Admiral Hunter. The number of adverse reactions to 
DOD-administered vaccines is tracked through the VAERS at the CDC and 
FDA.
    General Schoomaker. DOD uses the VAERS to report and track any 
suspected adverse events after vaccination. This system is also used by 
civilian vaccine manufacturers, healthcare professionals, and the 
public to report and track clinical events temporally associated with 
vaccination. From January 2005 to December 2009, there were a total of 
3,798 VAERS reports filed by DOD personnel. The number of VAERS reports 
filed by year is as follows:


2005.......................................................        352
2006.......................................................        525
2007.......................................................        794
2008.......................................................      1,080
2009.......................................................      1,047
                                                            ------------
  Total:...................................................      3,798


    Admiral Robinson. According to the MILVAX, DOD uses the VAERS to 
report and track any suspected adverse events after vaccination. This 
system is also used by civilian vaccine manufacturers, healthcare 
professionals, and the public to report and track clinical events 
temporally associated with vaccination. From January 2005 to December 
2009, there were a total of 3,798 VAERS reports filed by DOD personnel. 
The number of VAERS reports filed by year is as follows:

2005.......................................................        352
2006.......................................................        525
2007.......................................................        794
2008.......................................................      1,080
2009.......................................................      1,047
                                                            ------------
  Total....................................................      3,798


    General Green. DOD uses the VAERS to report and track any suspected 
adverse events after vaccination. This system is also used by civilian 
vaccine manufacturers, healthcare professionals, and the public to 
report and track clinical events temporally associated with 
vaccination. From January 2005 to December 2009, there were a total of 
3,798 VAERS reports filed by DOD personnel. The number of VAERS reports 
filed by year is as follows:


2005.......................................................        352
2006.......................................................        525
2007.......................................................        794
2008.......................................................      1,080
2009.......................................................      1,047
                                                            ------------
  Total....................................................      3,798



    As the VAERS form does not require the specification of the 
Service, it is not possible to determine how many of these reports were 
from or about Air Force members.
    Admiral Jeffries. According to the MILVAX, DOD requires the 
attending healthcare provider to submit a VAERS report if a potential 
adverse event is suspected. Additionally, anyone can submit a VAERS 
report if they feel that they have had an adverse reaction to a 
vaccine. From January 2005 through December 2009, there were 3,798 
reports filed by DOD personnel to VAERS.


2005.......................................................        352
2006.......................................................        525
2007.......................................................        794
2008.......................................................      1,080
2009.......................................................      1,047
                                                            ------------
  Total....................................................      3,798



    4. Senator McCaskill. Dr. Rice, Admiral Hunter, General Schoomaker, 
Admiral Robinson, General Green, and Admiral Jeffries, have any adverse 
vaccine injuries resulted in TSGLI claims? If so, how many?
    Dr. Rice and Admiral Hunter. Yes, there have been reports of 
adverse vaccine injuries which resulted in TSGLI claims.
    The Army reported three claims for TGLSI benefits due to adverse 
reactions to vaccines. The Marine Corps reported three claims for TGLSI 
benefits due to adverse reactions to vaccines. The Navy and Air Force 
have reported no claims for TGLSI benefits due to adverse reactions to 
vaccines.
    General Schoomaker. The Army TSGLI program has received four TSGLI 
claims with losses thought to be a result of vaccine injuries. The 
claimed losses were primarily those of Activities of Daily Living 
Losses (ADL), caused by a neurological or muscular dysfunction. One 
claim stated that the claimant would require surgery based upon a 
reaction to the vaccine and his ADLs would be impacted post surgery 
during recovery.
    Admiral Robinson. Navy's TSGLI database is managed by the Bureau of 
Naval Personnel and tracks the medical condition or event associated 
with the claim, but not necessarily the underlying cause. As such, the 
database does not explicitly track claims stemming from an adverse 
vaccine reaction. However, an electronic keyword search of the database 
was conducted, using terms such as ``vaccine,'' ``injection,'' and 
``allergic reaction.'' A follow-on manual search of claims in which the 
medical condition or event was not clearly identified in the electronic 
database was also conducted. These combined searches revealed that, as 
of 19 March 2010, no TSGLI claims filed by Navy personnel have resulted 
from an adverse vaccine reaction.
    General Green. The Air Force has not received any Active Duty, Air 
National Guard, or Air Force Reserve TSGLI claims identifying an 
adverse reaction to vaccine as a traumatic injury.
    Admiral Jeffries. The Marine Corps administration of the TSGLI plan 
is managed by the Manpower and Reserve Affairs (M&RA) division of 
Headquarters, Marine Corps and specifically the Wounded Warrior 
Regiment. The database maintained by the Wounded Warrior Regiment was 
queried and three claims related to a vaccine injury were discovered, 
one of which was that of Lance Corporal Lopez.

    5. Senator McCaskill. Dr. Rice, Admiral Hunter, General Schoomaker, 
Admiral Robinson, General Green, and Admiral Jeffries, how many 
servicemembers have been denied TSGLI claims for conditions and 
injuries related to adverse vaccine reactions?
    Dr. Rice and Admiral Hunter. A total of six servicemembers have 
been denied TSGLI claims for condition and injuries related to adverse 
vaccine reactions.
    The Army reported three denials of TSGLI benefits claims made due 
to adverse vaccine reactions. The Marine Corps reported three denials 
of TSGLI benefits claims made due to adverse vaccine reactions. The 
Navy and Air Force reported no denials to TGSLI benefits claims made 
due to adverse reactions to vaccines.
    General Schoomaker. The Army TSGLI program has received four TSGLI 
claims with losses thought to be a result of vaccine injuries. Each 
claim was denied due to a lack of medical documentation establishing a 
direct link to the claimed losses and the administration of the 
vaccine. Claims were also denied as not being a result of a traumatic 
event per requirements of the TSGLI program.
    Admiral Robinson. Navy's TSGLI database is managed by the Bureau of 
Naval Personnel and tracks the medical condition or event associated 
with the claim, but not necessarily the underlying cause. As such, the 
database does not explicitly track claims stemming from an adverse 
vaccine reaction. However, an electronic key word search of the 
database was conducted, using terms such as ``vaccine,'' ``injection,'' 
and ``allergic reaction.'' A follow-on manual search of claims in which 
the medical condition or event was not clearly identified in the 
electronic database was also conducted. These combined searches 
revealed that, as of 19 March 2010, no Navy personnel have been denied 
a TSGLI claim for conditions or injuries related to an adverse vaccine 
reaction.
    General Green. The Air Force has neither received nor denied any 
Active Duty, Air National Guard, or Air Force Reserve TSGLI claims 
identifying an adverse reaction to vaccine as a traumatic injury.
    Admiral Jeffries. The Marine Corps administration of the TSGLI plan 
is managed by the M&RA division of Headquarters, Marine Corps and 
specifically the Wounded Warrior Regiment. The database maintained by 
the Wounded Warrior Regiment was queried and three claims related to a 
vaccine injury were discovered, one of which was that of Lance Corporal 
Lopez.

    6. Senator McCaskill. Dr. Rice, Admiral Hunter, General Schoomaker, 
Admiral Robinson, General Green, and Admiral Jeffries, given that TSGLI 
is meant to cover traumatic injuries of servicemembers, what is your 
interpretation of whether Lance Corporal Lopez qualifies for TSGLI 
given the nature of his injuries from the DOD-administered vaccine, 
which caused him permanent and lifelong disability?
    Dr. Rice and Admiral Hunter. DOD concluded, based on current statue 
and policy, that Lance Corporal Lopez does not qualify for TSGLI given 
the nature of his injuries from the administered vaccine.
    Upon discharge a veteran would be entitled to monetary benefits and 
lifetime medical care for disabilities caused by lingering effects from 
vaccine reactions through the VA. However, DOD does not believe the 
TSGLI program is the appropriate vehicle for providing benefits for 
members who experience adverse reactions to vaccines.
    TSGLI was designed by Congress to provide severely injured 
servicemembers, who suffer a loss as a direct result of a traumatic 
event, with short-term monetary assistance. The definition of a 
traumatic event, according to 38 CFR 9.20, is, `` . . . the application 
of external force, violence, chemical, biological, or radiological 
weapons, or accidental ingestion of a contaminated substance causing 
damage to a living being.'' The TSGLI benefit is intended to lessen the 
economic burden on the member and the member's family which often 
ensues during the often long and difficult treatment and rehabilitation 
periods.
    General Schoomaker. It is tragic that Lance Corporal Lopez and 
other servicemembers have had adverse reactions to predeployment 
vaccinations. Preserving the health and safety of our servicemembers is 
my top concern. I would not consider this event to be a traumatic 
injury as defined by current law. Under the current law, inoculations 
are specifically excluded from TSGLI payment.
    TSGLI provides for payment to servicemembers who are severely 
injured (on or off duty) as the result of a traumatic event and suffer 
a loss that qualifies for payment under TSGLI. The servicemember must 
suffer a qualified loss that is a direct result of a traumatic event to 
qualify for TSGLI payment.
    Lance Corporal Lopez was given a required predeployment vaccination 
(smallpox). He had a severe reaction to the vaccination. As a result, 
he suffered temporary paralysis, was in a coma, and continues to 
struggle to independently perform activities of daily life. However, 
these injuries were not caused by a traumatic event under the VA's 
regulations governing TSGLI. These regulations define a traumatic event 
as ``the application of external force, violence, chemical, biological, 
or radiological weapons, accidental ingestion of a contaminated 
substance, or exposure to the elements that causes damage to the 
body.'' Also, specifically excluded from TSGLI payment is a loss caused 
by ``[d]iagnostic procedures, preventive medical procedures such as 
inoculations . . . or any complications arising from such procedures or 
treatment.''
    Lance Corporal Lopez's loss was caused by a smallpox vaccination. 
Smallpox is a serious, highly contagious, and sometimes deadly 
infectious disease. A smallpox outbreak would significantly affect 
military readiness. Administering the vaccination now, before an 
outbreak, is the best way to protect our troops. Very rarely, the 
smallpox vaccine can cause serious side effects. We will continue to 
enhance vaccine safety through research and education. We will also 
continue to optimize our screening process to ensure those at increased 
risk will not receive the vaccination.
    Admiral Robinson. Both the Code of Federal Regulations (CFR) (38 
CFR Sec. 9.20(e)(3)(i)(C)) and the August 5, 2009, TSGLI procedural 
guide specifically address this issue by stating that preventive 
medical procedures such as inoculations, and any complications arising 
from such procedures or treatment, are excluded from TSGLI payment.
    The Disability Evaluation System (DES) is the Uniformed Services' 
program to consider servicemembers whose ability to continue their 
military career is called into question as a result of their health 
state. This system does not delineate servicemembers based upon the 
cause of their injury or illness, with the potential exception of self-
inflicted cases, but rather the outcome and impact. The servicemember 
may be medically retired and compensated based on the level of 
disability associated with their injury or illness. Service-connected 
conditions and disabilities are also eligible for continuing care and 
potential compensation through the VA upon the servicemember's 
separation or retirement.
    General Green. TSGLI is not administered through the Surgeon 
General's office, but through the Air Force Office of the Deputy Chief 
of Staff for Manpower and Personnel. However, anthrax and smallpox 
vaccines are not covered under the TSGLI, but would be covered under a 
program administered by the Department of Health and Human Services 
under the Public Readiness and Emergency Preparedness Act of 2005 (42 
U.S.C. Secs. 247d-6d, 247d-6e). As the Air Force has not had the 
opportunity to review Marine Lance Corporal Lopez's medical record, we 
would not be able to comment further.
    Admiral Jeffries. Both the CFR (38 CFR Sec. 9.20(e)(3)(i)(C)) and 
the August 5, 2009, TSGLI procedural guide specifically address this 
issue by stating that preventive medical procedures such as 
inoculations, and any complications arising from such procedures or 
treatment, are excluded from TSGLI payment. Based upon this established 
guidance, TSGLI does not cover the injury and/or disability brought 
about by their adverse reaction to receipt of the small pox 
vaccination. Current policy focuses on the acquisition of the injury as 
the focus of coverage, rather than including the outcome and associated 
disability.

    7. Senator McCaskill. Dr. Rice, Admiral Hunter, General Schoomaker, 
Admiral Robinson, General Green, and Admiral Jeffries, do you think 
that Lance Corporal Lopez and people with similar injuries should 
receive compensation under TSGLI?
    Dr. Rice and Admiral Hunter. While I do think Lance Corporal Lopez 
and members with similar injuries should receive compensation, I do not 
think they should received TGSLI benefits resulting from adverse 
reactions to vaccinations, surgical trauma, or medical procedures given 
current policy.
    While the Lance Corporal Lopez situation is unfortunate, the TSGLI 
program employs the same industry standards and practices regarding an 
insurable loss as employed across the United States with respect to 
anyone who make claims covered by accidental death and dismemberment 
insurance. DOD follows the laws and regulations that embody these 
standards when adjudicating TSGLI claims. Specifically, vaccinations do 
not meet the definition of traumatic event as contemplated in the TSGLI 
statutes and regulations. Servicemembers who suffer adverse reactions 
to vaccines (to the degree that Lance Corporal Lopez suffered) would be 
entitled to monetary benefits and lifetime medical care for these 
disabilities through the VA.
    General Schoomaker. Lance Corporal Lopez and other servicemembers 
who sustain this injury may be entitled to receive a combination of 
military, veterans, and Social Security health and disability benefits. 
However, receiving compensation under TSGLI for this injury would be 
inconsistent with the policy and purpose of the current law.
    Military insurance programs such as TRICARE, SGLI, and TSGLI are 
modeled after commercial insurance policies. Specifically, TSGLI is 
modeled after commercial accidental death and dismemberment insurance. 
Like commercial insurance, TSGLI is a limited benefit that provides 
compensation for specific losses caused by specific events. Also, both 
TSGLI and commercial insurance policies specifically exclude payment 
for losses caused by medical treatment and procedures.
    Vaccinations are preventive medical procedures provided as part of 
the Army's force health-protection program. Unfortunately, some 
servicemembers will experience side effects or adverse reactions from 
the smallpox vaccine. Although rare, there are some serious side 
effects possible from the vaccine. We try to reduce the risk of side 
effects by exempting servicemembers who should not receive this 
vaccine. Like commercial insurance, this injury is not covered by TSGLI 
because it is a direct result of medical treatment and not a traumatic 
event.
    TSGLI is not the sole benefit available to servicemembers who 
suffer serious adverse reactions to vaccinations. TSGLI is very 
specific coverage that provides limited protection. The underlying 
policy and purpose for the TSGLI program will be significantly changed 
if a loss caused by a non-traumatic event qualifies for payment.
    Admiral Robinson. Both the CFR (38 CFR Sec. 9.20(e)(3)(i)(C)) and 
the August 5, 2009, TSGLI procedural guide specifically address this 
issue by stating that preventive medical procedures such as 
inoculations, and any complications arising from such procedures or 
treatment, are excluded from TSGLI payment.
    The DES is the Uniformed Services' program to consider 
servicemembers whose ability to continue their military career is 
called into question as a result of their health state. This system 
does not delineate servicemembers based upon the cause of their injury 
or illness, with the potential exception of self-inflicted cases, but 
rather the outcome and impact. The servicemember may be medically 
retired and compensated based on the level of disability associated 
with their injury or illness. Service-connected conditions and 
disabilities are also eligible for continuing care and potential 
compensation through the VA upon the servicemember's separation or 
retirement.
    General Green. The answer requires more than a simple yes or no 
reply. My understanding is that Congress modeled TSGLI after commercial 
accidental death and dismemberment policies with some expansion of 
benefits to address the unique needs of military service. Commercial 
accidental death and dismemberment policies specifically exclude 
disease and illness, including mental health conditions such as PTSD as 
is the case with the current TSGLI program. The TSGLI program also does 
not currently cover claims resulting from the diagnosis of, or medical 
or surgical treatment for, an illness or disease, or any complications 
arising from such medical or surgical treatment, or preventive medical 
procedures such as inoculations. Congress also expressed their intent 
that the basic TSGLI premium go no higher than its current level of $1 
per month. Expanding TSGLI to include claims resulting from medical 
treatments, illnesses, or preventive inoculations would almost 
certainly result in higher TSGLI premiums.
    Currently, our servicemembers cannot decline TSGLI coverage unless 
they also decline SGLI coverage. They automatically have the monthly $1 
premium deducted from pay. If expanding coverage results in a TSGLI 
premium increase, our concern is that it could change how the program 
is administered. An increase in premium may require giving 
servicemembers an option on whether to elect TSGLI coverage. If that 
occurs, our junior servicemembers may decline TSGLI coverage resulting 
in fewer servicemembers receiving coverage and payment for future 
traumatic injuries. While we support a broad TSGLI program that 
maximizes coverage to the widest degree possible, we do not support 
expanding coverage to the point that it results in an increase of the 
current TSGLI premium and a change in the program that would allow 
servicemembers to opt out. Any expansion of coverage needs to consider 
this possibility as this program is too important to our junior 
servicemembers to allow that to occur.
    Admiral Jeffries. Both the CFR (38 CFR Sec. 9.20(e)(3)(i)(C)) and 
the August 5, 2009, TSGLI procedural guide specifically address this 
issue by stating that preventive medical procedures such as 
inoculations, and any complications arising from such procedures or 
treatment, are excluded from TSGLI payment.
    The DES is the Uniformed Services' program to consider 
servicemembers whose ability to continue their military career is 
called into question as a result of their health state. This system 
does not delineate servicemembers based upon the cause of their injury 
or illness, with the potential exception of self-inflicted cases, but 
rather the outcome and impact. The servicemember may be medically 
retired and compensated based on the level of disability associated 
with their injury or illness. Service-connected conditions and 
disabilities are also eligible for continuing care and potential 
compensation through the VA upon the servicemember's separation or 
retirement.
                                 ______
                                 
               Questions Submitted by Senator Mark Begich
                           suicide prevention
    8. Senator Begich. General Schoomaker, I understand the Army has 
instituted a number of programs to address the increasing suicide rates 
among servicemembers. Can you provide an update on some of the 
programs?
    General Schoomaker. The Army has implemented several near-term 
projects to improve our understanding--such as the Army Campaign Plan 
for Health Promotion, Risk Reduction, and Suicide Prevention, and the 
Vice Chief of Staff's monthly suicide review meetings. The Army has 
also enlisted the help of the National Institute of Mental Health 
(NIMH) to conduct a long-term study on risk and resilience in the Army.
    The Army conducts extensive reviews of every suicide death, both 
Active Duty and non-Active Duty, to improve our understanding of why a 
soldier may choose to take his/her life. The Army Suicide Prevention 
Task Force has created a standardized 37 line report which units use to 
analyze the factors surrounding each soldier's death by suicide. This 
report is forwarded to the Pentagon within 30 days of the soldier's 
death, and a general officer conducts a back brief to the Vice Chief of 
Staff of the Army during his monthly suicide review meeting. This back 
brief is done via a world-wide video teleconference so that leaders 
across the Army can share lessons learned and improve early recognition 
of at-risk soldiers.
    The Army has created the Army Behavioral Health Integrated Data 
Environment database. This database will provide a standardized, 
enterprise-wide, capability to integrate information from dispersed 
legal, medical, and personnel databases into a comprehensive health 
surveillance database to support mental, behavioral, social health, and 
public health activities.
    NIMH has undertaken the Army Study to Assess Risk and Resilience in 
Servicemembers (Army STARRS), which is the largest study ever 
undertaken of suicide and mental health among military personnel. The 
purpose of Army STARRS is to identify, as rapidly and as scientifically 
as possible, modifiable risk and protective factors of suicidal 
behavior, to help inform the Army's ongoing efforts to prevent suicide 
and improve soldiers' overall psychological health and functioning.
    Army actions taken in 2009 to combat the increasing suicide rate 
follow:

    1.  Produced the interactive ``Beyond the Front'' training video.
    2.  Produced the ``Shoulder to Shoulder: No Soldier Stands Alone'' 
training video.
    3.  Updated AR 600-63 (Army Health Promotion) and DA Pam 600-24 
(Health Promotion, Risk Reduction and Suicide Prevention).
    4.  Published Suicide Awareness Pocket Guide for all soldiers.
    5.  Increased access to behavioral health and substance abuse 
counseling.
    6.  Funded NIMH grant for the Army STARRS, $50 million/5-year 
study--Quarterly Updates to VCSA to Accelerate Lessons Learned.
    7.  Initiated a tele-behavioral health screening pilot project with 
the 25th Infantry Division, involving 100 percent screening through 
face-to-face or live video counseling.
    8.  Approved nationally-recognized best-practice suicide 
intervention skills training for Army use to assist in early 
recognition of at-risk individuals.

    Army actions for 2010 follow:

    1.  Developing interactive ``Home Front'' training video.
    2.  Developing sequel to ``shoulder to shoulder'' training video.
    3.  Developing an additional skill identifier for certified suicide 
intervention skills trainers.
    4.  Expanding tele-behavioral health pilot project, to become the 
Comprehensive Behavioral Health System of Care and implementing it into 
the ARFORGEN cycle so behavioral health care is targeted at critical 
points (predeployment, deployment, reintegration, reset, et cetera).
    5.  Developing program effectiveness measures.
    6.  Using the Suicide Specialized Augmentation Response Team/Staff 
Assistance Team to support commanders by assessing programs, policies, 
and resources, and identify gaps to improve local suicide prevention 
programs.

    9. Senator Begich. General Schoomaker, in your opinion, are we 
doing enough?
    General Schoomaker. I will not be satisfied until suicide rates in 
the Army are reduced below the suicide rate for the civilian 
population. Despite our inability to halt the increase in suicide, I am 
very impressed with the prevention efforts of leaders across the Army. 
The Army has implemented many changes to programs, policies, and 
procedures in an effort to improve our suicide prevention programs. We 
have hired more behavioral health professionals, we are improving our 
screening methods, and we are using technology to expand access to our 
behavior health providers. We are constantly looking for ways to 
improve and have eagerly sought the assistance of numerous outside 
experts.
    The Army has documented behavioral health authorizations for 2,340 
providers. As of the first quarter of fiscal year 2010, the Army had an 
on-hand behavioral health provider inventory of 3,714, this equates to 
a 159 percent fill rate. However, given current workload requirements 
and accounting for the increased demand for psychological health 
support for soldiers and families, we have calculated a current 
``needs'' estimate of approximately 4,305 behavioral health providers. 
This represents an 86 percent fill rate when compared to the current 
on-hand inventory. We estimate that an additional 591 behavioral health 
providers are needed to meet current demand. The Army is actively 
engaged in the recruitment and accession of providers to meet the 
identified behavioral health requirements.
    Stigma remains a significant issue in America and Army culture. 
Army leaders are concerned that soldiers appear reluctant to seek 
behavioral healthcare due to stigma and/or fear of negative 
repercussions. As a result, programs have been developed to help 
decrease the stigma associated with soldiers seeking behavioral 
healthcare while also providing an increased layer of privacy.
    The Reengineering Systems of Primary Care Treatment in the military 
is a program designed to decrease the stigma associated with seeking 
behavioral health treatment by placing these services within primary 
care facilities. Through this program, any visit a soldier makes to 
his/her primary care physician for any reason is an opportunity to 
screen the soldier for symptoms that could indicate that he/she is 
struggling with symptoms associated with post-traumatic stress disorder 
(PTSD) or other behavioral health diagnoses. This program is also 
accessible via the web, where soldiers can self-refer. Services 
provided are confidential, unless it is determined that a soldier is at 
risk of harm to self or others.
    The Soldier Evaluation for Life Fitness program incorporates 
behavioral health as a routine component of the health readiness 
process for all soldiers returning to their home stations following 
deployment. Since every soldier receives a consultation on-site, no one 
is stigmatized when seen by a behavioral healthcare practitioner. 
Through the Soldier Evaluation for Life Fitness program, soldiers first 
complete a computer-based self-assessment. On-site clinicians review 
the results of the assessments immediately, allowing them to tailor 
their consultations to meet each soldier's unique needs. Soldiers can 
then be evaluated for individual health risks that may range from PTSD 
and other behavioral health diagnoses to physical health conditions.
    Military OneSource is a free information center and website where 
soldiers can seek assistance 24 hours/day, 7 days/week. Counseling is 
provided by phone or in person by Masters-level consultants on issues 
such as family support, emotional support, debt management, and legal 
issues for up to 12 sessions at no cost to the soldier. Military 
OneSource does not release information about users of the services, 
with the exception of issues of child abuse, elder abuse, spousal 
abuse, and/or risk of harm to self or others. Military OneSource can be 
accessed at www.militaryonesource.com or 1-800-342-9647. Soldiers may 
complete a free, voluntary online behavioral health self-assessment, 
and obtain referrals at www.MilitaryMentalHealth.org. This is an 
approach to assist soldiers and family members with identifying 
symptoms and getting assistance. It provides confidential and immediate 
feedback, as well as referrals to TRICARE, VA centers, and Military 
OneSource.
    Military and family life consultants are also available to assist 
soldiers who are experiencing difficulty coping with daily life 
concerns and issues. Military and family life consultants are Licensed 
Clinical Social Workers, Professional Counselors, Marriage and Family 
Therapists, and Psychologists. They provide six free informal and 
confidential counseling sessions. No records are kept and flexible 
appointment times and locations are offered. Soldiers may access 
military and family life consultants through the Army Community 
Services by self referral, without having to provide a reason for 
seeking these services, or via Military OneSource, who can assist them 
with the identification of a consultant in the soldier's local area.

                 comprehensive soldier fitness program
    10. Senator Begich. General Schoomaker, the Army's Comprehensive 
Soldier Fitness (CSF) program is a structured, long-term assessment and 
development program to build the resilience and enhance the performance 
of every soldier, family member, and Army civilian. Can you tell me 
more about this program, and the role of the Army Medical Department 
(AMEDD) in support of the program?
    General Schoomaker. The Army established the CSF program to 
increase the resilience of soldiers and families by developing their 
strengths in five important domains: physical, emotional, social, 
spiritual, and family. The CSF program will ensure that all soldiers 
undergo an assessment of their total fitness. The results of the 
assessment will direct individualized training, intervention, or 
treatment programs, as needed. This program will begin at accession, 
and, like physical fitness, will include reassessment at appropriate 
intervals. The CSF office applies accepted methodology and scientific 
rigor to ensure that all training, interventions, and treatments have 
demonstrated effectiveness.
    The AMEDD is a strong supporter of the CSF program. Although there 
is overlap with AMEDD goals, CSF is not a medical program. The AMEDD 
will implement CSF as will every other unit by taking the Global 
Assessment Tool (GAT), training Master Resilience Trainers (MRT), and 
implementing CSF training on our training calendar (as we would any 
other Warrior Task and Battle Drill). Additionally, the AMEDD supports 
the CSF physical dimension by providing medical/health-related data on 
the Soldiers Independent Operational Test to provide physical fitness 
metrics for the soldiers. Also, the AMEDD is instrumental in 
coordinating with CSF on state-of-the-art physical fitness training 
content and products for inclusion in the CSF online training modules, 
MRT training, and Warrior Task and Battle Drill training.

    11. Senator Begich. General Schoomaker, do you believe this program 
is properly funded?
    General Schoomaker. Yes, I am not aware of any requirements for CSF 
that have not been funded.

                        family health initiative
    12. Senator Begich. General Green, I understand the Air Force 
implemented the Family Health Initiative (FHI) which mirrors the 
American Academy of Family Physicians ``Patient Centered Medical Home'' 
concept and is built on the team-approach for effective care delivery. 
I also understand you have two pilot programs at Edwards Air Force 
Base, CA, and Ellsworth Air Force Base, SD. Can you provide an update 
on the status of these pilots?
    General Green. We began implementation of the FHI at Edwards Air 
Force Base and Ellsworth Air Force Base in 2008. As our most mature 
sites, we have seen outstanding improvement in patient continuity 
leading to improved patient and staff satisfaction. Additionally, as we 
have forged greater relationships through continuity with our patients, 
health care outcomes have improved accordingly, especially for our most 
complex patients with diseases such as diabetes mellitus. We have taken 
the lessons learned from our initial two sites and used them to improve 
FHI implementation at 11 additional locations across the Air Force in 
2009: Andrews, Bolling, Elmendorf, FE Warren, Hill, Lakenheath, 
Laughlin, Misawa, Patrick, Scott, and Sheppard Air Force Bases. The 
lessons learned at all 13 of these locations are being applied as we 
implement FHI and the Patient Centered Medical Home at 20 additional 
Air Force military treatment facilities (MTF) in 2010, with a goal of 
Air Force-wide implementation by the end of 2012.

    13. Senator Begich. General Green, do you believe this program 
should be implemented across DOD and the other Services?
    General Green. The Air Force FHI is based on a concept known as the 
Medical Home that originated in U.S. professional medical societies for 
primary care specialties. The Medical Home has become a Military Health 
System (MHS) strategic priority. The Army and Navy have prototype 
programs based on the Medical Home concept. We are exchanging 
information, ideas, and experiences with the Army and Navy as we move 
forward and adapt the processes to the missions we support. An 
advantage of sharing this as a MHS priority is the pursuit of common 
requirements supporting the Medical Home concept, reflected in the 
electronic health record (EHR) and personal health record requirements 
in DOD. We are excited about providing benchmark-quality primary care 
services to our patients.

                          center of excellence
    14. Senator Begich. Dr. Rice, can you give an update/status of 
section 1623, ``Center of Excellence in Prevention, Diagnosis, 
Mitigation, Treatment, and Rehabilitation of Military Eye Injuries'' 
that was in the National Defense Authorization Act for Fiscal Year 
2008? In general, this section stated that the ``Secretary of Defense 
shall establish within DOD a center of excellence in the prevention, 
diagnosis, mitigation, treatment, and rehabilitation of military eye 
injuries.''
    Dr. Rice. The Department has completed facility design of the 
Vision Center of Excellence (VCE). Contract award is pending, with a 
projected completion by third quarter of fiscal year 2011.
    The VCE is creating a staffing plan for Initial Operating 
Capability (IOC) and Full Operating Capability, to include functions, 
grades, classification, responsibilities, and mission of each 
subordinate division. We anticipate hiring IOC staff in the third 
quarter of fiscal year 2010.

                          specialist shortages
    15. Senator Begich. General Green, the 3rd Medical Corps at 
Elmendorf Air Force Base, headed by Colonel Paul Friedrichs, runs one 
of the best MTFs in the Air Force. However, specialty shortages at the 
MTF and in Alaska continue to plague the ability to treat patients. Is 
the Air Force looking at how to address those shortages by bringing in 
more specialists?
    General Green. I returned this week from my third visit to Alaska 
to learn more about how the Air Force Medical Service (AFMS) partners 
with our municipal, State, and Federal counterparts to improve access 
to care while sustaining the medical proficiency of our Air Force 
medics in Alaska. As part of this visit, I was able to travel with your 
Rural Director, Ms. Tiffany Zulkosky, to visit military medics bringing 
much-needed care to the residents of Kotzebue, Noorvik, and Selawik. As 
our military population has grown, the Air Force has added over 150 new 
medical authorizations at the third Medical Group to minimize the 
number of patients who must seek care downtown. We are actively 
pursuing sharing agreements with the VA and Alaska Native Medical 
Center to further expand the medical services we offer our patients.
    The AFMS programs medical resources based on population and mission 
requirements. The AFMS programmed an increase of specialty doctors and 
key medical enablers, such as nurses, medical technicians, and 
administrative support from fiscal years 2008 to 2011. As part of the 
fiscal years 2012 to 2017 Program Objective Memorandum planning, the 
AFMS is carefully reviewing the mix of services offered at each of our 
facilities including those at Eielson and Elmendorf Air Force Bases. We 
see continued opportunities to support State and local medical 
providers' efforts to build a trauma system for Anchorage, as well as 
to build robust Graduate Medical Education programs, and a seamless e-
health network that will help improve access for all patients.
                                 ______
                                 
               Questions Submitted by Senator John McCain
                        adara networks contract
    16. Senator McCain. Dr. Rice, what is the status of the DOD 
Inspector General's (IG) investigation into allegations of impropriety 
in the award of health information technology contracts to Adara 
Networks, Inc.?
    Dr. Rice. DOD policy does not permit comment on ongoing DOD IG 
investigations.

    17. Senator McCain. Dr. Rice, what were the findings and results of 
the internal investigation conducted by the Department into allegations 
of impropriety in the award of health information technology contracts 
to Adara Networks, Inc.?
    Dr. Rice. The preliminary review found the program did not fully 
adhere to the DOD Directive 5000 series, Federal Acquisition 
Regulations, Defense Federal Acquisition Regulations Supplement 
Acquisition Principles.
    There were errors in judgment and a lack of program and acquisition 
planning, transparency, and oversight. Software and documentation, 
intellectual property developed and owned by the MHS, was 
inappropriately provided to Adara Networks.

    18. Senator McCain. Dr. Rice, please identify the source and total 
amount of funds provided to Adara for work on the DOD EHR.
    Dr. Rice. The funding source was Operation and Maintenance--fiscal 
year 2007 and the total aount awarded was $9,944,792.53.

    19. Senator McCain. Dr. Rice, please identify and describe each 
product delivered to the government under the Adara contract, including 
reports, software, and/or electronic code.
    Dr. Rice. The following products were delivered to the government 
under the Adara contract:

         (1) Lot, Mesh Networking Technologies
         (1) Lot, Equipment, including software licenses, 
        necessary for an eight node infrastructure. Standard support 
        and maintenance--including 1 year of all minor releases, all 
        maintenance patches, and support coverage is included with the 
        software
         (8) Each, Multi Path Virtual Circuit Router
         (8) Each, Multi Path Dynamic Application Layer
         (8) Each, Multi Homed Application Layer (7) Object
         (8) Each, Multi Homed Application Layer (7) Host
         (8) Each, Multi Path Virtual Routers
         (8) Each, Multi Path Routing Software, Multi Path 
        Routing Protocol and Daemon
         (8) Each, Multi Path QoS Router
         (8) Each, Multi Path SOA Content Based Router
         (10) Each, Secure Communication Gateways
         (1) Each, Central Management Systems

    20. Senator McCain. Dr. Rice, are those products being utilized in 
ongoing development of the EHR? If not, why not?
    Dr. Rice. No, those products are not being utilized in ongoing 
development of the EHR.
    An Analysis of Alternatives (AoA) is currently being developed, 
which will provide materiel solutions to the requirement to the EHR. 
Once that solution is chosen, an acquisition strategy will be 
formulated in accordance with DOD Directive 5000, the Defense 
Acquisition System.

    21. Senator McCain. Dr. Rice, according to press reports, 
electronic code for the MHS was provided to Adara Networks, Inc. What 
companies under contract to DOD are in possession of that code at this 
time?
    Dr. Rice. Only Adara Networks, Inc., was in possession of that 
code.

    22. Senator McCain. Dr. Rice, what assurances can you give Congress 
that sensitive medical information is not at risk?
    Dr. Rice. I am confident sensitive medical information is not at 
risk.
    On December 7, 2009, in consultation with the TRICARE Management 
Activity (TMA) Privacy Office and TMA Information Assurance, the 
Defense Health Information Management System (DHIMS) Program Office 
determined that the overall risk of penetration of DOD health records, 
accounts, or other privileged/secured access sites or databases was 
low. The Computer Network Defense would prohibit unauthorized access to 
the production system.

    23. Senator McCain. Dr. Rice, has the Department imposed any 
sanctions with respect to future contracts on Adara Networks, Inc.?
    Dr. Rice. No, the Department has not imposed any sanctions with 
respect to future contracts on Adara Networks, Inc.

                       electronic health records
    24. Senator McCain. Dr. Rice, what is the schedule for development 
and delivery of an EHR for DOD?
    Dr. Rice. Armed Forces Health Longitudinal Technology Application, 
the existing DOD EHR, has been deployed worldwide since 2006. A 
schedule of the way ahead for the EHR will be developed and released 
following completion of the AoA for EHR capability.

    25. Senator McCain. Dr. Rice, is the program fully funded in the 
fiscal year 2011 request and in the Future Years Defense Plan?
    Dr. Rice. DOD's EHR program is fully funded in the fiscal year 2011 
request and in the Future Years Defense Plan.
                                 ______
                                 
             Questions Submitted by Senator Lindsey Graham
                           tricare contracts
    26. Senator Graham. Dr. Rice, last July, TRICARE Management 
Activity announced the selection of the contractors for the $55.5 
billion (over 5 years) TRICARE Third Generation (T-3) Managed Care 
Support Services Contracts. It is our understanding that as a result of 
protest filed by two of the incumbents, however, that transition work 
with the newly selected contractors was stopped pending the Government 
Accountability Office (GAO) protest review and decision. Current 
TRICARE managed care contracts remain in place until March 31, 2011, 
and health care delivery continues while options are being considered. 
I want to ensure that TRICARE beneficiaries continue to have timely 
access to high quality health care during the protest period and the 
critical transition period to the new contracts. What is the status 
regarding the evaluation of GAO's recommendations?
    Dr. Rice. We are concluding our evaluation of the GAO 
recommendations and will be announcing our approach to resolving the 
protest issues in the summer of 2010.

    27. Senator Graham. Dr. Rice, when will these contracts be awarded?
    Dr. Rice. We expect to take steps to resolve the remaining issues 
regarding these contracts in the summer of 2010.

    28. Senator Graham. Dr. Rice, since the 10-month transition 
deadline is approaching, does DOD expect to resume transition soon or 
will the current contracts be further extended?
    Dr. Rice. We believe transitions can be completed by April 2011, 
coinciding with the current contracts end date.

    29. Senator Graham. Dr. Rice, can you assure me that TRICARE's 
beneficiaries will not be harmed during this contract transition?
    Dr. Rice. I assure you TRICARE beneficiaries will not be harmed 
during this contract transition.
    The current regional health care contractors will continue to 
provide services to beneficiaries until March 31, 2011. Extensions to 
our current contracts will allow time for transition to the T-3 
contracts, while ensuring beneficiaries continue to receive high-
quality care and outstanding customer service.

                        medicating the military
    30. Senator Graham. Dr. Rice, Admiral Hunter, General Schoomaker, 
Admiral Robinson, General Green, and Admiral Jeffries, do you agree 
with the reporting in the Army Times on March 8, 2010, that: ``At least 
one in six servicemembers is on some form of psychiatric drug.'' If 
not, why not? What available data do you use to support your statement?
    Dr. Rice and Admiral Hunter. We do not agree with the Army Times 
reporting.
    In an analysis completed in February 2010, data from the Pharmacy 
Data Transaction Service (PDTS), reported less than 3 percent of all 
Active Duty members are on psychiatric drugs.
    The PDTS is a centralized data repository that allows us to build a 
common patient medication profile for all DOD beneficiaries. The data 
for this analysis was focused on two queries: (1) the number of unique 
Active Duty servicemembers who received any prescription, and (2) the 
number of Active Duty servicemembers that received any of the 
psychotropic medications as defined by the CENTCOM Pharmacy and 
Therapeutics Committee.
    General Schoomaker. I do not agree with the statistic used by the 
Army Times. The quote referred to data from the Mental Health Advisory 
Team (MHAT)-V Report from Afghanistan (2007), in which 17 percent of 
U.S. soldiers reported taking a medication for a mental health or sleep 
problem during their deployment. The MHAT-VI (2009) conducted a more 
systematic sampling of maneuver and support units across both the Iraq 
and Afghanistan theaters and separated medications for sleep and other 
mental health indications. Overall, in MHAT-VI, 3 to 6 percent of 
soldiers surveyed reported using a medication for a ``mental health or 
stress problem,'' and 8 to 14 percent reported using a medication for a 
sleep problem. (Note: These percentages cannot be added together, 
because some individuals were taking both categories. In-theater data 
were not available for sailors, marines, or Air Force personnel.)
    In a stratified random DOD-wide survey at CONUS and OCONUS 
installations involving Active Duty of all Services, 8.6 percent of 
servicemembers reported receiving a prescription for depression, 
anxiety, or sleep problems in the preceding 12 months (10.7 percent 
Army, 6.2 percent Navy, 7.9 percent Marines, 8.1 percent Air Force) 
(DOD Health Related Behaviors Among Active Duty Military Personnel 
2009).
    In January 2010, data from the PDTS which captures all 
prescriptions filled at MTFs, the TRICARE Mail Order Pharmacy, and 
civilian pharmacies (when paid for using the TRICARE benefit), 
indicated that 3.3 percent of Army Active Duty soldiers filled a 
prescription for an antidepressant in that month. Antidepressants 
include selective serotonin reuptake inhibitors (SSRIs), tricyclics, 
heterocyclics, and monoamine oxidase inhibitors (MAOIs). It should be 
noted, however, that this analysis does not include prescriptions 
filled in the deployed environment, and may not capture the full 
medication usage if soldiers received a prescription from outside the 
MHS, or a prescription prior to January that was for longer than a 1-
month period.
    Thus, the best data available suggest that the rate of current (1 
month) use of antidepressants specifically in CONUS is approximately 3 
percent and the estimate for any use of antidepressants during 
deployment is 3 to 6 percent. The rate is considerably higher when 
sleep and antianxiety medications are included in addition to 
antidepressants.
    Admiral Robinson. The quoted statistic regarding one in six 
servicemembers on some form of psychotropic drug is apparently derived 
from the fifth MHAT survey done in 2007. This was a survey of deployed 
Army personnel and included a question about taking a medication for 
help with sleeping or any mental health or stress problem. The result 
was about 17 percent of respondents said that they had taken a 
medication for one of these reasons. A soldier would have answered yes 
to this question if they had been given a few sleep aids to help with 
changing 12 time zones in 2 days, which is accepted medical practice, 
or been on a several-month course of antidepressants. Clearly, 
combining these two very different answers together is not ideal.
    To address this shortcoming, the MHAT 6 survey, completed in 2009, 
broke out the questions: (1) about taking a medication for sleep; and 
(2) about taking a medication for a mental health or stress problem. 
This resulted in a rate of 3 to 6 percent of respondents indicating 
they had taken a medication for mental health or stress. MHAT 6 results 
are consistent with other data points concerning psychotropic use by 
military personnel, including the Navy Behavioral Health Needs 
Assessment Survey (BHNAS) data from this year that indicates that about 
22 percent of respondents used sleeping medication during their 
deployment and 3.2 percent used medication for mental health reasons. 
The estimate of usage for mental health reasons of the adult U.S. 
civilian population approximates 10 percent. The Navy BHNAS is an 
assessment tool utilizing similar questions to the U.S. Army's Mental 
Health Assessment Tool (MHAT). It provides real time, actionable, unit 
level psychological health surveillance and is being used to assess 
Navy members who are deployed as individual augmentees.
    General Green. Thank you for the opportunity to address this 
concern regarding the health and well-being of our Air Force members 
and their use of psychotropic medications. The prevalence rate of 
psychotropic medication use in the Air Force on a single day, March 1, 
2010, was 1 in 17, or 5.8 percent, of the Active-Duty Force. This 
figure is a point prevalence of one day. The number of unique Air Force 
servicemembers who had one or more prescriptions for any psychotropic 
medication, including controlled prescription pain medications, on this 
date was 22,003 or 5.8 percent of the Active Force. When controlled 
prescription pain medications are removed, the number of unique 
servicemembers on a psychotropic medication changes to 17,962 or 4.7 
percent of the force. Psychotropic medications are used to treat many 
medical conditions beyond psychiatric syndromes such as the use of 
tricyclic antidepressants for chronic pain, and other antidepressant 
classes are also used to treat migraine headaches and fibromyalgia. The 
data was extracted from the MHS PDTS table in the M2 on March 1, 2010.
    Admiral Jeffries. The quoted statistic regarding 1 in 6 
servicemembers on some form of psychotropic drug is apparently derived 
from the fifth MHAT survey done in 2007. This was a survey of deployed 
Army personnel and included a question about taking a medication for 
help with sleeping or any mental health or stress problem. The result 
was about 17 percent of respondents said that they had taken a 
medication for one of these reasons. A soldier would have answered yes 
to this question if they had been given a few sleep aids to help with 
changing 12 time zones in 2 days, which is accepted medical practice, 
or been on a several-month course of antidepressants. Clearly, 
combining these two very different answers together is not ideal. To 
address this shortcoming, the MHAT 6 survey, completed in 2009, broke 
out the questions: (1) about taking a medication for sleep; and (2) 
about taking a medication for a mental health or stress problem. This 
resulted in a rate of 3 to 6 percent of respondents indicating they had 
taken a medication for mental health or stress. MHAT 6 results are 
consistent with other data points concerning psychotropic use by 
military personnel, including the Navy BHNAS data from this year that 
indicates that about 22 percent of respondents used sleeping medication 
during their deployment and 3.2 percent used medication for mental 
health reasons.
    The most current data, based on actual prescriptions filled by 
marines, demonstrate that less than 7 percent of marines filled a 
prescription for an antidepressant, antianxiety medication, or 
stimulant during all of 2009. At any one time the percentage is 
obviously even smaller. Estimates for the adult civilian population of 
the United States are higher.

    31. Senator Graham. Dr. Rice, Admiral Hunter, General Schoomaker, 
Admiral Robinson, General Green, and Admiral Jeffries, do you agree 
that many troops are taking more than one kind of psychiatric drug, 
``mixing daily cocktails,'' and that this behavior can lead to suicide?
    Dr. Rice and Admiral Hunter. No, we do not agree. While we are 
aware of a small number of troops who may be taking more than one kind 
of psychiatric drug to treat multiple symptoms justified by their 
clinical condition, this is not a common occurrence and we would not 
categorize it as many troops.
    Suicide is caused by multiple factors. We have not seen evidence 
directly correlating an increase in suicides with servicemembers who 
are prescribed multiple psychiatric drugs justified by clinical 
condition under the supervision of physicians. Independent studies have 
found that the benefits of antidepressants outweigh the risks of 
suicide.
    General Schoomaker. The Army is concerned with the health and 
resilience of all servicemembers and extends great effort to reduce the 
risk of loss of a single servicemember to the tragedy of suicide.
    In our soldier population, we use pharmacy data to provide a very 
precise accounting of how many soldiers are on multiple medications. We 
define multiple medications as two or more of any combination of sleep, 
psychotropic, or narcotic medications. For our Warriors in Transition, 
who have a variety of medical and psychiatric diagnoses, 703 (7.7 
percent) Warriors are on multiple medications out of a total population 
of 9,095 warriors. In the overall Active Duty population, 1,075 (0.2 
percent) soldiers are on multiple medications out of a population of 
557,642 soldiers.
    Reviewing completed suicides from 2001 to 2008, we found slightly 
more than one-third of the suicides had a history of psychotropic 
prescriptions, with 14 percent current prescriptions at time of death, 
and 19 percent within 3 months. We do not have the level of detail in 
our database to assess how many were on multiple medications.
    The Army has funded a 5-year, $50 million study with the National 
Institute of Mental Health to help answer questions about the 
relationship between psychiatric medications and suicide. This is a 
multi-pronged and multi-site study, led by the Uniformed Services 
University of the Health Sciences (USUHS) and supported by Harvard 
University, Columbia University, and the University of Michigan.
    Admiral Robinson. I do not agree with this statement. Sailors and 
marines who are taking medications have been carefully diagnosed, and 
when indicated, prescribed medications. Individuals placed on 
medications are closely monitored to ensure they are stable on the 
medications without side effects that would impair their ability to 
function or place them at risk. In addition, every sailor is screened 
prior to deployment via the NAVMED 1300/4 which addresses all medical 
requirements and is reviewed by a licensed medical provider to ensure 
individuals are medically suitable for deployment. Every marine is 
screened in a similar manner by their battalion surgeon to ensure they 
are suitable for deployment. Periodic surveillance of the psychological 
health of deployed sailors and marines is also being conducted.
    General Green. The Air Force is concerned with the health and 
resilience of all servicemembers and extends great effort to reduce the 
risk of loss of a single servicemember to the tragedy of suicide. In 
reviewing Air Force suicides over the past nearly 2 years we have seen 
no indication of a trend toward polypharmacy, or use and/or abuse of 
multiple psychotropic medications, in our servicemembers lost during 
this time. Data pulled from M2 reflects one day point prevalence for 
Active Duty Air Force personnel taking more than one psychotropic 
medication at the same time, or polypharmacy in psychotropics, on March 
1, 2010, was 6,061 or 1.6 percent of the Active Force. We have 
demonstrated vigilance in our management of servicemembers with chronic 
pain and complex medical management through guidance sent to the Chiefs 
of Medical Staff in an effort to ensure safe, multidisciplinary team 
management of servicemembers with chronic controlled pain medication 
use.
    The Air Force Suicide Prevention Program is also engaged in a 
number of studies with researchers at the USUHS to examine case data on 
past suicides, including data collected through our Suicide Event 
Surveillance System, and the DOD Suicide Event Report and Personal 
Health Assessment data, to look for factors that may allow us to better 
identify those at risk for suicide. Recent efforts in this area have 
allowed us to identify career fields that appear to be at greater risk 
for suicide, allowing leadership to target additional prevention 
efforts at these groups.
    The Air Force has also been collecting data on new recruits 
entering the Air Force regarding their past behavioral history. This 
data collection appears to show promise in allowing us to identify, 
from a recruit's earliest days in the Air Force, those airmen who may 
be at higher risk for a variety of problems. The Air Force is now 
exploring ways to reach out to these airmen to improve their ability to 
cope with the rigors of military life and improve resiliency.
    Admiral Jeffries. I do not agree that many marines are taking more 
than one kind of psychiatric medication and ``mixing daily cocktails.'' 
The most current data, based on actual prescriptions filled by marines, 
demonstrate that less than 7 percent of marines filled a prescription 
for an antidepressant, antianxiety medication or stimulant during all 
of 2009. At any one time the percentage is obviously even smaller. 
Servicemembers with more serious or complicated mental health 
conditions are more likely to be on multiple medications and these 
personnel are also more likely to attempt suicide. However, this is not 
a cause-and-effect relationship as much as a marker of a more serious 
condition.
    Internal Marine Corps suicide reviews have shown that regardless of 
duty station, deployment, or duty status, the primary stressors 
associated with marine suicides are problems in romantic relationships, 
physical health, work-related issues, such as poor performance and job 
dissatisfaction, and pending legal or administrative action. A fellow 
marine is the most likely person to notice a change in behavior that 
may be the first indication of an impending serious problem and the 
Marine Corps' strategy for dealing with the entire range of stress 
related issues starts with engaged leadership.

    32. Senator Graham. Dr. Rice, Admiral Hunter, and General Green, 
Brigadier General Loree Sutton, Director of the Center of Excellence 
for PTSD and TBI, recently testified to the House Veterans Affairs 
Committee that 17 percent of troops are currently on antidepressants. 
Is she correct?
    Dr. Rice and Admiral Hunter. Brigadier General Sutton's oral 
statement is correct that data from the 2007 MHAT-V Report from 
Afghanistan found 17 percent of U.S. Army soldiers reported taking 
medication for mental health or sleep problems while deployed. Those 
medications include, but are not limited to, antidepressants.
    General Green. Thank you for the opportunity to address this 
concern regarding the health and well-being of our Air Force members 
and their use of antidepressant medications. Antidepressant medications 
are used for more than psychiatric conditions alone. Antidepressants 
can be used in managing pain conditions, fibromyalgia, and migraine 
headaches, as examples. Thus the current use of antidepressant 
medications in the Air Force cannot be directly construed to imply 
prevalence of psychiatric conditions in our members.
    The Air Force has an antidepressant utilization rate of 1 in 63 or 
1.6 percent of the Active Force based upon data extracted from the MHS 
PDTS table in the M2 on March 1, 2010. This figure is a one-day point 
prevalence.

    33. Senator Graham. Admiral Hunter, has your office conducted any 
kind of study to examine the utilization of prescription medicines by 
Active Duty members? If so, what were the results?
    Admiral Hunter. The Utilization Management Division of the 
Pharmaceutical Operations Directorate, within the TRICARE Management 
Activity, conducts routine utilization studies based on various 
parameters. The results of these studies show use of prescription 
medication in the Active Duty population is well in line with trends we 
see in the non-Active Duty population.

    34. Senator Graham. Dr. Rice, Admiral Hunter, General Schoomaker, 
Admiral Robinson, General Green, and Admiral Jeffries, is more research 
needed on the effect of psychiatric drugs on performance of military 
duties?
    Dr. Rice and Admiral Hunter. Further research on the effects of 
psychiatric medications and how they relate to performance of military 
duties is needed for continual assessment. It is DOD policy that health 
care providers must recommend to commanders whether servicemembers with 
psychiatric disorders or who are prescribed psychotropic medication 
should be deployed or are fit for military duties.
    General Schoomaker. Yes, more research is needed to assess the 
effect of psychiatric drugs and all medications on the performance of 
military duties. This is especially true in deployed environments that 
may require prolonged vigilance and sustained coordination skills to 
ensure safe and effective functioning of servicemembers.
    Admiral Robinson. Psychiatric medications can and do effectively 
treat symptoms and permit individuals to deploy and to function without 
compromising performance. When individuals are placed on medications, 
they are closely monitored by their healthcare provider to ensure they 
are not experiencing side effects that may compromise their ability to 
perform their duties. Research on medication effects is currently 
underway in many sectors and clinical evidence uncovered in research is 
used to advise the selection of medications.
    General Green. Yes, more research is needed to assess the effect of 
not only psychiatric drugs, but all medications, on the performance of 
military duties. This is especially true in deployed environments that 
may require prolonged vigilance and sustained coordination skills to 
ensure safe and effective functioning of servicemembers.
    Admiral Jeffries. Psychiatric medications can and do effectively 
treat symptoms and permit individuals to deploy and to function without 
compromising performance. When individuals are placed on medications, 
they are closely monitored by their healthcare provider to ensure they 
are not experiencing side effects that may compromise their ability to 
perform their duties. Research on medication effects is currently 
underway in many sectors and clinical evidence uncovered in research is 
used to advise the selection of medications.

    35. Senator Graham. Dr. Rice, Admiral Hunter, General Schoomaker, 
Admiral Robinson, General Green, and Admiral Jeffries, can you comment 
on the reasons why various medicines, such as antidepressants, are 
prescribed and the potential benefits for servicemembers who are 
receiving them?
    Dr. Rice and Admiral Hunter. Antidepressants, often referred to as 
psychotropic or psychotherapeutic medications, are prescribed for a 
variety of reasons, including depression, recurrent headaches, pain, 
smoking cessation, and specific mental health disorders. 
Antidepressants, when used with proper medical supervision, in 
appropriate situations, and in conjunction with other treatments, are 
important and effective tools for supporting the mental health needs of 
our Armed Forces.
    These medications have changed the lives of servicemembers for the 
better. Each patient reacts differently to antidepressants, some 
require only short-term antidepressant treatment while others require 
long-term treatment for more resistant conditions.
    General Schoomaker. Antidepressants, when used with proper medical 
supervision, in appropriate situations, and usually in conjunction with 
other treatments, are an important and effective tool for supporting 
mental health needs, both in deployed settings and at home.
    Antidepressants are now prescribed for a variety of diagnoses. They 
are used for a variety of depressive disorders, and anxiety disorders 
including PTSD. Certain antidepressants are also used for headaches, 
pain, and sleep.
    There are many different types of antidepressants. The class known 
as selective serotonin re-uptake inhibitors is very safe, in general. 
Older agents, known as tricyclics, heterocyclics, and monoamine oxidase 
inhibitors have more side-effects and are used more rarely. Sometimes 
they are used for pain and headaches rather than depression. Finally, 
buproprion is also used as an anti-smoking aid.
    The degree of response to medication, ranging from little relief of 
symptoms to complete remission, depends on a variety of factors related 
to the individual and the particular disorder being treated. In 
general, antidepressants are effective for treating symptoms of 
depression, anxiety, and PTSD.
    Admiral Robinson. Medications such as antidepressants can be 
prescribed for a variety of reasons including depressive symptoms, 
anxiety, recurring headaches, pain, and smoking cessation. In addition, 
the use of medications can enable an otherwise nondeployable 
servicemember to effectively complete their mission in a deployed 
environment--greatly empowering the servicemember and significantly 
reducing the effects of mental health stigma.
    Stigma can be a significant factor in personnel not receiving 
treatment when treatment is needed. The use of medication in a deployed 
setting may suggest that servicemembers who need help are increasingly 
comfortable seeking help, which can significantly reduce the risk 
associated with untreated psychiatric problems, to include suicidal 
behavior associated with certain mental health conditions. A potential 
risk of suggesting that medication use is somehow a negative indicator 
or a problem is that it may increase stigma, thus inhibiting some from 
seeking critically important mental health treatment. Mental health 
medications, when used with proper medical supervision, in appropriate 
situations, and usually in conjunction with other treatments, can be a 
very appropriate and helpful part of personnel treatment, both in 
theater and at home and permit the servicemember to serve without the 
impairment that their untreated symptoms could impose.
    General Green. The prescription and management of medication, in 
all cases, must be done by a responsible physician working closely with 
their patient and sometimes the patient's family or other mental health 
professionals. This is the only way to ensure that the most effective 
use of medication is achieved with minimum risk of side effects or 
complications. Psychotropic medications have made dramatic changes in 
the treatment of mental disorders. Psychotropic medications also may 
make other kinds of treatment more effective by making it possible for 
the person to respond better to other therapy and treatment efforts.
    Like most drugs used in medicine, they correct or compensate for 
some malfunction in the body. Psychotherapeutic medications do not cure 
mental illness, but they do lessen its burden. The degree of response 
to medication, ranging from little relief of symptoms to complete 
remission, depends on a variety of factors related to the individual 
and the particular disorder being treated.
    Admiral Jeffries. Medications such as antidepressants can be 
prescribed for a variety of reasons including depressive symptoms, 
anxiety, recurring headaches, pain, and smoking cessation. In addition, 
the use of medications can enable an otherwise nondeployable 
servicemember to effectively complete their mission in a deployed 
environment--greatly empowering the servicemember and significantly 
reducing the effects of mental health stigma.
    Stigma can be a significant factor in personnel not receiving 
treatment when treatment is needed. The use of medication in a deployed 
setting may suggest that servicemembers who need help are increasingly 
comfortable seeking help, which can significantly reduce the risk 
associated with untreated psychiatric problems, to include suicidal 
behavior associated with certain mental health conditions.
    A potential risk of suggesting that medication use is somehow a 
negative indicator or a problem is that it may increase stigma, thus 
inhibiting some from seeking critically important mental health 
treatment. Mental health medications have solid medical evidence and 
research to support their use and when used with proper medical 
supervision, in appropriate situations, and usually in conjunction with 
other treatments, can be a very appropriate and helpful part of an 
individual's treatment. Appropriate use of these medications, both in 
theater and at home, along with leadership support, facilitate 
servicemembers continuing to serve without the impairment that their 
untreated symptoms could impose.

                      vision center of excellence
    36. Senator Graham. Admiral Hunter, one of the Senate Armed 
Services Committee's recommendations last year was to rapidly implement 
the programs and research mandated by Congress for the Vision Center of 
Excellence. How will the 2011 request support that Center?
    Admiral Hunter. The fiscal year 2011 budget request supports 
requirements for staffing towards full operational capability of the 
Vision Center of Excellence (VCE). This full operational capability 
will include civilian personnel and contract support, completion of 
Phase One and implementation of Phase Two of the Defense and Veterans 
Eye Injury and Vision Registry, establishment of the VCE Regional 
Clinical Centers of Excellence, Vision Support Cells and Vision 
Deployment Support Platforms, quarterly educational conferences and 
research symposia, and occupation of permanent facilities.

                   task force on wounded warrior care
    37. Senator Graham. Dr. Rice, last year Congress directed DOD to 
establish a task force to continuously examine care for wounded 
warriors. What is the status of that task force at this time?
    Dr. Rice. The task force is currently in the member nomination and 
establishment phase.
    The membership nomination slate is complete. The Department 
received input from the Services, Congress, White House Liaison Office, 
and private sector on the nominations. Currently, the recommended slate 
of 14 members is being reviewed within the Department and will be 
completed by April 30, 2010.
    The logistical support has been established by the Washington 
Headquarters Services for facilities, administrative support, and 
charter. Additionally, the initial support personnel for the task force 
have been identified along with a preliminary budget.
    Throughout this process, we are committed to working with Congress 
on this vital task force to examine care for wounded warriors.

                           health care reform
    38. Senator Graham. Dr. Rice, to the best of your knowledge, are 
there any primary negative effects of the newly enacted health reform 
legislation that will negatively impact health care benefits for 
military personnel, retirees, and their families?
    Dr. Rice. No, I do not believe the Patient Protection and 
Affordable Care Act will have any negative impacts on health care 
benefits for military personnel, retirees, and their families.

    39. Senator Graham. Dr. Rice, are there any secondary effects, such 
as cutting Medicare payments to physicians and hospitals, or expanding 
access to care, that could hurt military health care in the future?
    Dr. Rice. There may be secondary effects to TRICARE, but we will 
ensure these effects will not hurt military health care in the future.
    Because of this statutory connection between Medicare and TRICARE 
reimbursement rates, Medicare payment provisions of the Patient 
Protection and Affordable Care Act will affect TRICARE. We will monitor 
access to care and, when necessary, use available tools such as 
locality based waivers to increase payment levels for physicians to 
ensure adequate access to care for our beneficiaries.

                         health care workforce
    40. Senator Graham. Dr. Rice, do you agree that America and the 
military are facing a serious shortage of health care professionals 
that will only grow over time?
    Dr. Rice. Yes, I agree there is a shortage of health care 
professionals in the military and America. The military departments 
have a declining inventory of some wartime critical medical 
specialties. There is also a growing shortage of physicians and nurses 
in the United States. The pool of medical school applicants is 
shrinking and the population traditionally applying for the Health 
Professions Scholarship Program (HPSP) has been declining.

    41. Senator Graham. Dr. Rice, how will this shortage of health care 
professionals affect the military, and are we adequately preparing for 
it now?
    Dr. Rice. Currently, the military has a declining inventory of some 
wartime critical medical specialties which will affect the care of our 
servicemembers.
    To prepare for and counteract these shortages, the Department 
relies on Multiyear Special Pay and Incentive Special Pay as critical 
tools for managing the medical force. Also, DOD annually convenes the 
Health Professions Incentives Working Group, to make recommendations on 
incremental adjustments to the existing financial incentives for 
retention underneath the Federal cap.

    42. Senator Graham. General Schoomaker, Admiral Robinson, General 
Green, and Admiral Jeffries, you testified recently to the Senate 
Appropriations Subcommittee on Defense that you all face shortages in 
medical personnel. Where are your greatest shortages?
    General Schoomaker. The AMEDD is experiencing force-wide shortages 
in certain specific specialties and specialty shortages in certain 
locations. However, despite the persistent deployment tempo, the 
national shortage of many healthcare disciplines, and the compensation 
gap between military and civilian providers, the Army is doing well 
recruiting and retaining healthcare providers. Recruiting and retention 
authorities and bonuses are working, but we need to maintain constant 
vigilance.
    The most difficult skill sets to recruit and retain include: fully-
qualified physicians with surgical or primary care specialties, 
dentists (general and specialty), behavioral health professionals, and 
nurse anesthetists. According to the U.S. Army Recruiting Command 
(USAREC), one of the greatest challenges in the recruitment of 
healthcare professionals is simply a lack of awareness of Army 
Medicine. USAREC is attempting to alleviate this challenge by adopting 
a strategy of increased marketing of the benefits of Army Medicine.
    Additionally, the AMEDD is currently short at the grade of major 
(O4) across all corps. This is a function of several phenomena; the 
most notable being the loss of officers in the grade of captain (O3) 
who had completed their obligation prior to implementation of current 
retention initiatives, thus decreasing the number of officers available 
to promote to the grade of O4. While this overall grade imbalance is 
true, each corps also has specific specialty shortages at differing 
grades, signifying a potential capability gap. Recent recruiting 
success has increased the company grade inventory that will increase 
the inventory at the rank of major if these junior officers are 
retained, select specialty training, and earn promotion.
    We are addressing resolution of specific specialty shortages 
through precision recruiting, training, and retention initiatives. We 
must continue to take full advantage of the recruiting and retention 
authorities and bonuses provided by Congress if we are to maintain the 
recent strong results. Our experience over the last decade has proven 
that incentives, bonuses, and special pays work.
    Admiral Robinson.

------------------------------------------------------------------------
                                     Percent
           Subspecialty               Manned    Current INV   Authorized
------------------------------------------------------------------------
Medical Corps
  Surgery........................          84          176          210
  Family Medicine................          84          353          418
  Psychiatry.....................          83           93          112
  Preventive Medicine............          69           38           55

Dental Corps
  General Dentist................          86          365          424
  Oral Surgeon...................          81           70           86
  Prosthodontist.................          80           44           55
  Endodontist....................          89           42           47

Medical Service Corps
  Clinical Psychologist..........          84          106          126
  Physician assistant............          75          180          241
  Social Work....................          66           23           35
  Podiatry.......................          80           16           20

Nrse Corps
  Critical Care Nursing..........          73          290          396
  Perioperative Nursing..........          81          240          295
  Mental Health Nurse                      55           11           20
   Practitioner..................
  Family Nurse Practitioner......          82           72           88
------------------------------------------------------------------------

    Medical Corps
         Recruiting and retaining general surgeons, preventive 
        medicine physicians, family medicine physicians, and 
        psychiatrists will remain a challenge over the next several 
        years. Wartime demand, perceived inequities in pay compared 
        with the civilian sector, and limited student pipelines are 
        contributing factors.

    Dental Corps
         Dental Corps has difficulty directly accessing and 
        retaining oral surgeons, prosthodontists, and general dentists 
        because of the pay gap between military and civilian 
        compensation. A general dentist pay package offering 
        significant compensation increases is currently routing through 
        DOD. Additionally the DOD Health Professions Incentive Working 
        Group will be recommending a $20,000 per year increase in 
        incentive special pay for oral surgeons in fiscal year 2011.

    Medical Service Corps
         Our greatest shortages are physician assistants, 
        clinical psychologists, podiatrists, and social workers. 
        Retention and recruiting has been affected due to high 
        operational commitments.

    Nurse Corps
         High operational commitments are affecting recruiting 
        and retention in all of Navy's nurse practitioner specialties.

    General Green. The top 10 medical fields not manned to 
requirements:

      Medical Corps (4):

      1.  Flight Surgery (RAM) 182/213* = 85.4 percent (high value, 
deployable specialty)
      2.  Trauma Surgery 11/19** = 57.9 percent (includes 45SXK AFS 
only; Health Manpower Personnel Data System (HMPDS) data included this 
sub-specialty within general surgery career field, hence sub-specialty 
not reported separately; high value, deployable specialty)
      3.  General Surgery 83/86** = 96.5 percent (includes 45S AFS 
only; HMPDS data shows 87/83* @ 104.8 percent; due to declining manning 
and increasing authorizations for fiscal year 2010, higher number 
reported under HMPDS; high value, deployable specialty--using Critical 
Skills Retention Bonus (CSRB) to maintain numbers)
      4.  Family Practice 495/551** = 89.8 percent (recent AFMS 
emphasis on FHI dramatically drove increased authorizations, while 
pipeline remains at flat rate due to demands of other specialties, 
rising authorizations in fiscal year 2010 over HMPDS data of 473/435 @ 
108.7 percent significantly dropped percent manning for fiscal year 
2010)

      Nurse Corps (2):

      1.  Operating Room Nurse 219/237* = 92.4 percent (high value, 
deployable specialty)
      2.  Flight Nurse 100/190* = 52.6 percent (high value, deployable 
specialty/air transport wartime demand)

      Biomedical Sciences Corps (2):

      1.  Clinical Psychologists 215/255* = 84.3 percent (increasing 
wartime demand/limited pipeline)
      2.  Pharmacists 233/253* = 92.1 percent (high value, deployable 
specialty)

      Enlisted Medical Corps (2):

      1.  Independent Duty Medical Technician 415/625* = 66.4 percent 
(high value, deployable specialty)
      2.  Orthopedic Technician 98/151* = 64.9 percent (high value, 
deployable specialty)
---------------------------------------------------------------------------
    Data source: *Fiscal Year 2009 HMPDS, **9 Apr. 10 AFPC/DS data 
extrapolation by Lt Col Terry Mathews/SG1D

    Admiral Jeffries. I did not testify at the referenced hearing. This 
question is most appropriately answered by the Service Surgeons 
---------------------------------------------------------------------------
General.

    43. Senator Graham. General Schoomaker, Admiral Robinson, General 
Green, and Admiral Jeffries, does the budget request fully fund your 
requirements for scholarships, special pays, loan repayment, and 
accession and retention bonuses that you need to ensure the future 
readiness of the military medical components?
    General Schoomaker. The budget request does not fully fund all 
requirements for scholarships, special pays, loan repayment, and 
accession/retention bonuses across all components. For the Active 
component, the budget fully funds requirements for scholarship and loan 
repayment programs. Sweeping changes made to the DOD Health Professions 
Special Pay Program by Section 661 of National Defense Authorization 
Act for Fiscal Year 2008 expanded special pay opportunities to include 
psychologists, social workers, physician assistants, veterinarians, 
general dentists, and critical wartime specialty accessions. Army 
Medical Command is working closely with the Army staff to ensure 
special pays are supported to the maximum extent possible.
    For the Army Reserve, the budget request fully funds the Health 
Professions Scholarship Program and the Army Reserve Health Incentives 
Program. While the budget request does not fully fund the Army Reserve 
to achieve the health professions recruiting mission, it does account 
for increases in mission accomplishment. As these incentives are 
implemented, the Army Reserve will continue to analyze the return on 
investment in terms of recruiting and retention and update our models 
appropriately to ensure the incentives programs continue to be properly 
funded.
    For the Army National Guard, the budget request fully funds 
existing requirements. However, greater than 30 percent of the Army 
National Guard's current Medical, Dental, and Medical Specialists Corps 
personnel are within 1 year of their retirement eligibility date and 
are not eligible for incentives under current DOD regulations. The Army 
is reviewing proposals to ensure all available incentives are available 
to our critical skill personnel, regardless of the number of years' 
service they have within the Reserve components.
    Admiral Robinson. The President's budget for fiscal year 2011 fully 
funds incentive programs for recruitment and retention of Navy 
healthcare professionals. We continue to closely monitor these programs 
to identify any need for additional resources that may be required to 
meet emerging growth requirements and future readiness among healthcare 
professionals.
    General Green. For the current fiscal year 2010 budget and the 
fiscal year 2011 budget submission, the AFMS is provided sufficient 
money from the Line of the Air Force to cover our current projected 
cost of the Medical Special and Incentive Pays Program (special pays, 
accession bonuses, incentive pays, and retention bonuses). Any cuts to 
the fiscal year 2011 budget submission affecting Air Force Special and 
Incentive Pays program will have a drastic and lasting effect on 
accession and retention of our critical specialties. The money under 
the Medical Special and Incentive Pays Program covers all medical 
entitlements and contracted pays. Our incentive and retention pays are 
all contract linked and require military obligations for the fully-
qualified member to receive. Our accession bonuses are currently 
covered for the projected increase in fully-qualified health 
professions officers recruiting requirements and also require a 
mandatory military obligation to be eligible. To avoid a possible 
revolving door program of accessions and separations, the AFMS will 
require an adjustment to the Line of the Air Force money provided to 
the AFMS for Medical Special and Incentive Pays Program, possibly as 
early as fiscal year 2014 or fiscal year 2015. As these newly accessed 
health professions officers complete their initial military obligations 
and become eligible to either separate or contract for enhanced 
compensation contracts under the new authorities of 37 U.S.C. 335, we 
must remain within 75 percent of comparable direct salary compensation 
to stay viable and competitive with the private sector health care 
employment market and retain these critical and experienced health care 
professionals.
    HPSP/Financial Assistance Program funding for fiscal year 2010 from 
the Air Force Reserves and Defense Health Program are fully funded. 
Current projected funds will support our steady state of 1,666 
participants starting in fiscal year 2011.
    Admiral Jeffries. The President's budget for fiscal year 2011 fully 
funds incentive programs for recruitment and retention of Navy 
healthcare professionals. We continue to closely monitor these programs 
to identify any need for additional resources that may be required to 
meet emerging growth requirements and future readiness among healthcare 
professionals.

                             mental health
    44. Senator Graham. Dr. Rice, Admiral Hunter, General Schoomaker, 
Admiral Robinson, General Green, and Admiral Jeffries, we recently 
received a report from DOD which concluded that: there is an increased 
need for civilian mental health care providers within DOD; that the 
supply in the civilian labor market may not meet the demand; and we 
should pilot a scholarship program for civilian mental health providers 
in exchange for a commitment to serve in areas where there are DOD 
beneficiaries. Do you agree that such a program could be beneficial?
    Dr. Rice and Admiral Hunter. We agree there is an increased need 
for mental health providers with DOD. We are working hard to ensure the 
MHS remains competitive to recruit from the civilian labor market and 
to answer the Deputy Secretary of Defense's challenge to ``grow our 
own'' mental health professionals.
    To those ends, we have proposed legislation for a scholarship 
program for health professionals, initially targeting mental health 
professionals. This legislation is entitled Health Professions 
Financial Assistance Program for Civilians. This program will give the 
Services authority to provide pay and allowances for civilians toward 
their education within the health professions focusing on mental health 
professions. This program will be given in exchange for a commitment to 
DOD service, ensuring additions to our inventory of critical 
specialties. We request congressional support for this important 
legislation.
    General Schoomaker. I have concerns about piloting a scholarship 
program for civilian mental health providers. Such a scholarship 
program may not work for all behavioral health specialties, as each 
specialty has unique educational requirements. Physicians who attend 
medical school would have to commit to a particular specialty (e.g., 
psychiatry) when applying to medical school. Very few people enter 
medical school with a clear idea of what specialty to pursue and many 
change their mind several times during the 4 years of medical training. 
Therefore, requiring a person to commit to a particular specialty prior 
to entering medical school is not practical. In addition, there is no 
guarantee that the person will match to a residency training program in 
that specialty 4 years later.
    Similarly, a scholarship program for clinical psychologists could 
face significant difficulty. Clinical psychologists complete 3 to 4 
years of academic coursework plus a dissertation and a 1-year 
internship prior to award of the doctorate; they follow this with an 
additional year of post-doctoral supervision prior to licensure. There 
are many opportunities for students to be derailed from their training 
plans that make a scholarship program problematic. The Army has a tight 
process for selecting HPSP recipients for the military, but we still 
find almost 20 percent of students do not meet qualification standards 
by the time they reach the internship. Each student who does not 
complete their training is a loss of about $100,000.
    The Army already has an educational program for producing social 
workers. We are in the second year of the new Army Masters of Social 
Work (MSW) program. Originally only offered to servicemembers, the MSW 
program has expanded to include Federal service employees, and will 
further expand next year to include non-Federal civilians.
    The Army has expended great effort and has seen strong success 
recruiting civilian behavioral health providers over the last 5 years. 
Army records indicate an increase of 861 civilian behavioral health 
providers from March 2006 to March 2010, or 105 percent increase for a 
total on-board strength of 1,680 civilian behavioral health employees. 
Increases among these behavioral health occupations include: (1) 
Psychologists (an increase from 288 to 533 or an 85 percent increase); 
(2) Social Workers (an increase from 369 to 854 or a 131 percent 
increase); (3) Psychiatrists (an increase from 89 to 131 or a 47 
percent increase); and (4) Psychiatric Registered Nurses (an increase 
from 73 to 162 or a 122 percent increase). To achieve the 105 percent 
increase in civilian behavioral health providers, Army Medical Command 
(MEDCOM) has aggressively pursued several actions. For the past 3 
fiscal years, MEDCOM centrally funded $1.5 million annually for the 
student loan repayment program for registered nurses, including 
psychiatric registered nurses. MEDCOM also set aside monies for 
recruitment, relocation, and retention incentives for all healthcare 
occupations. A little more than $11 million was granted to civilian 
employees in the four behavioral health occupations during the last 18 
months through the end of March 2010.
    Admiral Robinson. Navy Medicine has been generally successful 
hiring civilian and contract mental health providers. The Services, as 
well as the VA, continue to pursue a limited pool of applicants which 
has become more challenging especially in remote locations. Careful 
cost-benefit analyses in support of initiatives such as a civilian 
scholarship program must be conducted and the potential impact on 
current military scholarship programs must be assessed. We would not 
support competing scholarship programs. We rely on our current military 
scholarship programs as the primary source for commissioning military 
health care providers.
    General Green. With respect to the idea of a civilian scholarship 
program, I feel that the establishment of such a program would compete 
with the recruitment of Active Duty mental health providers, which has 
been a significant challenge for the Air Force. This would be 
particularly true for our HPSP. While civilian employee mental health 
providers are a pivotal part of the military mental health care 
delivery system, we recommend continuing to emphasize the recruiting 
and retention of Active Duty providers who can fill certain roles only 
they can perform--most notably deployment.
    We already have existing, vacant civilian mental health provider 
positions and so the issue is how to better recruit and retain civilian 
providers, with a particular focus on those Air Force bases located in 
areas underserved by civilian mental health providers. To do this, we 
should seek to maximize a number of initiatives already in place that 
could have positive effect on this situation:

    1.  Existing DOD Direct Hire Authority for medical occupations is a 
valuable recruiting tool and has made a positive impact on medical 
occupation accessions.
    2.  Multiple tools are available for civilian employees for both 
accession and retention purposes:

           Recruitment bonuses for new accessions (up to 25 
        percent of base salary)
           Retention allowances to sustain high caliber 
        employees (up to 25 percent of base salary)
           Credit for non-Federal and Uniformed Service 
        experience for annual leave accrual for new employees
           Student Loan Repayment for new accessions ($10,000 
        per year with $60,000 max payment)

    3.  Superior Qualification Appointments (for GS employees only) 
provides an advance in-hire rate up to Step-10 of assigned grade.

    In addition, I would like to see incentives for those professionals 
willing to relocate and work on bases underserved by local civilian 
mental health professionals. Those areas generally provide very little 
in the way of a pool of candidates for positions on base.
    Lastly, I encourage Congress to consider reviewing TRICARE 
reimbursement rates and business rules to see if there may be 
opportunities to encourage community civilian providers to join and 
expand existing TRICARE networks. Family members in certain markets 
frequently report challenges accessing providers willing and able to 
accept network referrals.
    Admiral Jeffries. Navy Medicine has been generally successful 
hiring civilian and contract mental health providers that support the 
Marine Corps. The Services, as well as the VA, continue to pursue a 
limited pool of applicants which has become more challenging especially 
in remote locations. Careful cost-benefit analyses in support of 
initiatives such as a civilian scholarship program must be conducted 
and the potential impact on current military staffing and scholarship 
programs must be assessed prior to initiating such an effort. Current 
military scholarship programs are the primary source for commissioning 
military health care providers that support the Marine Corps and the 
development of a competing program may have undesirable consequences.

                          tricare for reserves
    45. Senator Graham. Admiral Hunter, I was gratified to learn that 
enrollment in TRICARE for Reserves has grown significantly since last 
year but there is still concern among the personnel chiefs of the 
Services that the word is not getting out to reservists. How can we 
improve the marketing of this program?
    Admiral Hunter. We are committed to improving the marketing of this 
program to reach every potential TRICARE Reserve Select (TRS) 
beneficiary.
    TRICARE Management Activity and OASD (Reserve Affairs) are 
collaborating to ensure each Reserve component member has the necessary 
information to make an educated decision regarding the purchase of TRS.
    Reserve Affairs issued a Policy Memorandum governing TRS. This 
requires each of the Reserve components to develop and execute a 
communications plan to all of their members. The Communications Plan 
for 2010 is designed to emphasize informing both Reserve members and 
family members, to enable the entire military family to make the health 
care decision together.

    46. Senator Graham. Admiral Hunter, I am not happy to hear that 
implementation of TRICARE for Gray Area reservists is taking so long. 
When will it be up and running?
    Admiral Hunter. We anticipate TRICARE