[Senate Hearing 111-]
[From the U.S. Government Publishing Office]



 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2010

                              ----------                              


                        THURSDAY, JUNE 18, 2009

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:30 a.m., in room SD-192, Dirksen 
Senate Office Building, Hon. Daniel K. Inouye (chairman) 
presiding.
    Present: Senators Inouye and Cochran.

                       NONDEPARTMENTAL WITNESSES

STATEMENT OF ALEC PETKOFF, DEPUTY DIRECTOR, NATIONAL 
            SECURITY COMMISSION, THE AMERICAN LEGION

             OPENING STATEMENT OF SENATOR DANIEL K. INOUYE

    Chairman Inouye. I'm pleased to welcome all of you to this 
hearing, where we'll receive public testimony pertaining to 
various issues related to the fiscal year 2010 Defense 
appropriations request.
    Because we have so many witnesses who wish to present 
testimony, I'd like to remind each witness that, unfortunately, 
they'll have to be limited to 3 minutes. Like to have this all 
day, but I have a supplemental appropriations pending on the 
floor.
    So at this point, I'd like to recognize the first witness, 
Mr. Alec Petkoff, deputy director of the--national security of 
The American Legion.
    Mr. Petkoff. Thank you, Mr. Chairman.
    Mr. Chairman, I want to thank you for inviting The American 
Legion to share its views on defense appropriations for fiscal 
year 2010.
    Since its founding in 1919, The American Legion remains 
steadfast in support of a strong national defense. The United 
States is a Nation at war, still battling against extremist 
Islamists all over the world. The United States also must be 
prepared for any number of threats to our national security, 
whether they arise from powerful nation states, rogue nation 
states, nonstate violent extremists, natural disasters, or 
instability resulting from economic downturns in the world 
economy.
    Our need for a ready and robust military is clear. Now is 
not the time to slow down or reduce the level of spending 
required to keep our country safe from this spectrum of 
threats. From quality-of-life issues, to force structure, to 
military healthcare, to procurement, none of these areas should 
be neglected at the expense of the other. With this in mind, we 
would like to briefly highlight some vital areas of concern.
    The first area of concern is the size of the active duty 
force. For decades, The American Legion has advocated for an 
active duty force of at least 2.1 million members. Since 
September 11, 2001, we have seen the results of having a force 
that is too small in relation to our national security needs. 
The results have been dramatically bad for our military 
servicemembers. These results are multiple deployments without 
adequate dwell time, straining military servicemembers, and 
likewise their families, to the breaking point; the required 
implementation of stop-loss, and the dramatic transformation of 
the National Guard from a strategic force to an operational 
force, which has increased our risk and reduced our strategic 
freedom of action. These results have had negative impacts on 
readiness and quality of life.
    Three years ago, Congress decided to increase the size of 
the force, adding 65,000 soldiers to the Army. This initiative 
has been a success. The Army reached its increased recruiting 
goal earlier this year, 2 years ahead of schedule. The Grow the 
Force Initiative has been successful, but that does not mean it 
should end.
    This is reinforced by Defense Secretary Robert Gates, who 
said, in testimony before the Senate Armed Services Committee 
last month, that despite the success of the Grow the Force 
Initiative, he remains concerned by the limited dwell time that 
our soldiers have between deployments. Therefore, The American 
Legion recommends further funding to significantly increase the 
size of the force beyond the original Grow the Force 
Initiative.
    The American Legion also has the following recommendations 
for the subcommittee:
    In military personnel, The American Legion supports a 
military pay raise from the suggested 2.9 percent to 3.9 
percent, to help close the civilian-military pay gap, and 
additional funds for Reserve Officer Training Corps.
    In operation and maintenance, with respect to defense 
health programs, The American Legion supports the full funding 
of TRICARE for retirees, dependents, and all Reserve forces. 
The American Legion also supports wounded warrior care 
improvements, to include outreach and treatment for traumatic 
brain injury and all mental and combat-stress related 
illnesses. And finally, funding for a standalone DOD research 
program into blood cancers, through the congressionally 
directed medical research program.
    In procurement, the Army should obtain necessary equipment 
to man the full complement of 48 brigade combat teams, as 
opposed to the proposed cutback to 45, and continue to refit 
and update the equipment of our Reserve forces, and timely 
procurement of advanced Air Force and Navy weapons systems, 
aircraft, and ships.
    In research, development, testing and evaluation, increases 
in missile defense, electronic warfare technology, and weapons 
technology are needed. Cuts to missile defense seem unwise.
    And finally, military construction--construction 
improvements to base medical facilities, commissaries, 
exchanges, and other facilities. And we urge that whenever a 
base realignment and closure is conducted, that certain base 
facilities, such as medical facilities, commissaries, 
exchanges, and other facilities, be preserved for use by active 
duty, reservists, retired military, veterans, and their 
families.
    The American Legion, again, thanks the chairman for having 
this important hearing, and for inviting us to present our 
views. I look forward to continue working with this 
subcommittee on these important issues of national defense.
    Chairman Inouye. Thank you very much. I would welcome any 
written material you may have.
    Mr. Petkoff. I would like to submit our written testimony 
for the record at this time, Mr. Chairman.
    Chairman Inouye. Thank you.
    [The statement follows:]

                   Prepared Statement of Alec Petkoff

    Mr. Chairman and members of the Subcommittee, thank you for 
inviting The American Legion to share its views on defense 
appropriations for fiscal year 2010. Since its founding in 1919, The 
American Legion remains steadfast in its support of a strong national 
defense which is reflected in the Preamble to The American Legion 
Constitution, namely, ``To uphold and defend the Constitution of the 
United States of America,'' and ``to inculcate a sense of individual 
obligation to the community, state and nation.''
    The United States is a Nation at war still battling against 
extremist Islamists all over the world. The United States also must be 
prepared for any number of threats to our national security whether 
they arise from powerful nation-states like Russia or China; rogue 
nation-states like Iran, North Korea or Somalia; natural disasters; or 
instability resulting from economic downturns in the world economy. Our 
need for a robust military is clear. Now is not the time to slow down 
or reduce the level of spending required to keep our country safe. With 
this in mind, The American Legion offers the following recommendations 
with a brief summary of explanation followed by a more complete 
rendering of The American Legion's views and recommendations:

 APPROPRIATIONS PROPOSALS FOR SELECTED GENERAL DISCRETIONARY PROGRAMS FOR DEPARTMENT OF DEFENSE FOR FISCAL YEAR
                                                     2010\1\
                                                  [In Billions]
----------------------------------------------------------------------------------------------------------------
                                                                                    Proposed
                                                                   Funding for       defense       The American
                                                                   fiscal year     funding for   Legion's fiscal
                                                                      2009         fiscal year      year 2010
                                                                                      2010       recommendations
----------------------------------------------------------------------------------------------------------------
Total Defense Spending.........................................          $654.7          $663.7           $728.2
Military Personnel.............................................          $142.7          $149.6             $150
Operation and Maintenance......................................          $273.5          $276.2           $315.7
Defense Health Programs (Operation and Maintenance)............           $25.7           $26.9        \2\ $63.2
Procurement....................................................          $133.2          $131.2           $136.2
Research, Development, Test and Evaluation.....................           $81.7           $78.9             $100
Military Construction..........................................             $28           $22.9           $26.3
----------------------------------------------------------------------------------------------------------------
 \1\ Includes Overseas Contingency Operations or OCO funding.
 \2\ Increase already included in Operation and Maintenance.

    Military Personnel.--Military pay raise from 2.9 to 3.4 percent to 
help close the civilian/military pay gap. Additional funds for Reserve 
Officer Training Corps (ROTC).
    Operation and Maintenance.--The Administration's overall modest 
increase in operations and maintenance is found mostly in the line 
item, ``Administration and Servicewide Activities'' while the line item 
``Operation Forces'' actually gets a decrease. While one can only 
assume the decrease is predicated on a drawdown of forces in Iraq, The 
American Legion recommends that more funds be allocated in case the 
plans for withdrawal are found to be premature by either the Iraqi 
government or more importantly our commanders on the ground.
    Defense Health Programs.--Fully fund TRICARE for retirees, 
dependents and all reserve forces; Stand alone fund for blood cancers; 
Wounded Warrior Care improvements.
    Procurement--Army.--Obtain necessary equipment to man the full 
complement of 48 BCTs, Navy--Oppose shifting the Navy Aircraft Carrier 
program to a 5-year build cycle. Longer cycles only mean larger costs 
and a weakened force. Air Force--Continue to purchase more F-22 Raptors 
and to hasten purchase and building of the aerial refueling tankers. 
Reserve Forces--Continue to refit and update equipment.
    Research, Development, Test and Evaluation.--Increases in missile 
defense, electronic warfare technology, and weapons technology needed. 
Cuts to missile defense are unwise.
    Military Construction.--Construction and improvements to base 
medical facilities, commissaries, exchanges and other facilities.
    The American Legion upholds the following national security 
principles as fundamental to the best interests of the United States:
  --The National Security Strategy needs to be reassessed so that 
        missions and resources are more closely aligned, particularly 
        during the upcoming Quadrennial Defense Review.
  --The credibility of the United States in an unstable world needs to 
        be maintained by retaining requisite military capabilities to 
        deal with actual and potential threats.
  --Such a strategy requires that the Armed Forces be more fully 
        structured, equipped and budgeted to achieve this strategy.
  --Active and reserve military end strengths should be increased to an 
        absolute minimum of 2.1 million for the foreseeable future.
  --At least 12 full-strength Army Divisions, 11 deployable Navy 
        aircraft carrier battle groups, three or more Marine Corps 
        Expeditionary Forces, and 13 or more active Air Force fighter 
        wing equivalents should be retained, as the minimum needed 
        baseline force.
  --Defense budgets should be funded at least 4 percent of Gross 
        Domestic Product (GDP) during time of peace, and at 5 percent 
        or more during time of war to fund both people and weapons 
        requirements.
  --The National Guard and Reserves must be realistically manned, 
        structured, equipped, trained, fully deployable and maintained 
        at high readiness levels, and not over-utilized in order to 
        accomplish their increasing and indispensable missions and 
        roles in the national defense.
  --Peacetime Selective Service registration should be retained so as 
        to maintain a viable capability to rapidly reconstitute forces 
        in the event of emergencies or war.
  --Force modernization for the Armed Forces needs to be realistically 
        funded, and not further delayed, or the United States is likely 
        to unnecessarily risk American lives in the years ahead. 
        Production of airlift and sealift assets needs to be expedited.
  --The American people expect that whenever Armed Forces are 
        committed, that they will be committed only when America's 
        vital national interests are threatened and only as a last 
        resort after all reasonable alternatives have been explored and 
        tried.
  --Peacekeeping, peace enforcement, peace-making and humanitarian 
        operations detract from military readiness to conduct combat 
        operations across the full spectrum of potential conflicts. 
        Such operations should be limited, congressionally approved and 
        separately appropriated on a case-by-case basis.
  --The honorable nature of military service should be upheld, as it 
        not only represents fulfillment of American patriotic 
        obligation, but is also a privilege and responsibility of 
        citizenship that embodies the highest form of service to the 
        Nation.
  --The United States Government must honor its obligations to all 
        service members, veterans, military retirees and their families 
        with equitable earned benefits, lasting military retirement 
        compensation and other appropriate incentives, such as timely 
        access to quality health care for all beneficiaries.
  --Major incentives for military service should include an enhanced GI 
        Bill for education and training, improved quality-of-life 
        features, and a reduced operational tempo in order to recruit 
        and retain a high-quality and fully manned, professionally led 
        force.
  --The United States Government is urged to retain the necessary 
        deployed forces worldwide to accomplish short-term as well as 
        long-term commitments and contingencies.
    The American Legion would like to thank Subcommittee Members for 
their hard work on previous legislation to improve the quality-of-life 
for America's Total Force military, retirees, and their families.
    This portion of the statement will contain issues on the following 
subject areas:
  --Quality-of-Life;
  --Force Structure;
  --Manpower and Weapons Systems;
  --POW/MIA.

                            QUALITY-OF-LIFE

    It is with particular purpose that The American Legion address 
quality-of-life issues before the issues of ``force structure'' and 
``manpower and weapons systems'' as concerns our national defense. 
Maintaining a high quality-of-life for our service members has to be 
the first priority of any nation that seeks to defend its interests at 
home or abroad. Whether it be the infantryman, the pilot, the mechanic, 
or the cook, America needs to be able to attract and retain the best 
and brightest our Nation has to offer. Without such Americans to answer 
the call to service, all other money spent on defense will be in vain. 
And so it is with good reason that The American Legion is first 
concerned with the enhancement of quality-of-life issues for active-
duty service members, Reservists, the wounded and disabled, military 
retirees, and their families. If we are to win the war on terror, and 
prepare for the wars of tomorrow--in this decade and beyond--we must 
take care of the DOD's (Department of Defense) greatest assets; namely, 
its men and women in uniform.
    The United States must honor its obligations to all service members 
(past, present and future) and their families. The American Legion 
urges the Congress and DOD to support and fund quality-of-life features 
for Active-Duty, National Guard and Reservists as well as military 
retirees, veterans and their dependents, and military survivors. This 
is including but not limited to, the following:
  --Military pay comparability for the Armed Forces and regular 
        increases in the Basic Allowances for Quarters; renovation and 
        construction of military quarters and increased funding for 
        child day care centers are direly needed. Pay raises must be 
        competitive with the private sector;
  --Adequate medical, mental and dental health services; morale, 
        welfare and recreational facilities; and non-privatized 
        exchanges and commissary facilities. The Defense Commissary 
        Agency (DECA) and its functions should be retained and not 
        relegated to the military services;
  --Preserving an attractive retirement system for the active and 
        Reserve components and annual cost-of-living adjustments 
        (COLAs) paid at the same rate and concurrently with other 
        Federal retiree COLAs; oppose any changes to the military 
        retirement system, whether prospective or retroactive, that 
        would violate contracts made with military retirees and 
        undermine morale and readiness;
  --Requiring that the Services perform mandatory physical 
        examinations, without waivers, for all separating veterans;
  --Fully funding the concurrent receipt of military retirement pay, 
        military separation pays, and Department of Veterans Affairs 
        (VA) disability compensation as well as Special Compensation 
        pays for disabled military retirees;
  --That the Survivor Benefit Plan and Dependency and Indemnity 
        Compensation (SBP/DIC) offset be eliminated;
  --TRICARE for Life and the TRICARE Senior Pharmacy program for 
        Medicare-eligible military retirees, their dependents and 
        military survivors, should be adequately funded; and regular 
        cost-of-living adjustments to military retirement deployment 
        pay, capital gains tax exclusions, tax-free and increased death 
        gratuity payments, and combat zone tax exclusions for service 
        in South Korea;
  --Congressional re-enactment of Impact Aid to fund the local public 
        school education of military dependents;
  --Adequately protecting the American public and the Armed Forces from 
        the actual or potentially harmful effects of friendly and 
        hostile chemical, biological and nuclear agents or munitions;
  --Urging the Congress to extend and improve additional quality-of-
        life benefits, allowances and privileges to the National Guard 
        and Reserves involved in homeland security and other missions 
        so as to more closely approximate those of the active force. 
        Military retirement pay and TRICARE healthcare for members of 
        the Reserve Components should be authorized before age 60. 
        Hazardous duty and incentive pays for Reservists should be the 
        same as active duty; tax credits to private businesses that pay 
        the difference between military and civilian salaries to 
        mobilized Reservists and restore travel exemptions for Reserve 
        and Guard members for expenses associated with attending 
        drills;
  --Military health care should also be provided to members of the 
        Reserve Components and their dependents, who become injured 
        while on active duty status regardless of the number of days 
        served on active duty, to the same degree as active duty 
        members under the same circumstances;
  --Whenever a Base Realignment and Closure (BRAC) is conducted, The 
        American Legion will urge that certain base facilities such as 
        base medical facilities, commissaries, exchanges and other 
        facilities be preserved for use by active duty and Reservist 
        personnel and military retired veterans and their families;
  --Walter Reed Army Medical Center not be closed until after Overseas 
        Contingency Operations have ended;
  --That the numerous, recurring and serious pay problems experienced 
        by the Active and Reserve Components be immediately resolved; 
        and
  --Traumatic Brain Injury and Combat Stress Disorders be diagnosed and 
        effectively treated in the military.

Wounded Warrior Care
    The respective branches of the military often like to pontificate 
on how they all ``take care of their own.'' Nowhere is this statement 
put more to the test than when dealing with the combat and severely 
wounded. Since the Building 18 episode at Walter Reed Army Medical 
Center, a well-deserved spotlight was put on the whole transition 
process for outgoing military personnel. The resulting findings were 
somewhat surprising in that it was not the quality of medical care that 
was in question, but rather it was everything else. Some of those 
issues included electronic transference of medical records; scheduling 
of appointments; housing; family support issues; the Physical 
Evaluation Board (PEB) and Medical Evaluation Board (MEB) process; 
applying for VA benefits and receiving them without a gap in pay upon 
discharge from the military; endless forms, paperwork and tests.
    The American Legion supports many of the reforms, most of which are 
still in the form of pilot programs, that address these issues. Warrior 
Transition Units (WTUs) need to be fully funded and fully staffed. PEB/
MEB process needs to be overhauled. Great strides have been made since 
2007, but the progress made (particularly in the area of the WTUs) not 
only needs to be maintained but expanded.
    The American Legion supports some of the recommendations of the 
President's Commission on Care for America's Returning Wounded Warriors 
(the Dole/Shalala Commission). Under the Commission's proposal, service 
members found unfit for military duty (a determination made by DOD 
based on a joint VA/DOD collaborative examination process) would be 
awarded a lifetime annuity payment by DOD based on years of service and 
rank. The purpose of this annuity is to compensate for the loss of the 
service member's military career.
    As these reforms are instituted, the new rating system and 
compensation should be made retroactive to correct those past egregious 
disability decisions and call for the re-rating and reevaluation of 
immediate past military disability retired personnel.
    Since Operations Enduring Freedom and Iraqi Freedom began, over 
5,000 Americans have given their lives in our operations in Iraq and 
Afghanistan and over 34,000 have been wounded in action. Of those 
wounded, over 15,700 did not return to duty. Caring for our military 
and ensuring good quality-of-life for the service member and the family 
is part of the ongoing cost of war and national security.
    The fiscal year 2009 budget has $3 billion to improve army 
barracks, military hospitals, and other facilities. The American Legion 
recommends a minimum of $3.4 billion for fiscal year 2010 in order to 
ensure that there are no delays in construction and improvement of 
living quarters and medical facilities.
    The fiscal year 2009 budget has $25.8 billion, $2.4 billion above 
2008, for medical care. This includes $300 million for traumatic brain 
injury (TBI) and psychological health. The American Legion applauds 
Congress for this increase and recommends that funding for fiscal year 
2010 be $28 billion in order to sustain current costs and to improve 
treatment for TBI and psychological health professionals, particularly 
for the Reserve force that may live in rural areas.

Force Health Protection
    The American Legion continues to actively monitor the DOD's 
implementation of Force Health Protection policies and urges continual 
congressional oversight to ensure that all Force Health Protection laws 
and policies, including thorough pre- and post-deployment physical and 
mental examinations, are being properly implemented in a consistent 
manner by all military branches.
    The American Legion also urges DOD to actively track and follow-up, 
with proper medical care, adverse reactions to vaccinations as well as 
any and all health-related complaints associated with the ingestion of 
controversial drugs such as pyridostigmine bromide and Lariamand. In 
addition, The American Legion urges DOD to continually improve its 
treatment of service personnel who have been diagnosed with post-
traumatic stress disorder and/or traumatic brain injury.
Concurrent Receipt of Military Retired and Severance Pays and 
        Disability Compensation and Their Dependents
    Military retired pay and disability compensation have been 
erroneously equated in one form or another for too long. One pay is 
earned through service and the other is compensation for debilitating 
injuries that were acquired while in service (on the job, so to speak). 
To offset one against the other is clearly unfair.
    The American Legion expresses its gratitude to the Congress for the 
authorization of both Combat-Related Special Compensation (CRSC) and 
partial concurrent receipt for over 200,000 disabled military retirees 
but urges the Congress to authorize and fund full concurrent receipt 
for all disabled military retirees to include those rated at 40 percent 
and below and to authorize the CRSC payment of military disability 
retiree pay and VA disability compensation for those disabled military 
retirees.
    Additionally, The American Legion urges Congress to eliminate the 
phase-in of provisions in Public Law 108-136 so as to accelerate 
restored retired pay in less than 10 years and to authorize the 
concurrent receipt of military severance pay for less than 30 percent 
disabled service members and VA disability compensation.

TRICARE
    The American Legion has a longstanding position that it should 
prevail upon any Administration and DOD to reconsider any proposals to 
implement any increases in the military retirees' TRICARE enrollment 
fees, deductibles, or premiums. The American Legion urges Congress to 
fully fund military and VA healthcare programs for beneficiaries as 
well as a permanent TRICARE program for Guardsmen and Reservists. The 
American Legion recommends that the following guidelines be 
incorporated as part of the DOD healthcare package for military 
retirees, dependents and military survivors:
  --Administrative barriers to an effective TRICARE system to include 
        raising TRICARE provider reimbursements; program portability 
        between TRICARE regions; reducing delays in claim payments; and 
        increasing electronic claims processing need to be removed. 
        Improve TRICARE enrollment procedures, beneficiary education, 
        decrease administrative burdens, eliminate non-availability 
        requirements and eliminate unnecessary reporting requirements;
  --TRICARE programs to include the TRICARE for Life and the TRICARE 
        Senior Pharmacy programs which are used by 1.3 million 
        Medicare-eligible military retirees and their dependents should 
        be fully funded annually;
  --Restore TRICARE reimbursement policy to pay up to what TRICARE 
        would have paid had there been no other health insurance as was 
        the policy before 1993;
  --Dual eligible disabled retirees continue to receive health care 
        from both military treatment facilities and VA medical centers. 
        TRICARE Prime Remote should be included for military retirees, 
        dependents and military survivors;
  --All military beneficiaries should be authorized to receive dental 
        and visual care at military treatment facilities;
  --Retired Reservists and their dependents should be eligible for 
        TRICARE coverage when they become eligible to receive 
        retirement pay; The American Legion urges that all discharging 
        service members, active and Reservists be required to have 
        discharge and retirement physical examinations; physicals 
        should not be optional or abbreviated;
  --Adequate military medical personnel, to include graduates of the 
        Uniformed Services University of Health Sciences and members of 
        the Commissioned Officer Corps of the Public Health Service, 
        should be retained on active duty to provide health care for 
        active duty and retired military personnel and their 
        dependents;
  --The Federal Employee Health Benefits Plan (FEHBP) should be 
        authorized as an alternative to TRICARE for those military 
        retirees and dependents who can afford such premiums;
  --TRICARE fees should not be increased except as authorized by 
        Congress, not by DOD;
  --Military construction funding should be authorized for the 
        construction of Walter Reed Military Medical Center and the 
        Fort Belvoir Army Community Center;
  --If Congress increases TRICARE fees, the increases should be at a 
        rate no larger than the rate of pay increases for Active, 
        Reserve, National Guard, military and medical retirees, and 
        military survivors.

Quality-of-Life for National Guard and Reserve Forces
    The American Legion urges Congress and DOD to pass legislation and 
create policy that addresses all the needs of the Reserve forces to 
include:
  --Full range of active duty retention bonuses and recruiting 
        incentives, pay promotions and health care quality-of-life be 
        applicably activated to the National Guard and Reserve;
  --Qualified Reservists should be authorized to receive Military 
        retirement pay and TRICARE healthcare before age 60;
  --Hazardous duty and incentive pays for Reservists set the same as 
        active-duty;
  --Creating tax credits to private businesses paying the difference 
        between military and civilian salaries to mobilized Reservists;
  --Restoring travel exemptions for Reserve and Guard members for 
        expenses associated with attending drills;
  --Military health care provided to members of the Reserve Components 
        and their dependents, who become injured while on active duty 
        status regardless of the number of days served on active duty;
  --Retired Reservists and their dependents should be eligible for 
        TRICARE coverage when they become eligible to receive 
        retirement pay;
  --All discharging Reservists should be required to have complete 
        discharge and/or retirement physical examinations to the same 
        standard as the active-duty force.

General Quality-of-Life Issues
            Armed Forces Retirement Homes
    The American Legion urges the Congress to support and fund those 
measures, to include annual Congressional appropriations, which will 
provide for the long-term solvency and viability of the Armed Forces 
Retirement Home--Washington. The American Legion also strongly supports 
the rebuilding of the Armed Forces Retirement Home at Gulfport, 
Mississippi.
            Support for the Selective Service Registration Program
    The American Legion supports the retention of the Selective Service 
Registration Program as being in the best interests of all Americans, 
and its maintenance is a proven cost-effective, essential, and rapid 
means of reconstituting the required forces to protect our national 
security interests.
            Reforming the Military Absentee Voting System
    The American Legion urges that appropriate laws and guidelines be 
developed at Federal, State and local levels with the intent that all 
military absentee voters and their families will have their votes 
counted in every election. The American Legion also recommends that the 
sending and receiving of blank and completed military absentee ballots 
be accomplished electronically as much as possible.
            Military Commissaries
    The American Legion urges DOD and the Congress to continue full 
Federal funding of the military commissary system and to retain this 
vital non-pay compensation benefit system. This quality-of-life benefit 
is essential to the morale and readiness of the dedicated men and women 
who have served, and continue to serve, the national security interests 
of the United States. The American Legion opposes any efforts to 
institute ``variable pricing'' or to privatize the military commissary 
system or to dismantle or downsize the Defense Commissary Agency.
            Military Funeral Honors
    The American Legion reaffirms that the Congress should mandate and 
appropriately fund DOD and the Military Services, to include 
reimbursing the National Guard, so as to provide military honors upon 
request at veterans' funerals in coordination with Veterans' Service 
Organizations such as The American Legion at local levels. The 
Department of Defense should implement equitable and expedient 
reimbursement procedures for members of the veterans' service 
organizations who participate in military funeral honors.
    The American Legion also recommends that an action be taken to 
change the wordage, as currently written in Section 578 Public Law 106-
65 to: That any and all funeral directors performing services for any 
veteran of The United States armed forces shall be required to ask the 
veteran's family member or other interested party if military honors 
are requested, at no expense to the family, rather than placing the 
burden upon the veteran's family at this time of bereavement.

                            FORCE STRUCTURE

    The current active-duty personnel level has been funded to maintain 
just under 1.37 million active-duty service members. Military leaders 
had been making up manpower shortages by increasing the OPTEMPO, 
increasing rotations to combat zones, and by over-utilizing the Reserve 
Components. American military personnel are deployed to over 150 
countries worldwide. Many of these personnel are from the Reserve 
Components. Multiple deployments, particularly to combat zones, are 
often the core element of the recruitment and retention challenges that 
have confronted the Army. While all the services have met or exceeded 
their recruitment goals for 2008, this is due in large part to the 
uncertainty in the economy and to the great successes our forces are 
having in Iraq. All of the services could find themselves in 
recruitment difficulties again if the economy recovers quickly or if 
casualties begin to rise again either in Iraq, Afghanistan or some 
other area of the world where our national security is threatened. We 
applaud Congress for funding the requested end strength increases of 
7,000 for the Army, 5,000 for the Marine Corps, and 1,300 for the Army 
Guard for fiscal year 2009. However, The American Legion insists that 
these nominal increases are not enough to adequately provide for the 
needs of a strong national security posture. The active force combined 
with the reserve force still only totals under 1.75 million. As stated 
previously, The American Legion urges an active and reserve force of 
2.1 million.
    Modernization of weapons systems is vital to properly equip the 
armed forces, but is totally ineffective without adequate personnel to 
effectively operate state-of-the-art weaponry. No military personnel 
should go into battle with unarmed or under-armored vehicles or without 
body armor or with vehicles and helicopters that are approaching or 
exceeding their service lives. America stands to lose its service 
members on the battlefield and during training exercises due to aging 
equipment. The current practice of trading off force structures and 
active-duty personnel levels to recoup or bolster modernization or 
transformation resources must be discontinued. The Army and the Marine 
Corps need to be immediately funded to reset their combat forces so as 
to maintain their readiness.
    The American Legion recommends restoring former military force 
structures and increasing active-duty end strengths so as to improve 
military readiness and to more adequately pursue the Overseas 
Contingency Operations (OCO). The American Legion seeks to improve 
alignment of service levels with missions to ease deployment rates and 
improve quality-of-life features. Ensuring readiness also requires 
retaining the peacetime Selective Service System to register young men 
for possible military service in case of a national emergency. Military 
history repeatedly demonstrates that it is far better to err on the 
side of preserving robust forces to protect America's interests than to 
suffer the consequences of an inadequate force structure or military 
non-readiness, especially during time of war.
    America needs a more realistic strategy with appropriate force 
structure, weaponry, and equipment with increased active-duty and 
Reserve components and readiness levels to achieve its national 
security objectives.

Other Force Structure Issues and Recommendations
            Support for the Non-Federal Roles of the National Guard
    The active-duty force must be able to better accomplish its 
operational objectives around the globe without relying so heavily on 
the National Guard. The Guard must go back to its primary roles in 
homeland security and used as a mainly strategic asset and not as an 
operational one. The American Legion urges the Congress to retain 
National Guard units at reasonable readiness levels so that in addition 
to their active duty missions they may continue to provide civil 
disturbance and natural and man-made disaster assistance; perform civil 
defense and drug interdictions functions as well as other essential 
State or Federal roles as required to include border security.
            Uniformed Services University of the Health Sciences (USU)
    The American Legion urges the Congress to: continue its 
demonstrated commitment to USU, as a national asset, for the continued 
provision of uniquely educated and trained uniformed physicians, 
advanced practice nurses, and scientists dedicated to careers of 
service in the Army, Navy, Air Force, and the United States Public 
Health Service; support timely construction at the USU campus during 
fiscal years 2009-2010; continue funding the University's collaborative 
effort for sharing its chemical, radiological and biological, nuclear 
and high yield explosive (CBRNE) expertise and training; support 
development of the USU Immersive, Wide Area Virtual Environment (WAVE) 
Simulation for CBRNE/WMD Medical Readiness Training; support funding 
for the Graduate School of Nursing Teaching/Educational Programs; and, 
encourage continued close collaboration and progress towards the OSD-
proposed Joint Medical Command and WRNMMC with USU as the core academic 
health center.
            Aeronautical and Space Exploration
    The American Legion deems it imperative that the United States, in 
the face of increasing competition, maintain its hard-won status as the 
world leader in aeronautics and aircraft production and in space 
exploration and research. To realize this goal, we urge the Congress to 
provide:
  --Adequate funding for the Nation's civilian and military aerospace 
        research and development programs to maintain U.S. 
        technological leadership.
  --Adequate funding to build, upgrade and enhance the Nation's 
        civilian and military aerospace research facilities and wind 
        tunnels.
  --A renewed national commitment to education involving academia in 
        aeronautical and aerospace engineering research and 
        technologies insuring a state-of-the art educated work force.
  --Over-watch and investigate functions and related activities with 
        respect to the transfer of American aerospace technology 
        abroad.
            Combating Cyberspace Threats
    The American Legion urges the Congress to appropriate the necessary 
funding and resources to combat the continuing cyberspace and other 
threats to the United States in the 21st Century.
            National Missile Defense System
    The American Legion urges the United States Government to develop 
and continue to deploy a national missile defense system which is in 
the national interest of the United States and the American people and 
an essential ingredient of our homeland security.
    Considering the growing threats of rocket and missile attacks by 
Iran and North Korea, proposed cuts to missile defense seem unwise. 
Even if cuts are being made in systems that are not deemed successful, 
those monies should be reallocated to those defense systems that are 
working.

                      MANPOWER AND WEAPONS SYSTEMS

    The President's fiscal year 2010 Defense budget request should 
require continued funding to sustain current Overseas Contingency 
Operations (OCO) while maintaining the war-fighting capabilities of the 
Armed Forces. For years, the increased Operations Tempo (OPTEMPO), OCO, 
and budgetary shortfalls have had a devastating impact on military 
readiness, modernization, and personnel.
    The American Legion recommends that the fiscal year 2010 Defense 
appropriations bill should include higher military pay raises and 
allowances as well as recruitment bonuses and incentives. The Defense 
Health Program, to include the TRICARE health care system, needs to be 
fully funded without new or increased TRICARE fees. Authorizations for 
continued higher spending on modernization must include: the resetting, 
repairing and procuring of Army weapons systems and equipment; 
continued spending for development of, and fielding, Joint Strike 
Fighters for the Air Force and Navy; and, procurement of more F-22A 
Raptor fighter jets and aerial refueling tankers for the Air Force.
    The American Legion urges Congress to increase defense spending to 
levels that represent at least 5 percent of GDP. This represents not 
only ongoing needs, but also the shared burden of the American people 
during a time of war.
    Defense budgets, military manpower and force structures are 
currently one-third of their 1986 peacetime levels. Military 
capabilities are at significantly lower levels than the Persian Gulf 
War in 1991. With only 10 active Army divisions in the inventory, it is 
little wonder that thousands of Reservists and Guardsmen have been 
called to active-duty to bolster homeland security and in fighting the 
wars in Iraq and Afghanistan. The current plan to cap the Brigade 
Combat Team numbers to 45, as opposed to the recommended 48, is a 
terrible case of robbing Peter to pay Paul. While the size of the force 
will still increase, the actual size of combat ready ground forces will 
still be inadequate. If our national security needs require more 
administrators and trainers, then so be it, but it should not come at a 
cost of a reduction in combat ready forces.
    The American Legion, along with its previous quality-of-life and 
force structure recommendations, further recommends the following as 
regards the purchasing of weapons systems and armaments in general:
Rebuilding America's Defense Industrial Base
    The American Legion urges the new administration and the Congress 
to rebuild America's industrial base by continuing to adequately fund 
research, development and acquisition budgets to assure that our 
military production can meet national requirements especially when U.S. 
military power is committed. Rebuilding America's industrial base 
could, and perhaps should, be part of the administration's plan to 
reinvigorate the economy.
    We encourage the new Administration and the Congress in the 
rebuilding of America's defense industrial base by having a proper 
balance of policies that:
  --Increase and then sustain domestic production at levels that 
        maintain a robust and internationally competitive defense 
        industry.
  --Keep the arms industry internationally competitive.
  --Ensure that the United States is not putting itself at risk by 
        having our armaments produced offshore.
            Buy American
    The American Legion urges Congress to require Government 
contractors to utilize American-made components and subsystems in 
construction of their equipment over those made by foreign 
subcontractors for use by the United States military services to ensure 
the defense of the country, as well as the continued employment of 
Americans and veterans at subcontractor facilities.
            Foreign Investments in the American Defense Industry
    The American Legion urges the U.S. Government to ensure that 
foreign entities are not permitted to own critical industries, 
especially those involved in producing defense items. The American 
Legion further opposes the transfer and sales of sensitive technologies 
which may endanger our national security and economic interests.
            Commercial Shipbuilding for Defense
    The American Legion urges the Congress to vigorously act to stop 
the further erosion of our vital maritime capability by boosting naval 
budgets, promoting commercial shipbuilding, expanding the use of U.S. 
flagships in world commerce, and resisting foreign actions that would 
further damage America's defense industrial base.
            Procurement of Sufficient F-22 Aircraft
    The American Legion advocates that the procurement of F-22 Raptor 
aircraft should be approved and funded by Congress for the stated USAF 
requirement of 381 and that such procurement be funded through 
additional appropriations even if that should result in an increase in 
the overall National Defense Budget.

                         MILITARY CONSTRUCTION

    Military Construction is directly related to the quality-of-life of 
the service member and their dependants. As such, Military Construction 
must be funded to a level that meets the immediate and future needs of 
DOD. The cornerstone to a strong national defense is not based on 
weapon systems purchased or the way the force structure is organized, 
but rather, the way military service members and their families are 
treated and cared for on military installations within the continental 
United States and overseas. In today's All-Volunteer Armed Forces, 
maintaining the highest quality-of-life standards is the least we 
should do in the interest of national security and as the thanks of a 
grateful Nation to those who serve.

Military Construction
    The $26.3 billion recommendation is based of the current force 
structure of 1.75 million. This recommendation also accounts for the 
modest upcoming authorized increases in the sizes of the Army and 
Marine Corps.
    In fiscal year 2009, $25 billion, ($4.4 billion above fiscal year 
2008) was appropriated for Military Construction. The large increase is 
mostly due to the costs of implementing Base Realignment and Closure 
(BRAC) and plans to increase the size of the Army and Marine Corps. It 
should be noted that The American Legion recommends a 2.1 million man 
force structure as opposed to the current force size. As such, if 
authorization and funding for the expansion of the active-duty and 
reserve force increased by an additional 50,000 service members for 
fiscal year 2010 (in order to get closer to The American Legion's 
recommended force structure level), The American Legion would recommend 
$31.3 billion for Military Construction funding for the construction 
associated with such an expansion of forces.

Quality-of-Life and BRAC
    A quality-of-life concern that must be considered is the welfare of 
our retired military. Often, when a service member retires from 
service, whether medically of by longevity, they choose to live in 
close proximity to a military installation. They choose this in order 
to have access to the benefits they earned from honorable service. 
Those benefits include access to base medical facilities, commissaries, 
exchanges and other facilities.
    Whenever a Base Realignment and Closure (BRAC) is conducted, The 
American Legion will urge that certain base facilities (such as base 
medical facilities, commissaries, exchanges and other facilities) be 
preserved for use by active-duty and Reservist personnel and military 
retired veterans and their families.
    One key element of quality of life for service members and their 
families is the quality of their housing, whether it is supplied by the 
military in the form of on-base housing, or the availability and 
quality of off-base housing. Long standing policy of DOD has been to 
rely on local community housing. This policy comes into conflict with 
reality where there is a localized influx of military families, whether 
from BRAC or ``Grow the Army''-like programs.
    Currently, roughly 63 percent of all military families reside in 
off-base, private sector housing. A further 26 percent reside in 
residences built under the Military Housing Privatization authorities. 
Of the remaining 11 percent, 8 percent live in Government-owned housing 
and 3 percent in (primarily overseas) leased housing. However, the 
transience of forces may cause localized market problems in the coming 
years, as changes occur resulting from BRAC, Grow the Force 
initiatives, global re-posturing and joint basing. Some installations 
may suddenly find they have a surplus of housing as a result, while in 
other areas housing availability may be in deficit. Ensuring that 
service members and their families have access to safe, affordable and 
sufficient housing must remain a priority in order to address the 
quality of life for these families.
    One initiative which has received excellent reviews from the 
services has been the Military Housing Privatization Initiative (MHPI) 
which encourages high quality construction, sustainment, and renovation 
of military housing by leveraging capital and expertise from the 
private sector. Under this initiative, 94 projects have been awarded, 
allowing the DOD to eliminate nearly all inadequate domestic family 
housing. This program should be continued and expanded with additional 
resources.
    Numerous media reports surfaced last year of troops returning from 
OCO to barracks that were unsatisfactory. In one case, a distraught 
father of a soldier with the 82nd Airborne at Fort Bragg, NC went so 
far as film the living conditions and to publicize it through social 
networking sites. Following this renewed interest, the Army in 
particular began a sweeping inspection of all its living facilities and 
barracks to ascertain the level of need that many of them required in 
terms of maintenance and repair. The reforms resulted in the First 
Sergeants Barracks Initiative (FSBI) where the barracks are continually 
monitored for needed repairs, and ``ownership'' of barracks for 
deployed troops is transferred to post control for the duration of the 
deployment. This successful innovation should be adequately funded to 
accomplish these needed renovations.
    In October of 2007, Secretary of the Army Pete Geren initiated a 
program entitled the ``Army Family Covenant.'' At the time he stated:
    The Health of our all-volunteer force, our Soldier-volunteers, our 
Family-volunteers, depends on the health of the Family. The readiness 
of our all-volunteer force depends on the health of the Families. I can 
assure you that your Army leadership understands the important 
contribution each and every one of you makes. We need to make sure we 
step up and provide the support families need so the army stays healthy 
and ready.
    This covenant addressed various ways to improve family readiness 
by:
  --Standardizing and funding existing family programs and services;
  --Increasing accessibility and quality of healthcare;
  --Improving Soldier and Family Housing;
  --Ensuring excellence in schools, youth services, and child care; and
  --Expanding education and employment opportunities for family 
        members.
    While we enlist soldiers, airmen, marines and navy personnel, we 
also re-enlist families. Issues of the covenant from which funding 
comes under the rubric of the Military Construction appropriations 
should be funded fully to ensure that we maintain a high level of 
quality of life, and thereby ensure a higher rate of reenlistment for 
the Armed Forces.
    The commitment to this program by the Army was demonstrated by the 
testimony of Keith Easton, Assistant Secretary of the Army for 
Installations on March 12. He noted that the Army Family Covenant 
Program has shown significant progress in meeting its' goals since it 
came into existence. The program itself shows a commitment and 
understanding of the importance of family in our force structure and 
maintaining readiness and force levels. This program is another which 
should be expanded through adequate funding, to ensure the well being 
of service members and demonstrate the national commitment towards 
helping them individually and collectively prosper and reach their 
potential.
    Increased spending in the area of military construction not only 
serves the strategic needs of the armed forces but also the needs of 
the service members. It takes approximately 8 years to build a senior 
Non-Commissioned Officer. To lose a member of the armed forces like 
that to the civilian world, because they feel they can have a better 
quality of life for them and their family outside of the services, is a 
cost that can not be recouped.
    The American Legion fully supports the Army Family Covenant Program 
and engages all of its 14,000+ local American Legion posts to become 
involved.
Wounded Warrior Care
    All branches of the armed forces ascribe to the ethic that they 
``take care of their own.'' Nowhere is this statement put more to the 
test than when dealing with the combat and severely wounded. Since the 
Building 18 episode at Walter Reed Army Medical Center, a well-deserved 
spotlight was put on the whole transition process for outgoing military 
personnel. The fiscal year 2009 budget has $3 billion to improve army 
barracks, military hospitals, and other facilities. The American Legion 
recommends a minimum of $3.4 billion for fiscal year 2010 in order to 
ensure that there are no delays in construction and improvement of 
living quarters and medical facilities.
    Further, The American Legion advocates that Walter Reed Army 
Medical Center should not be closed until after the wars in Iraq and 
Afghanistan have ended. As such Walter Reed Army Medical Center needs 
to be funded at levels high enough to meet and exceed the high 
standards of care our service members deserve.
Uniformed Services University of the Health Sciences
    The American Legion has supported the Uniformed Services University 
of the Health Sciences (USU), since its establishment in 1972 as the 
Nation's Federal Academic Health Center. USU is dedicated to providing 
uniquely educated and trained uniformed officers for the United States 
Army, Navy, Air Force and Public Health Service. USU alumni are 
currently serving over 20-year careers and thus providing continuity 
and leadership for the Military Health System (MHS) as physicians, 
advanced practice nurses and scientists. USU F. Edward Heert School of 
Medicine has a year-round, 4-year curriculum that is nearly 700 hours 
longer than found at other U.S. medical schools. These extra hours 
focus on epidemiology, health promotion, disease prevention, tropical 
medicine, leadership and field exercises. Doctoral and Masters degrees 
in the biomedical sciences and public health are awarded by 
interdisciplinary and department-based graduate programs within the 
School of Medicine. Programs include infectious disease, neuroscience, 
and preventive medicine research.
    USU Graduate School of Nursing offers a Master of Science in 
Nursing degree in Nurse Anesthesia, Family Nurse Practitioner, 
Perioperative Clinical Nursing, Psychiatric Mental Health Nurse 
Practitioner, and a full and part-time program for a Ph.D. degree in 
Nursing Science. The university's continuing education program is 
unique and extensive, serving and sustaining the professional and 
readiness requirements of the Defense Department's worldwide military 
healthcare community.
    The university's nationally ranked military and civilian faculty 
conduct cutting edge research in the biomedical sciences and in areas 
specific to the DOD health care mission such as combat casualty care, 
infectious diseases and radiation biology. The university specializes 
in military and public health medicine, focusing on keeping people 
healthy, disease prevention, and diagnosis and treatment. USU faculty 
offer significant expertise in tropical medicine and hygiene, 
parasitology, epidemiologic methods and preventive medicine.
    The Department of Defense and the United States Congress have 
recognized that the extensive military-unique and preventive health 
care education provided in the multi-service environment of USU ensures 
Medical Readiness and Force Health Protection for the MHS. USU is 
recognized as the place where students receive thorough preparation to 
deal with the medical aspects of Weapons of Mass Destruction, including 
chemical, radiological and biological, nuclear and high yield explosive 
(CBRNE) terrorism or other catastrophe. USU has developed similar 
training for civilian first responders, medical professionals and 
emergency planners. USU is also uniquely qualified and experienced in 
simulation technology, education and training.
    With the establishment by the Office of the Secretary of Defense 
(OSD) of a Joint Medical Command in fiscal year 2008, the role of USU 
will expand. Plans to establish the Walter Reed National Military 
Medical Center (WRNMMC) by 2011 has created close collaboration between 
the Armed Services Flag Officers and the President of USU to create a 
world-class military academic health center, expanding the role of USU.
    As stated previously, The American Legion urges the Subcommittee 
to: continue its demonstrated commitment to USU, as a national asset, 
for the continued provision of uniquely educated and trained uniformed 
physicians, advanced practice nurses, and scientists dedicated to 
careers of service in the Army, Navy, Air Force, and the United States 
Public Health Service; support timely construction at the USU campus 
during fiscal years 2009-2010; continue funding the University's 
collaborative effort for sharing its chemical, radiological and 
biological, nuclear and high yield explosive (CBRNE) expertise and 
training; support development of the USU Immersive, Wide Area Virtual 
Environment (WAVE) Simulation for CBRNE/WMD Medical Readiness Training; 
support funding for the Graduate School of Nursing Teaching/Educational 
Programs; and, encourage continued close collaboration and progress 
towards the OSD-proposed Joint Medical Command and WRNMMC with USU as 
the core academic health center.

Armed Forces Retirement Homes
    The United States Soldiers' and Airmen's Home (USSAH) and the 
United States Naval Home (USNH), jointly called the Armed Forces 
Retirement Home (AFRH), are continuing care facilities which were 
created more than 150 years ago to offer retirement homes for 
distinguished veterans who had served as soldiers, sailors, airmen and 
Marines in our Nation's conflicts. The AFRH system, which is available 
to retiree veterans from all the Armed Services whose active duty was 
at least 50 percent enlisted or warrant officer, has been supported by 
a trust fund resourced by 50 cents a month withheld from active duty 
enlisted and warrant officer paychecks as well as from fines and 
forfeitures from disciplinary actions, resident fees and interest 
income. The extensive downsizing of the Armed Forces has resulted in a 
39 percent decrease in that revenue and, coupled with rising nursing 
home care costs, the Homes have been operating at an $8-10 million 
annual deficit which would reportedly require both Homes to close their 
doors.
    The American Legion urges the Subcommittee to support measures 
which will provide for the long-term solvency and viability of the 
Armed Forces Retirement Home--Washington, DC. The American Legion also 
strongly supports the rebuilding of the Armed Forces Retirement Home at 
Gulfport, Mississippi which was destroyed by Hurricane Katrina.
American Battle Monuments Commission
    The American Battle Monuments Commission (ABMC) was established by 
law in 1923, as an independent agency of the Executive Branch of the 
United States Government. The Commission's commemorative mission 
includes:
  --Designing, constructing, operating and maintaining permanent 
        American cemeteries in foreign countries.
  --Establishing and maintaining U.S. military memorials, monuments and 
        markers where American armed forces have served overseas since 
        April 6, 1917, and within the United States when directed by 
        public law.
  --Controlling the design and construction of permanent U.S. military 
        monuments and markers by other U.S. citizens and organizations, 
        both public and private, and encouraging their maintenance.
    The resulting United States Military Cemeteries have been 
established throughout the world and are hallowed grounds for America's 
war dead. United States Military Cemeteries existing in foreign 
countries today are in need of adequate funding for repair, 
maintenance, additional manpower and other necessities to preserve the 
integrity of all monuments and cemeteries which are realizing increased 
numbers of visitors annually.
    Adequate funding and human resources to the American Battle 
Monuments Commission must be provided in order to properly maintain and 
preserve these hallowed, final resting places for America's war dead 
located on foreign soil. In fiscal year 2009, $59.5 million, $15 
million above fiscal year 2008 was provided for the care and operation 
of our military monuments and cemeteries around the world. The American 
Legion applauded this increased funding and supports the continued full 
funding for the needs of the American Battle Monuments Commission.
Funding for Joint POW/MIA Accounting Command
    The American Legion has long been deeply committed to achieving the 
fullest possible accounting for U.S. personnel still held captive, 
missing and unaccounted for from all of our Nation's wars. The level of 
personnel and funding for the Joint POW/MIA Accounting Command (JPAC) 
has not been increased at a level commensurate with the expanded 
requirement to obtain answers on Americans unaccounted from wars and 
conflicts prior to the Vietnam War. It is the responsibility of the 
U.S. Government to account as fully as possible for America's missing 
veterans, including--if confirmed deceased--the recovery of their 
remains when possible. The Congress has a duty and obligation to 
appropriate funds necessary for all Government agencies involved in 
carrying out strategies, programs and operations to solve this issue 
and obtain answers for the POW/MIA families and our Nation's veterans. 
This accounting effort should not be considered complete until all 
reasonable actions have been taken to achieve the fullest possible 
accounting. The American Legion calls on Congress to provide increases 
in personnel and full funding for the efforts of JPAC, the Defense POW/
Missing Personnel Office (DPMO), the Life Sciences Equipment 
Laboratory, and the Armed Forces DNA Laboratory, including specific 
authorization to augment assigned personnel when additional assets and 
resources are necessary. The American Legion remains steadfast in our 
commitment to the goal of achieving the fullest possible accounting for 
all U.S. military and designated civilian personnel missing from our 
Nation's wars.
    JPAC was forced to reduce field operations in pursuit of missing 
U.S. personnel in early 2006 due to a failure of DOD to provide 
adequate funding. The mission of JPAC has been expanded by Congress to 
include investigation and recovery operations dating back to and 
including unaccounted for WWII personnel, while funding levels have not 
increased to meet this requirement. The headquarters currently utilized 
by JPAC is no longer capable of housing neither the expanded command 
nor the expanded laboratory requirements for forensic identifications. 
The American Legion calls on the Congress to ensure that JPAC has at 
least $62 million per year in operation funds and an additional $64 
million per year for fiscal year 2010 through fiscal year 2011 for JPAC 
military construction funds as part of the budget for the Department of 
Defense in connection with JPAC. The American Legion calls on the 
Congress to ensure that such funds be approved and restricted for use 
for no purpose other than those included in the mission statement of 
the Joint POW/MIA Accounting Command, Hickam AFB, Hawaii.
    The American Legion commends Admiral Timothy Keating, Commander, 
U.S. Pacific Command, for his commitment to seek U.S. Navy funding in 
the amount of $105 million to begin construction of a new JPAC 
headquarters, including a state-of-the-art laboratory in fiscal year 
2010, to be completed in fiscal year 2011. Furthermore, The American 
Legion urges the Congress to fully fund this U.S. Navy military 
construction project to ensure that those who serve our Nation--past, 
present, and future--are returned and accounted for as fully as 
possible.

                               CONCLUSION

    The United States continues to fight in OCO and defend our vital 
national interests. While America may be safer and has not suffered 
another tragic event on our soil since the tragic day of 9/11/01, the 
world is still not a safe place. The American Legion thanks the 
Subcommittee for inviting The American Legion to this hearing and looks 
forward to working with Congress and the administration on the many 
issues in National Defense facing our country.

    Chairman Inouye. And now the deputy director of the 
National Military Family Association, Ms. Kelly Hruska.

STATEMENT OF KELLY B. HRUSKA, GOVERNMENT RELATIONS, 
            DEPUTY DIRECTOR, NATIONAL MILITARY FAMILY 
            ASSOCIATION
    Ms. Hruska. Thank you, Mr. Chairman, for the opportunity to 
highlight the National Military Family Association's belief 
that 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, not merely 
added on as a part of supplemental funding. Programs must 
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 your help 
over the past years in addressing many of these important 
issues.
    The increased access to resources and programs by the Joint 
Family Support Assistance Program, now offered in all States 
and territories, allows families to receive added help when 
they need it, during all cycles of deployment. The Military 
Family Readiness Council held its first informal meeting in 
December. We feel this will be an effective tool in identifying 
programs that work, and in helping to eliminate overlapping or 
redundant programs, as the council reviews existing resources 
for military families. In an effort to make their efforts more 
credible, our association would like to see more funding set 
aside to be used for pilot programs that may come out of the 
council's recommendations, or allows DOD to replicate best 
practices, as necessary. This seed funding would streamline the 
bureaucracy and get the pilot programs out to families faster.
    Huge strides have been made in the building of brick-and-
mortar child development centers on military installations. 
Within the next year or two, thousands of spaces will become 
available for our military families. But, the need for more 
spaces will still exist. Innovative strategies are needed to 
address the non-availability of after-hours childcare and 
respite care. We applaud the partnership between the services 
and the National Association of Childcare Resources and 
Referral Agencies that provides subsidized childcare to 
families who cannot access installation-base child development 
centers. Including National Guard and Reserve families. 
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 piloted 24/7 programs. 
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 the Army 
Family Covenant, has rolled out more resources for respite care 
of families of deployed services. Respite care is needed across 
the board for 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 appreciate the recent increase to the special survivor 
indemnity allowance, for surviving spouses, but the elimination 
of the dependency and indemnity compensation offset to the 
survivor benefit plan annuity should still remain a high 
priority.
    Our association recognizes and appreciates the many 
resources and programs that support our military families 
during this time of war. The need will not go away the day the 
war ends. We believe it is imperative these programs be 
included in the regular budget process.
    In our written statement we have identified other ways to 
assist military families, and will be glad to expand on those 
suggestions, should you have any questions.
    Military families--one size does not fit all, but they are 
united in their sacrifices in support of their servicemembers 
and our Nation. We ask you to help the Nation sustain and 
support them.
    Thank you, sir.
    Chairman Inouye. I thank you very much, Ms. Hruska.
    And to all the witnesses, if you have supporting documents 
and memos, please feel free to submit them, because I can 
assure you we'll read them.
    [The statement follows:]

                 Prepared Statement of Kelly B. Hruska

    Chairman Inouye and Distinguished Members of this 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. You recognize the sacrifices made by 
today's service members and their families by focusing on the many 
elements of their quality of life package: access to quality health 
care, robust military pay and benefits, support for families dealing 
with deployment, and special care for the families of the wounded, ill 
and injured and those who have made the greatest sacrifice.
    In this statement, our Association will expand on several issues of 
importance to military families: Family Readiness; Family Health; 
Family Transitions.

                            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 service 
members 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 
of the past several years that recognized many of these important 
issues. The increased access to resources and programs provided by the 
Joint Family Support Assistance Program (JFSAP), now offered in all 
States and territories, allows families to receive added help when they 
need it during all cycles of deployment. The Military Family Readiness 
Council held its first informal meeting in December. We feel this will 
be an effective tool in identifying programs that work and in helping 
to eliminate overlapping or redundant programs as the Council reviews 
existing resources for military families. Our Association is proud to 
represent military families as a member of the Council.
    Our Association believes that it is imperative full funding for 
family readiness programs be included in the regular budget process and 
not merely added on as part of supplemental funding.
Child Care
    The Services--and families--continue to tell us more child care is 
needed to fill the ever growing demand, including hourly, drop-in, 
respite, and after-hour child care. We've heard stories like this:

    Child care facilities on base are beyond compare--for spouses and 
military members who work nine to five. In our increasingly service-
oriented economy, the job I have has me working until at least seven 
most days, and usually as late as midnight 1 to 2 days a week. When my 
husband deploys or has a stint on second shift, I run out of options 
quickly. I have been unable to get another, more conventional job in 
the 2 years I have been in this area . . . there are minimum 
requirements as to what shifts I need to work to maintain full-time 
employment at my current workplace, and I cannot have those waived for 
an entire deployment.

    Innovative strategies are needed to address the non-availability of 
after-hour 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 (NACCRRA) that 
provides subsidized childcare to families who cannot access 
installation based child development centers. 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 that 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.
    At our Operation Purple Healing Adventures camp for families of 
the wounded, ill and injured, we were told 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.
    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 for families of deployed service members 
and the wounded, ill and injured.
Working with Youth
    Older children and teens must not be overlooked. School personnel 
need to be educated on issues affecting military students and 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, Operation Purple provides a safe and fun environment in 
which military children feel immediately supported and understood. Last 
year, with the support of private donors, we achieved our goal of 
sending 10,000 military children to camp. We also were successful in 
expanding the camp experience to families of the wounded and bereaved. 
This year, we expect to maintain those numbers by offering 95 weeks of 
camp in 37 States and territories, as well as conducting several pilot 
family reintegration retreats in the National Parks.
    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 contracted with the RAND 
Corporation in 2007 to conduct a pilot study aimed at the current 
functioning and wellness of military children attending Operation 
Purple camps and assessing the potential benefits of the OPC program in 
this environment of multiple and extended deployments. The results of 
the pilot study were published last spring and confirmed much of what 
we have heard from individual families. They also highlighted gaps in 
our current knowledge, including how family relationships are affected 
by deployment and reintegration. The study looked at differences in 
child and caregiver experiences based on Service component, such as how 
life is different during deployment for families from the Active 
Component compared to those in the Guard or Reserve.
    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 
is following these families for 1 year, and interviewing the non-
deployed caregiver/parent and one child per family between 11 and 17 
years of age at three time points over that year. Recruitment of 
participants has been extremely successful because families are eager 
to share their experiences. RAND is currently gathering information 
from these families for the 6-month follow-up survey. Preliminary 
findings from the first round of surveys provide additional support for 
the pilot study results and identify new areas to investigate. This 
includes examining the relationship between the total months of 
deployment that a family experiences and its association with non-
deployed caregiver's mental health and child's well-being at school and 
at home. In addition, RAND is assessing the impact of reintegration on 
the families and how this varies by a service member's rank and Service 
component.
    This study will provide valuable data to inform the future creation 
and implementation of services for children and families. More 
specifically, we hope this study will provide more detailed and clearer 
understanding of the impact of multiple and extended deployments on 
military children and their families. We expect to present the final 
study results in Spring 2010.
National Guard and Reserve
    Our Association would like to thank Congress for authorizing many 
provisions that affect our Reserve Component families, who have 
sacrificed greatly in support of our Nation. We continue to ask 
Congress to fully fund these programs so vital to the quality of life 
of our National Guard and Reserve families.
    The National Military Family Association has long realized the 
unique challenges our Reserve Component families face and their need 
for additional support. This need was highlighted in the final report 
from the Commission on the National Guard and Reserves, which confirmed 
what we had always asserted: ``Reserve Component family members face 
special challenges because they are often at a considerable distance 
from military facilities and lack the on-base infrastructure and 
assistance available to active duty families.'' While citing a robust 
volunteer network as crucial, the report also stated that family 
readiness suffers when there are too few paid staff professionals 
supporting the volunteers.
    Our Association would also like to thank Congress for the 
provisions which allowed for the implementation of the Yellow Ribbon 
Reintegration program which is so crucial to the well-being of our 
Reserve Component families. We urge Congress to make the funding for 
this program permanent. We also believe that family members should be 
paid a travel allowance to attend these important reintegration 
programs. Furthermore, DOD and service providers need to move away from 
the one-size fits all approach to reintegration which does not work for 
all the Reserve Components due to the specific nature of each mission 
and the varying length of deployments.
    Our Association asks Congress to fully fund the Yellow Ribbon 
Reintegration program and other provisions affecting our Reserve 
Component families and to move away from the one-size fits all approach 
to reintegration.
Military Housing
    Privatized housing is a welcome change for military families and we 
are pleased the fiscal year 2009 NDAA called for an annual report that 
addresses the best practices for executing privatized housing 
contracts. With our depressed economy, increased oversight is critical 
to ensure timely completion of these important projects. Project delays 
negatively impact the quality of life of our families.
    Commanders must be held accountable for the quality of housing and 
customer service in privatized communities. Housing areas remain the 
responsibility of the installation Commander even when managed by a 
private company. Services members who are wounded and must move to a 
handicap accessible home or break their lease provisions due to short-
notice PCS orders should not be penalized. Service members should not 
languish on wait lists while civilians occupy housing. While 
privatization contracts permit other non-military occupants for vacant 
units, Commanders must ensure that privatized housing is first and 
foremost meeting the needs of the active duty population of the 
installation. In some cases, this will require modification or 
renegotiation of contracts.
    Our Association feels there needs to be a review of BAH standards. 
While families who live on the installation are better off, families 
living off the installation are forced to absorb more out-of-pocket 
expenses in order to live in a home that will meet their needs. BAH 
standards are based on an outdated concept of what would constitute a 
reasonable dwelling. For example, in order to receive BAH for a single 
family dwelling a service member must be an E9. However, if that same 
service member lived in military housing, he or she would likely have a 
single family home at the rank of E6 or E7. BAH standards should mirror 
the type of dwelling a service member would occupy if government 
quarters were available.
    Our Association believes that BAH standards should be reviewed and 
should better reflect the type of dwelling the service member would 
occupy if government quarters were available.
Commissaries and Exchanges
    The commissary is a key element of the total compensation package 
for service members and retirees and is valued by them, their families, 
and survivors. Not only do our surveys indicate that military families 
consider the commissary one of their most important benefits, during 
this economic downturn, many families are returning to the commissary 
to help them reduce their grocery budget. In addition to providing 
average savings of more than 30 percent over local supermarkets, 
commissaries provide an important tie to the military community. 
Commissary shoppers get more than groceries at the commissary. They 
gain an opportunity to connect with other military family members and 
to get information on installation programs and activities through 
bulletin boards and installation publications. Finally, commissary 
shoppers receive nutrition information and education through commissary 
promotions and educational campaigns contributing to the overall health 
of the entire beneficiary population.
    Our Association appreciates the provision included in the fiscal 
year 2009 NDAA allowing the use of proceeds from surcharges collected 
at remote case lot sales for Reserve Component members to help defray 
the cost of those case lot sales. This inclusion helps family members, 
not located near an installation partake in the valuable commissary 
benefit.
    Our Association is concerned there will not be enough commissaries 
to serve areas experiencing substantial growth, including those 
locations with service members 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.
    The military exchange system serves as a community hub, in addition 
to providing valuable cost savings to members of the military 
community. Equally important is the fact that exchange system profits 
are reinvested in important Morale, Welfare and Recreation (MWR) 
programs, resulting in quality of life improvements for the entire 
community. We believe 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. Exchanges must also 
continue to be responsive to the needs of deployed service members in 
combat zones and have the right mix of goods at the right prices for 
the full range of beneficiaries.
Family Care Plans
    We have heard from single parent and dual military families about 
the expenses incurred when they have to relocate their children to 
another location when they are activated for deployment. This issue was 
raised within the Army Family Action Plan process. Service members 
requiring activation of Family Care Plans are not compensated for the 
travel of dependents and shipment of the dependent's household goods. 
Some items such as infant equipment, computers and toys are necessary 
for the emotional and physical well-being of the children in their new 
environment during an already stressful time. Implementation of the 
Family Care Plan should not create additional financial hardship and 
emotional stress on the service member and family.
    We recommend that changes be made to the DOD Joint Travel 
Regulations to provide for travel and shipment of household goods to 
fulfill the needs of a deploying service member's Family Care Plan.

                             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 (MTF) 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 an interview with syndicated Military Update columnist Tom 
Philpott in December of 2008, MG (Dr.) Elder Granger, deputy director 
of TRICARE, gave the Military Health System (MHS) an overall grade of 
``C-plus or B-minus''. His 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. In 
previous testimony before this subcommittee we have noted the failure 
of MTFs to meet TRICARE Prime access standards and to be held 
accountable in the same way as the TRICARE contractors are for meeting 
those standards in the purchased care arena.
    In discussions with families the main issues are: access to their 
Primary Care Managers (PCM); getting appointments; 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. Families familiar with how the MHS referral system 
works seem better able to navigate the system. Those families who are 
unfamiliar experienced delays in receiving treatment or decide to give 
up on the referral process and never obtain a specialty appointment.
    Case management for military beneficiaries with special needs is 
not consistent across the MHS, whether within the MTFs or in the 
purchased care arena. Thus, military families end up managing their own 
care. The shortage of available health care providers only adds to the 
dilemma. 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. Meanwhile, 
the coordination of the military family's care is being done by a non-
synergistic health care system. Incongruence in the case management 
process becomes more apparent when military family members transfer 
from one TRICARE region to another and is further exasperated when a 
special needs family member is involved. Each TRICARE Managed Care 
Contractor has created different case management processes. There needs 
to be a seamless transition and a warm handoff between TRICARE regions 
for these families and the establishment of a universal case management 
process across the MHS.
    Our wounded, ill, and injured service members, veterans, and their 
families are assigned case managers. In fact, there are many different 
case managers: Federal Recovery Coordinators (FRC), Recovery Care 
Coordinators, each branch of Service, TBI care coordinators, VA 
liaisons, etc. The goal is for a seamless transition of care between 
and within the two governmental agencies: DOD and the VA. However, with 
so many to choose from, families often wonder which one is the 
``right'' case manager. We often hear from families, some who have long 
since been medically retired with a 100 percent disability rating or 
others with less than 1 year out 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 these families alone trying to navigate a 
variety of complex health care systems trying to find the right 
combination of care. Many qualify for and use Medicare, VA, DOD's 
TRICARE direct and purchased care, private health insurance, and State 
agencies. Does this population really need all of these different 
systems of receiving health care? Why can't the process be streamlined?
            TRICARE
    While Congress temporarily forestalled increases over the past 2 
years, we believe DOD officials will continue to support large 
increased retiree enrollment fees for TRICARE Prime combined with a 
tiered system of enrollment fees, the institution of a TRICARE standard 
enrollment fee and increased TRICARE Standard deductibles. Two reports, 
the Task Force on the Future of the Military Health Care and The Tenth 
Quadrennial Review of Military Compensation Volume II, recently 
recommended the same.
    We acknowledge the annual Prime enrollment fee has not increased in 
more than 10 years and that it may be reasonable to have a mechanism to 
increase fees. With this in mind, we have presented an alternative to 
DOD's proposal should Congress deem some cost increase necessary. The 
most important feature of our proposal is that any fee increase be no 
greater than the percentage increase in the retiree cost of living 
adjustment (COLA). If DOD thought $230/$460 was a fair fee for all in 
1995, then it would appear that raising the fees simply by the 
percentage increase in retiree pay is also fair. We also suggest it 
would be reasonable to adjust the TRICARE Standard deductibles by tying 
increases to the percentage of the retiree annual COLA. We stand ready 
to provide more information on this issue if needed.
            Support for Special Needs Families
    We applaud Congress and DOD's desire to create a robust health care 
and educational service 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.
    There was discussion last year by Congress and military families 
regarding the ECHO program. The fiscal year 2009 NDAA included a 
provision to increase the cap on certain benefits under the ECHO 
program to $36,000 per year for training, rehabilitation, special 
education, assistive technology devices, institutional care and under 
certain circumstances, transportation to and from institutions or 
facilities, because certain beneficiaries bump up against it. 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 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.
            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 may prove to be more 
cost-effective for the government than subsidizing 72 percent of the 
costs of TRICARE Reserve Select for National Guard or Reserve members 
not on active duty.
            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 access to mental health services.
    National provider shortages in the psychological 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 psychological 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.
    We have heard the main reason for the VA not providing health care 
and psychological health care services is because they cannot be 
reimbursed for care rendered to a family member. However, the VA is a 
qualified TRICARE provider. This allows the VA to bill for services 
rendered in their facilities to a TRICARE beneficiary. There may be a 
way to bill other health insurance companies as well. The VA needs to 
look at the possibility for other methods of payments.
            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 service members, retirees, their 
families, and survivors.
    We appreciate the inclusion of Federal pricing for the TRICARE 
retail pharmacies in the fiscal year 2008 NDAA. However, we 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 the 
overall negotiation of future drug prices by Medicare and civilian 
private insurance programs.
    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 OTC drugs be a covered pharmacy benefit and 
there be a zero co-pay for TMOP Tier 1 medications.
            National Health Care Proposal
    Our Association is cautious about current rhetoric by the 
Administration and Congress regarding the establishment of a National 
health care insurance program. As the 111th Congress takes up a 
National health care insurance proposal, we request consideration of 
how this legislation will also impact TRICARE, military families' 
access to health care, and especially recruitment and retention of our 
service members at a time of war.
            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 Advisory 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.
    Our Association does not support the recommendation of the Task 
Force on the Future of Military Health Care to carve out one regional 
TRICARE contractor to provide both the pharmacy and health care 
benefit. We agree a link between pharmacy and disease management is 
necessary, but feel this pilot would only further erode DOD's ability 
to maximize potential savings through TMOP. We were also disappointed 
to find no mention of disease management or a requirement for 
coordination between the pharmacy contractor and Managed Care Support 
Contractors in the Request for Proposals for the new TRICARE pharmacy 
contract. The ability certainly exists for them to share information 
bi-directionally and should be established.
    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.
    Our Association suggests this Subcommittee DOD reassess the 
resource sharing program used prior to the implementation of the T-Nex 
contracts and take the steps necessary to ensure Military Treatment 
Facilities (MTF) meet access standards with high quality health care 
providers.
    We also suggest this Subcommittee direct the Department to make 
case management services more consistent across the direct and 
purchased care segments of the MHS.
    Our Association recommends a 1-year transitional active duty ECHO 
benefit for the family members of service members who retire.
    We believe tying increases in TRICARE enrollment fees to the 
percentage increase in the Retiree Cost of Living Adjustment (COLA) is 
a fair way to increase beneficiary cost shares should Congress deem an 
increase necessary.
    We oppose DOD's proposal to institute a TRICARE Standard enrollment 
fee and believe Congress should reject this proposal because it changes 
beneficiaries' entitlement to health care under TRICARE Standard to 
just another insurance plan.
    Our Association strongly believes an enrollment fee for TFL is not 
appropriate.
    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 service members and their families 
cope with the aftermaths 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 to stress reduction 
techniques, to individual or family counseling, to 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 service members and families 
experience numerous lengthy and dangerous deployments, we believe the 
need for confidential, preventative psychological health services will 
continue to rise. It will also remain high for some time even after 
military operations scale down.
            Access to Behavioral Health Care
    Our Association is concerned about the overall shortage of 
psychological 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 service members and 
their families. While families are pleased more psychological health 
providers are available in theater to assist their service members, 
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 compassion fatigue, creating burnout and 
exacerbating the provider shortage problem.
    We have seen an increase in the number of psychological 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 psychological health provider list on the 
contractor's websites that the provider is full and no longer taking 
patients. The list must be up-to-date in order to handle real time 
demands by families. We need to continue to recruit more psychological 
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 service members. Family members are a key component to a 
service member's psychological well-being. We recommend an extended 
outreach program to service members, veterans, and their families of 
available psychological health resources, such as DOD, VA, and State 
agencies. Families want to be able to access care with a psychological 
health provider who understands or is sympathetic to the issues they 
face.
    Frequent and lengthy deployments create a sharp need in 
psychological health services by family members and service members 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 psychological 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. 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.
            Availability of Treatment
    Do DOD, VA and State agencies have adequate psychological 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 service members. 
The team found the top non-combat 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. 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 service member's 
separation, the families find themselves ineligible for TRICARE, and 
are very rarely eligible for healthcare through the VA. Many will 
choose to locate in rural areas lacking available psychological health 
providers. We need to address the distance issues families face in 
finding psychological health resources and obtaining appropriate care. 
Isolated service members, 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; and
  --educating civilian network psychological health providers about our 
        military culture as the VA incorporates Project Hero.
            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 as well as service members 
who leave the military following the end of their enlistment. They 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 no 
mental health providers available. Policy makers 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.
            Wounded, Ill, and Injured Families
    When designing support for the wounded, ill, and injured in today's 
conflict, our Association believes the government, especially DOD, VA, 
and State agencies, must take a more inclusive view of military and 
veterans' families. Those who have the responsibility to care for the 
wounded service member must also consider the needs of the spouse, 
children, parents of single service members, siblings, and other 
caregivers. Family members are an integral part of the health care team 
and recovery process.
    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 service members 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 service members and the veterans 
on a regular basis. And, 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 services members 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 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 restrict 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. 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, or injured service 
member 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 
service members); and sponsor a longitudinal study, similar to DOD's 
Millennium Cohort Study, in order to get a better understanding of the 
long-term effects of war on our military families.
            Children
    Our Association is concerned about the impact deployment and/or the 
injury of the service member is having on our most vulnerable 
population, children of our military and veterans. Multiple 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 service members. 
Their families find stress can be overwhelming, but are afraid to reach 
out for assistance for fear of retribution to the service member's 
career. They often choose not to seek care for themselves or their 
families.
    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 Military Treatment Facility (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 encourage partnerships between government agencies, DOD, VA and 
State agencies and recommend they reach out to those private and non-
governmental 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.
            Caregivers
    In the 7th year of the Global War on Terror, care for the 
caregivers must become a priority. 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 service members 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 
service member'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 service members and veterans must be educated about 
the effects of mTBI and PTSD in order to help accurately diagnose and 
treat the service member/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.
            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.
    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 is piloting two family 
retreats in the National Parks to promote family reintegration 
following deployment.
    We recommend an extended outreach program to service members, 
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 service members); and sponsor a 
longitudinal study, similar to DOD's Millennium Cohort Study, in order 
to get a better understanding of the long-term effects of war on our 
military families.
    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 Service Members Have Wounded Families
    Our Association asserts that behind every wounded service member 
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 service member must also consider the 
needs of the spouse, children, parents of single service members and 
their siblings, and the caregivers. We appreciate the inclusion in the 
fiscal year 2008 NDAA Wounded Warrior provision for health care 
services to be provided by the DOD and VA for family members. 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 service member is still on active duty status.
    Reintegration programs become a key ingredient in the family's 
success. In the spring of 2008, our Association held a focus group 
composed of wounded service members and their families to learn more 
about issues affecting them. Families find themselves having to 
redefine their roles following the injury of the service member. 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 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. We piloted a 
Operation Purple Healing Adventures camp to help wounded service 
members and their families learn to play again as a family and plan one 
more in the summer of 2009.
    Brooke Army Medical Center (BAMC) has recognized a need to support 
these families by expanding in terms of guesthouses co-located 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 BAMC's which has found a way to embrace the family unit 
during this difficult time.
            Transitioning for the Wounded and Their Families
    Transitions can be especially problematic for wounded, ill, and 
injured service members, 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 
service member has been wounded and ending with the DOD, VA, and State 
agencies working together, creating a seamless transition, as the 
wounded service member 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 
service members 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. Service members 
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 certain programs offered to active 
duty, such as ECHO for 3 years. Following that period, they would pay 
TRICARE premiums at the rate for retirees. Service members 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
    Caregivers need to be recognized for the important role they play 
in the care of their loved one. The VA has made a strong effort in 
supporting veterans' caregivers. The DOD should follow suit and expand 
their definition. Caregivers of the severely wounded, ill, and injured 
services members have a long road ahead of them. In order to perform 
their job well, they must be given the skills to be successful. This 
will require the caregiver to be trained through a standardized, 
certified program, and appropriately compensated for the care they 
provide. The time to implement these programs is while the service 
member is still on active duty status.
    Our Association proposes that new types of financial compensation 
be established for caregivers of injured service members and veterans 
that could begin while the hospitalized service member is still on 
active duty and continue throughout the transition to care under the 
VA. This compensation should recognize the types of medical and non-
medical care services provided by the caregiver, travel to appointments 
and coordinating with providers, and the severity of injury. It should 
also take into account the changing levels of service provided by the 
caregiver as the veteran's condition improves or diminishes or needs 
for medical treatment changes. These needs would have to be assessed 
quickly with little time delay in order to provide the correct amount 
of compensation. The caregiver should be paid directly for their 
services, but the compensation should be linked to training and 
certification paid for by the VA and transferable to employment in the 
civilian sector if the care is no longer needed by the service member. 
Our Association looks forward to discussing details of implementing 
such a plan with Members of this Subcommittee.
    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. Perhaps, caregivers of severely injured 
service members or veterans can be given the option of buying health 
insurance through the Federal Employees Health Benefit Program or 
through enrollment in CHAMPVA. A mechanism should also be established 
to assist caregivers who are forced out of the work force to save for 
their retirements, for example, through the Federal Thrift Savings 
Plan.
    There must be a provision for transition 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.
    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 themselves. Caregivers' responsibilities 
start while the service member is still on active duty.
            Relocation Allowance
    Active Duty service members and their spouses qualify through the 
DOD for military orders to move their household goods (known as a 
Permanent Change of Station (PCS)) when they leave the military 
service. Medically retired service members are given a final PCS move. 
Medically retired married service members are allowed to move their 
family; however, medically retired single service members only qualify 
for moving their own personal goods.
    The National Military Family Association is requesting the ability 
for medically retired single service members to be allowed the 
opportunity to have their caregiver's household goods moved as a part 
of the medical retired single service member's PCS move. This should be 
allowed for the qualified caregiver of the wounded service member 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 service member 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 service member 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 service member. Instead of trying to create 
the services in the area, a better solution may be to allow the 
medically retired service member, 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 service 
member's medical physician, the service member, and the caregiver. All 
aspects of care for the medically retired service member and their 
caregiver shall be considered. These include a holistic examination of 
the medically retired service member, 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 
service member and his/her 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.
    Provide transitioning wounded, ill and injured service members and 
their families a bridge of extended active duty TRICARE eligibility for 
3 years, comparable to the benefit for surviving spouses.
    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 service member.
    Service members medically discharged from service and their family 
members shall be allowed to continue for 1 year as active duty for 
TRICARE and then start the Continued Health Care Benefit Program 
(CHCBP) if needed.
            Senior Oversight Committee
    Our Association is appreciative of the provision in the fiscal year 
2009 NDAA continuing the DOD/VA Senior Oversight Committee (SOC) for an 
additional year. We understand a permanent structure is in the process 
of being established and manned. We urge Congress to put a mechanism in 
place to continue to monitor DOD and VA's partnership initiatives for 
our wounded, ill, and injured service members and their families, while 
this organization is being created.
    The National Military Family Association encourages the Armed 
Service Committee along with the Veterans' Affairs Committee to talk on 
these important issues. We can no longer be content on focusing on each 
agency separately because this population moves too frequently between 
the two agencies, especially our wounded, ill, and injured service 
members and their families.
    We would like to thank you again for the opportunity to provide 
information on the health care needs for the service members, veterans, 
and their families. Military families support the Nation's military 
missions. The least their country can do is make sure service members, 
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 service members 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.

                           FAMILY TRANSITIONS

    Our Association will promote policies and access to programs 
providing training and support for families during the many transitions 
they experience.

Survivors
    In the past year, the Services have been focusing on outreach to 
surviving families. In particular, the Army's SOS (Survivor Outreach 
Services) 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 ask that the active duty TRICARE Dental benefit be extended to 
surviving children to mirror the active duty TRICARE medical benefit to 
which they are now eligible. We also ask that eligibility be expanded 
to those Reserve Component family members who had not been enrolled in 
the active duty TRICARE Dental benefit prior to the service member's 
death.
    Our Association recommends that surviving children be allowed to 
remain in the TRICARE Dental Program until they age out of TRICARE 
eligibility and that eligibility be expanded to those Reserve Component 
survivors who had not been enrolled prior to the service member'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 service member'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 service member was 
alive and on active duty. The percentage of loss is even greater for 
survivors whose service members served longer. Those who give their 
lives for their country deserve more fair compensation for their 
surviving spouses.
    We appreciate the establishment of a special survivor indemnity 
allowance as a first step in the process to eliminate the DIC offset to 
SBP.
    We believe several other adjustments could be made to the Survivor 
Benefit Plan. 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 ask the DIC offset to SBP be eliminated to recognize the length 
of commitment and service of the career service member and spouse. We 
also request that SBP benefits be allowed to be paid to a Special Needs 
Trust in cases of disabled family members.

Spouse Employment, Unemployment
    Our Association appreciates the expansion of the Military Spouse 
Career Advancement Accounts. We look forward to the rollout and full 
implementation of the expanded program and hope that the definition of 
``portable careers'' is broad enough to support the diverse military 
spouse population. 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 service 
members, and to provide tax credits to military spouses to offset the 
expense in obtaining career licenses and certifications when service 
members are relocated to a new duty station within a different State.

Families on the Move
    Our Association is concerned about the timely implementation of the 
Defense Personal Property Program, formerly titled ``Families First.'' 
Worldwide rollout is still incomplete and it is unclear if customer 
satisfaction surveys are incorporated into the carrier ranking process. 
Full Replacement Value has been rolled out, but is handled differently 
by each carrier. Families are confused about how and where to file 
claims. Congressional oversight is needed to press for implementation 
of this program and deliver the best possible service to our families.
    Our Association is grateful for the addition of the weight 
allowance for spousal professional materials. We ask that Congress 
broaden the language to require the Service Secretaries to implement 
this much needed benefit.
    A PCS move to an overseas location can be especially stressful. 
Military families are faced with the prospect of being thousands of 
miles from extended family and living in a foreign culture. At many 
overseas locations, there are insufficient numbers of government 
quarters resulting in the requirement to live on the local economy away 
from the installation. Family members in these situations can feel 
extremely isolated; for some the only connection to anything familiar 
is the local military installation. Unfortunately, current law permits 
the shipment of only one vehicle to an overseas location, including 
Alaska and Hawaii. Since most families today have two vehicles, they 
sell one of the vehicles.
    Upon arriving at the new duty station, the service member requires 
transportation to and from the place of duty leaving the military 
spouse and family members at home without transportation. This lack of 
transportation limits the ability of spouses to secure employment and 
the ability of children to participate in extra curricular activities. 
While the purchase of a second vehicle alleviates these issues, it also 
results in significant expense while the family is already absorbing 
other costs associated with a move. Simply permitting the shipment of a 
second vehicle at government expense could alleviate this expense and 
acknowledge the needs of today's military family.
    Our Association requests that Congress ease the burden of military 
PCS moves on military families by pressing for the full implementation 
of the Defense Personal Property Program and by authorizing the 
shipment of a second vehicle for families assigned to an overseas 
location on accompanied tours.

Education of Military Children
    While our Association remains appreciative for the additional 
funding you provide to civilian school districts educating large 
numbers of military children, DOD Impact Aid still remains under-
funded. We urge Congress to increase funding for schools educating 
large numbers of military children to $60 million for fiscal year 2010. 
We also encourage you to make the additional funding for school 
districts experiencing growth available to all school districts 
experiencing significant enrollment increases and not just to those 
districts meeting the current 20 percent enrollment threshold. The 
arrival of several hundred military students can be financially 
devastating to any school district, regardless of how many of those 
students the district already serves. This supplement to Impact Aid is 
vital to school districts that have shouldered the burden of ensuring 
military children receive a quality education despite the stresses of 
military life.
    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. With over 70,000 military 
families returning to the United States, at the same time the Army is 
moving over one third of its soldiers within the United States, we urge 
Congress to authorize an increase in this level of funding until BRAC 
and Global Rebasing moves are completed.
    Although it does not fall under the purview of this Subcommittee, 
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 service members and their families. Under this provision, 
colleges and universities receiving Federal funding under the act will 
be required to offer in-State tuition rates for active duty service 
members and their families and provide continuity of in-State rates if 
the service member receives orders for an assignment 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.
    Our Association congratulates the DOD Office of Personnel and 
Readiness and the Council of State Governments (CSG) for drafting the 
Interstate Compact on Educational Opportunity for Military Children and 
for spearheading the adoption of this important legislation. Designed 
to alleviate many of the transition issues facing military children, 
the Compact has now been adopted in 20 States. In addition, Hawaii has 
a Compact bill awaiting their Governor's signature, and 11 other States 
are working active legislation this year. With 10 States needed to 
enact the Compact, the first meeting of the Interstate Commission on 
Educational Opportunity for Military Children met in October 2008. Our 
Association is pleased to have been a member of both the Advisory Group 
and Drafting Team, and has been working actively to support the 
adoption of this Compact, which will greatly enhance the quality of 
life of our military children and families.
    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 to 
allow all school districts experiencing a significant growth in their 
military student population due to BRAC, Global Rebasing, or 
installation housing changes to be eligible for the additional funding 
currently available only to districts with an enrollment of at least 20 
percent military children.

Spouse Education
    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. In 2007, we 
published Education and the Military Spouse: The Long Road to Success, 
based on spouse scholarship applicant survey responses, identifying 
education issues and barriers specific to military spouses. The entire 
report may be found at www.nmfa.org/education.
    The survey found military spouses, like their service members and 
the military as a whole, value education and set education goals for 
themselves. Yet, military spouses often feel their options are limited. 
Deployments, the shortage of affordable and quality child care, 
frequent moves, the lack of educational benefits and tuition assistance 
for tuition are discouraging. For military spouses, the total cost of 
obtaining a degree can be significantly higher than the cost for 
civilian students. The unique circumstances that accompany the military 
lifestyle have significant negative impacts upon a spouse's ability to 
remain continuously enrolled in an educational program. Military 
spouses often take longer than the expected time to complete their 
degrees. More than one-third of those surveyed have been working toward 
their goal for 5 years or more. The report offers recommendations for 
solutions that Congress could provide:
  --Ensuring installation education centers have the funding necessary 
        to support spouse education programs and initiatives;
  --Providing additional child care funding to support child care needs 
        of military spouse-scholars;
  --Helping to defray additional costs incurred by military spouses who 
        ultimately spend more than civilian counterparts to obtain a 
        degree.
    Our Association wishes to thank Congress for passing the Post 9/11 
G.I. Bill for service members and for including transferability of the 
benefit to spouses and children. We will continue to monitor the 
implementation of this benefit, and hope to see the regulations posted 
soon.

Military Families--Our Nation's Families
    We thank you for your support of our service members 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 service members 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 population. Working together, we can improve the quality 
of life for all these families.

    Chairman Inouye. Our next witness represents the Fleet 
Reserve Association: Mr. John Davis, director of legislative 
programs.
    Mr. Davis.

STATEMENT OF JOHN R. DAVIS, DIRECTOR, LEGISLATIVE 
            PROGRAMS, FLEET RESERVE ASSOCIATION
    Mr. Davis. Good morning, Chairman Inouye. My name is John 
Davis, and I want to thank you for the opportunity to express 
FRA's views today.
    The association also wants to thank the Obama 
administration for adequately funding healthcare without a 
proposed TRICARE fee increase.
    FRA believes that raising TRICARE fees during the war on 
terror would send the wrong message, and that could impact 
recruitment and retention. A recent FRA survey indicates that 
more than 90 percent of all active duty, retired, and veteran 
respondents cited healthcare as their top quality-of-life 
benefit. That is why FRA supports the Military Retirees Health 
Care Protection Act, H.R. 816, that would prohibit increasing 
TRICARE fees unless approved by Congress.
    FRA welcomes the 10-percent increase in funding to provide 
case managers and mental health counselors to heal and 
rehabilitate our wounded warriors. Adequate funding is 
necessary for a seamless transition and quality services for 
wounded warriors, especially those with traumatic brain injury 
(TBI) and post traumatic stress disorder (PTSD).
    FRA is also grateful for the administration calling for 
improvements to concurrent receipt. And it's also mentioned in 
the budget resolution.
    The offset for chapter 61 retirees would be phased out over 
5 years. FRA supports legislation authorizing the immediate 
payment of concurrent receipt of full military retired pay and 
veterans disability compensation for all disabled retirees. And 
this improvement is a big step toward achieving that goal. And 
if authorized, we urge the subcommittee to provide funding.
    FRA strongly supports the funding of the 3.4 percent pay 
increase for active duty pay, which is one-half of 1 percent 
above the administration's request. Pay increases, in recent 
years, have contributed to improved morale, readiness, and 
retention. Better pay reduces family stress, especially for 
junior enlisted. Military pay and benefits must reflect the 
fact that military service is very different from work in the 
private sector. FRA strongly supports the fully funded family 
readiness program and stands foursquare in support of our 
Nation's reservists. Due to the demands of the war on terror, 
Reserve units are now increasingly being mobilized to augment 
active duty components. As a result of these operational 
demands, the Reserve component is no longer a strategic 
reserve, but is now an operational reserve. And that is an 
integral part of the total force. That is why, if authorized, 
FRA supports funding for retroactive eligibility for early 
retirement benefit, to include reservists who have supported 
contingency operations since September 11, 2001.
    The 2008 Defense Authorization Act reduced the Reserve 
retirement age by 3 months for every 90 days of active duty, 
but this only applies to the service after the effective date 
of the legislation, which is January 28, 2008, and leaves out 
more than 600,000 reservists mobilized since 9/11.
    Thank you again for giving me this opportunity to speak.
    Chairman Inouye. Thank you very much, Mr. Davis.
    [The statement follows:]

                  Prepared Statement of John R. Davis

                                OVERVIEW

    Mr. Chairman, ensuring that wounded troops, their families and the 
survivors of those killed in action are cared for by a grateful Nation 
remains an overriding priority for the Fleet Reserve Association (FRA). 
The Association thanks you and the entire Subcommittee for your strong 
and continuing support of funding for the Department of Defense (DOD) 
portion of the Wounded Warrior Assistance Program. Another top FRA 
priority is full funding of the Defense Health Program (DHP) to ensure 
quality care for active duty, retirees, Reservists, and their families.

                      THE FISCAL YEAR 2010 BUDGET

    The DOD request totals $663.8 billion for fiscal year 2010, which 
is a base budget increase of $20.5 billion representing a 4-percent 
increase over fiscal year 2009 (2.1 percent in real growth). It is 
noteworthy that for the first time in 4 years, the proposed budget 
fully funds military health care programs without calling for a TRICARE 
fee increase. FRA appreciates the reluctance of the new administration 
to shift health care costs to beneficiaries, and the inclusion of 
additional money to make improvements in current receipt to expand the 
number of disabled military retirees receiving both their full military 
retired pay and VA disability compensation. The budget also calls for a 
2.9-percent active duty pay increase that equals the Employment Cost 
Index (ECI), $1.1 billion to fund military housing and support programs 
for service members and their families, and $3.3 billion to support 
injured service members in their recovery, rehabilitation, and 
reintegration.
    As Operation Iraqi Freedom ends and troops depart from Iraq, some 
will be urging reductions in spending, despite the need to bolster 
efforts in Afghanistan and other operational commitments around the 
world. FRA understands the budgetary concerns generated by the current 
economic slowdown but advocates that cutting the DOD budget during the 
Global War on Terror would be short sighted and that America needs a 
Defense budget that will provide adequate spending levels for both 
``benefits and bullets.''
    This statement lists the concerns of our members, keeping in mind 
that the Association's primary goal is to endorse any positive safety 
programs, rewards, quality of life improvements that support members of 
the Uniform Services, particularly those serving in hostile areas, and 
their families, and survivors.

                            WOUNDED WARRIORS

    A two-front war, a lengthy occupation and repeated deployments for 
many service members has put a strain on the DOD/VA medical system that 
treats our wounded warriors. The system is impacted not only by volume 
but by the complexity of injuries and the military has shown that it is 
woefully inadequate in recognizing and treating cases of Traumatic 
Brain Injury (TBI) and Post Traumatic Stress Disorder (PTSD).
    In recent years substantial progress has been made in the treatment 
of the Nation's wounded warriors. The fiscal year 2010 budget provides 
$3.3 billion to support injured service members in their recovery and 
rehabilitation and FRA appreciates the $300 million increase over 
fiscal year 2009 for mental health programs which includes additional 
case managers, and mental health counselors. The budget also provides 
for an expedited Disability Evaluation System (DES), and construction 
of 12 additional wounded warrior transition complexes. The budget also 
continues implementation of the Walter Reed National Military Medical 
Center, Bethesda, Maryland, DeWitt Army Community Hospital, Fort 
Belvoir, Virginia, and BRAC projects within the national capitol 
region. More than $400 million is targeted for medical research for 
Traumatic Brain Injury (TBI) and other casualty treatment issues. FRA 
advocates for resources to support an effective delivery system between 
DOD and VA to ensure seamless transition and quality services for 
wounded personnel, particularly those suffering from PTSD and TBI.
    Adequate funding is essential to providing pre- and post-deployment 
screenings for mental and physical injuries, and if authorized 
compensation, training, and health care coverage for family members 
forced into service as full-time caregivers for the severely wounded 
warriors. Further, the War on Terror has seen an increasing percentage 
of women serving in the military (15 percent in 2009 as compared to 4.4 
percent in 1988) and combined with the asymmetrical nature of the 
conflict will undoubtedly cause an increasing number of women 
casualties that will place unique demands upon the military health care 
system requiring additional associated funding.

                              HEALTH CARE

    Adequately funding health care benefits for all beneficiaries is 
part of the cost of defending our Nation and a recent FRA survey 
indicates that more than 90 percent of all active duty, retired, and 
veteran respondents and most Reserve participants cited health care as 
their top quality-of-life benefit. Accordingly, protecting and/or 
enhancing health care access for all beneficiaries is FRA's top 2009 
legislative priority.
    Health care costs both in the military and throughout society have 
continued to increase faster than the Consumer Price Index (CPI) making 
this a prime target for those wanting to cut the DOD budget. Many 
beneficiaries targeted in recent proposals to drastically increase 
health care fees are those who served prior to enactment of the recent 
and significant pay and benefit enhancements and receive significantly 
less in retired pay than those serving and retiring in the same pay 
grade with the same years of service today. They clearly recall 
promises made to them about the benefit of health care for life in 
return for a career, and many believe they are entitled to ``free'' 
health care for life based on the Government's past commitments.
    For these reasons, FRA strongly supports ``The Military Retirees' 
Health Care Protection Act'' (H.R. 816) sponsored by Representatives 
Chet Edwards (TX) and Walter Jones (NC). The legislation would prohibit 
DOD from increasing TRICARE fees, specifying that the authority to 
increase TRICARE fees exists only in Congress.
    DOD must continue to investigate and implement other TRICARE cost-
saving options as an alternative to shifting costs to retiree 
beneficiaries. FRA notes progress in this area in expanding use of the 
mail order pharmacy program, Federal pricing for prescription drugs and 
a pilot program of preventative care for TRICARE beneficiaries under 
age 65, and elimination of co-pays for certain preventative services. 
The Association believes these efforts will prove beneficial in slowing 
military health care spending in the coming years.
    Our Nation is at war and imposing higher health care costs on 
retirees would send a powerful negative message not only to retirees, 
but to those currently serving about the value of their service. The 
prospect of drastically higher health care fees for retirees is also a 
morale issue with the senior enlisted communities who view this as an 
erosion of their career benefits. Unlike private sector employees, 
military retirees have answered the call to serve, and most have done 
so under extremely difficult circumstances while separated from their 
families to defend the freedoms we enjoy today.

                           CONCURRENT RECEIPT

    FRA appreciates a boost in compensation for benefiting disabled 
retirees in the new Administration's budget. The fiscal year 2010 
budget includes funding for expansion of concurrent receipt of military 
retired pay and VA disability compensation to retirees who were 
medically retired from service (Chapter 61 Retirees). Under current law 
these benefits (CRDP) are offset by the amount of VA disability 
compensation. This offset would be phased-out over 5 years. FRA 
supports legislation authorizing the immediate payment of concurrent 
receipt of full military retired pay and veterans' disability 
compensation for all disabled retirees, and these improvements reflect 
a big step toward achieving this goal.

                       PROTECT PERSONNEL PROGRAMS

    Active Duty Pay.--FRA strongly supports the authorization and 
funding of a 3.4 percent fiscal year 2010 pay increase which is 
consistent with past support of annual active duty pay increases that 
are at least 0.5 percent above the Employment Cost Index (ECI). The 
Association also supports targeted increases, as appropriate for mid-
career and senior enlisted personnel to help close the remaining 2.9 
percent pay gap between active duty and private sector pay.
    Adequate and targeted pay increases authorized in recent years, 
particularly for middle grade and senior petty and noncommissioned 
officers, have contributed to improved morale, readiness, and 
retention. Better pay reduces family stress, especially for junior 
enlisted and may reduce the need for military personnel use of short-
term pay day loans unaware of the ruinous long-term impact of excessive 
interest rates. Military pay and benefits must reflect the fact that 
military service is very different from work in the private sector.
    End Strength.--Adequate active duty and Reserves end strengths are 
essential to success in Operations Enduring Freedom (OEF) and Iraqi 
Freedom, and other commitments around the world. The fiscal year 2010 
budget supports additional end strength for the Marine Corps (202,000) 
and halts Navy end strength reductions. The Association supports 
funding to support these proposals and also strongly supports funding 
for bonuses for service members with extended deployments.

                            FAMILY READINESS

    FRA supports a fully funded, robust family readiness program which 
is 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, and they often are being asked 
to do without in other important areas.
    The availability of child care is especially important when so much 
of the force is deployed and this program, along with other family 
readiness programs must be adequately funded in fiscal year 2010 and 
beyond.
    BRAC and Rebasing.--Adequate resources are required to fund 
essential quality of life programs and services at bases impacted by 
the Base Realignment and Closure (BRAC) and rebasing initiatives. FRA 
is concerned about sustaining commissary access, MWR programs and other 
support for service members and their families particularly at 
installations most impacted by these actions. These include Guam, where 
a significant number of Marines and their families are being relocated 
from Okinawa. The shortage of funds is curtailing or closing some of 
the activities while the costs of participating in others have recently 
increased.
    Family Housing.--The Association welcomes the $200 million more for 
family housing, child care, and other support services over the fiscal 
year 2009 budget. Adequate military housing that's well maintained is 
critical to retention and morale.
    Child and Youth Programs.--MCPON Rick West testified before the 
House Appropriations Subcommittee on Military Construction and Veterans 
Affairs in February 2009 that there is a need for more child care 
facilities since the Navy currently provides for only 72 percent of 
capacity while the goal is 80 percent. Access to child care is 
important and FRA urges Congress to authorize adequate funding for this 
important program.

                             RESERVE ISSUES

    FRA stands foursquare in support of the Nation's Reservists. Due to 
the demands of the War on Terror, Reserve units are now increasingly 
being mobilized to augment active duty components. As a result of these 
operational demands, Reserve component is no longer a strategic Reserve 
but is now an operational Reserve that is an integral part of the total 
force. And because of these increasing demands on Reservists to perform 
multiple missions abroad over longer periods of time, it's essential to 
improve compensation and benefits to retain currently serving personnel 
and attract quality recruits.
    Retirement.--If authorized, FRA supports funding retroactive 
eligibility for the early retirement benefit to include Reservists who 
have supported contingency operations since 9/11/2001 (S. 831/S. 644). 
The fiscal year 2008 Defense Authorization Act (H.R. 4986) reduces the 
Reserve retirement age (age 60) by 3 months for each cumulative 90-days 
ordered to active duty. The provision however only applies to service 
after the effective date of the legislation, and leaves out more than 
600,000 Reservists mobilized since 9/11 for Afghanistan and Iraq and to 
respond to natural disasters like Hurricane Katrina. About 142,000 of 
them have been deployed multiple times in the past 6 years.
    Family Support.--FRA supports resources to allow increased outreach 
to connect Reserve families with support programs. This includes 
increased funding for family readiness, especially for those 
geographically dispersed, not readily accessible to military 
installations, and inexperienced with the military. Unlike active duty 
families who often live near military facilities and support services, 
most Reserve families live in civilian communities where information 
and support is not readily available. Congressional hearing witnesses 
have indicated that many of the half million mobilized Guard and 
Reserve personnel have not received transition assistance services they 
and their families need to make a successful transition back to 
civilian life.

                               CONCLUSION

    FRA is grateful for the opportunity to present the organization's 
views to this distinguished Subcommittee. The Association reiterates 
its profound gratitude for the extraordinary progress this 
Subcommittee, with outstanding staff support, has made in advancing a 
wide range of enhanced benefits and quality-of-life programs for all 
uniformed services personnel, retirees, their families and survivors. 
Thank you.

    Chairman Inouye. I'd like to point out that, at this 
moment, several subcommittees are having their meetings or 
conferences. As a result, you can see that they're busy 
elsewhere. The vice chairman of this subcommittee had to go to 
the Energy Committee subcommittee, because he is the senior 
member there.
    So, if I may, I'd like to call upon him for any remarks he 
may have.

                   STATEMENT OF SENATOR THAD COCHRAN

    Senator Cochran. Mr. Chairman, thank you very much.
    I'm pleased to be able to come by and join you in thanking 
these witnesses for preparing testimony, and giving us the 
benefit of your observations and experience and interest as we 
review the budget for this next fiscal year for the Department 
of Defense and related agencies.
    Because of your experiences and your knowledge, we take 
what you say very seriously, and we will carefully review your 
statements and make sure that the subcommittee considers them 
as we proceed through our appropriations process for this next 
fiscal year.
    Thank you.
    Chairman Inouye. Thank you very much.
    And next, the Chief Executive Officer of the Air Force 
Sergeants Association, Command Master Sergeant John McCauslin, 
of the Air Force.

STATEMENT OF COMMAND MASTER SERGEANT JOHN R. McCAUSLIN, 
            UNITED STATES AIR FORCE (RET.), CHIEF 
            EXECUTIVE OFFICER, AIR FORCE SERGEANTS 
            ASSOCIATION
    Sergeant McCauslin. Good morning, Chairman Inouye, Senator 
Cochran.
    On behalf of the 125,000 members of the Air Force Sergeants 
Association, I thank you for your continued support of our 
airmen and their families. I appreciate this opportunity to 
present our perspective of six important areas of priority for 
the fiscal year 2010 defense appropriations.
    First, Air Force manpower and equipment. AFSA strongly 
believes the aging fleet of legacy Air Force systems, 
facilities, and equipment needs to be modernized. However, we 
also know the truly most valuable weapon that America has are 
those serving this Nation, especially the men and women wearing 
chevrons.
    Operational demands, including deployments, have greatly 
increased to include intelligence activity, reconnaissance, and 
surveillance resources, the newest combatant command in Africa, 
the new Air Force Cyber Command, increased activity in 
Afghanistan and elsewhere overseas. Therefore, AFSA supports 
General Schwartz's request for more F-35 aircraft to do our job 
of preserving peace through deterrence.
    Quality of life. Our Nation's military should not be 
considered a financial burden, but considered a national 
treasure, as they preserve our national security for all that 
live here. If we expect to retain this precious resource, we 
simply must provide they and their families with decent and 
safe work centers, family housing and dormitories, healthcare, 
childcare, physical fitness centers, and recreational programs 
and facilities. Tremendous strides have been made to improve 
access to quality childcare and fitness centers on our military 
installations, and we're grateful to the Department of Defense 
and Congress for these collective efforts. However, there's 
still much work to be done. I have personally visited over 125 
Air Force installations in the States and overseas these past 3 
years, and I can assure you that the demand for adequate 
childcare and decent, affordable housing is a top priority 
among our airmen and their families' decision to stay or get 
out.
    Veterans Affairs healthcare funding. AFSA believes that the 
healthcare portion of Veterans Affairs (VA) funding should be 
moved to mandatory annual spending. One of the Nation's highest 
obligations is their willingness to fully fund VA healthcare 
facilities and other programs for those who have served in the 
past or are serving today and will serve in the future.
    On a positive note, we're particularly pleased by the 
tremendous support of Congress and this subcommittee to 
implement and fund wounded warrior programs across America.
    The Air Force Sergeants Association applauds the actions of 
this subcommittee, other committees and subcommittees, to 
directly address the issue of unique health challenges faced by 
our women veterans. AFSA urges an increase to the VA budget so 
that they can appropriately care for these female veterans, now 
and in the future.
    Regarding the educational benefits. The post-9/11 GI bill 
was a giant step forward, even though there are still some 
funding shortfalls being currently worked by Senator Webb's 
office, and we urge your subcommittee's support.
    And finally, my final point concerns basic military pay and 
the tremendous pay gap, for these last 15 years, that you've 
helped us close. However, we still have serious problems in the 
junior enlisted. For example, enrollment in food stamps rose 25 
percent in the military this last year alone. Our junior 
enlisted are all volunteers serving our Nation, yet thousands 
remain on food stamps.
    In conclusion, this was a very brief presentation of our 
perspective for you. Our detailed, typed testimony has been 
personally delivered to your subcommittee staff for inclusion 
today.
    Thank you very much.
    Chairman Inouye. I thank you very much, Command Master 
Sergeant.
    [The statement follows:]

            Prepared Statement of John R. ``Doc'' McCauslin

    Mr. Chairman and distinguished committee members, on behalf of the 
125,000 members of the Air Force Sergeants Association, (AFSA), I thank 
you for your continued support of Airmen and their families. I 
appreciate this opportunity to present our perspective on priorities 
for the fiscal year 2010 defense appropriations.
    The Air Force Sergeants Association (AFSA) represents Air Force 
Active Duty, Air National Guard, Air Force Reserve Command, including 
active, retired and veteran enlisted Airmen and their families. We are 
grateful for this subcommittee's efforts, and I cannot overstate the 
importance your work is to those serving this Nation.
    You certainly have a daunting task before you and shoulder the 
tremendous responsibility as you wisely appropriate limited resources 
based on many factors. The degree of difficulty deciding what is funded 
isn't lost on us. It is significant.

                           AIR FORCE MANPOWER

    AFSA strongly believes the aging fleet of legacy Air Force systems, 
facilities, and equipment needs to be modernized. However, we also know 
the truly most valuable weapon America has are those serving this great 
Nation, especially the men and women wearing chevrons of the enlisted 
grades.
    We are deeply concerned about the recent Air Force drawdown of 
manpower in order to facilitate funding of system modernization and 
recapitalization but we greatly appreciate Congressional support that 
has reinstated some of that lost resource. The impact on Air Force 
ability to maintain the highest level of readiness was felt throughout 
the smaller force and it placed even more stress on our maintainers and 
security forces.
    Although well-intended, that drawdown did not appear to have 
yielded the results envisioned. Some efficiency was gained as Airmen 
exercised innovation and continuous process improvement in order to 
accomplish more. The ole adage ``do more with less'' certainly and 
quickly became a reality.
    Operational demands including deployments have increased over this 
same time--increased intelligence activity, reconnaissance and 
surveillance (ISR) resources, supporting the newest combatant command 
in Africa, the new Air Force Cyber Command based in Louisiana, 
increased activity in Afghanistan, and elsewhere overseas. The Air 
Force has increased its capabilities to ward off threats from the cyber 
domain and accomplishing the expanding workload associated with more 
inspections and maintenance to keep aging airframes mission ready.
    With the appropriate recommendations from the Armed Service 
committees, we need to continue offering enlistment bonuses for those 
career fields that are physically demanding and highly skilled hard to 
fill jobs since 2001. With Congressional assistance, coupled with the 
hard work of our Air Force recruiters, we can continue to meet the 
required annual needs of new Combat Controllers, Para-rescue; Tactical 
Air Control Party; Explosive Ordinance Disposal; Security Forces; 
Linguist and Survival, Evasion, Resistance, and Escape Instructors. The 
amount offered at the initial enlistment ranges from $2,000 to $13,000, 
depending on the career specialty and terms of enlistment. These are 
currently the only fields offering enlistment bonuses for fiscal year 
2009. Congress authorized hazardous duty allowance for all DOD 
firefighters, still today the services have not funded this program. 
The Air Force has over 3,000 firefighters who have been authorized this 
allowance by Congress but not funded.
    AFSA believes a course correction is needed to avert severe 
adverse, long-term consequences that have already begun to affect 
morale, retention and combat readiness. We strongly support increasing 
and fully funding Air Force end strength to 332,800.

                            QUALITY OF LIFE

    Our Nation's military should not be considered a financial burden 
but considered a national treasure as they preserve our national 
security for all that live here. If we expect to retain this precious 
resource, we must provide they and their families, with decent and safe 
work centers, family housing and dormitories, health care, child care 
and physical fitness centers, and recreational programs and facilities. 
These areas are a prime recruitment and retention incentive for our 
Airmen and their families. This directly impacts their desire to 
continue serving through multiple deployments and extended separations 
from family and friends.
    This Nation devotes considerable resources to train and equip 
America's sons and daughters--a long term investment--and that same 
level of commitment should be reflected in the facilities and equipment 
they use and in where they live, work, and play.
    We urge extreme caution in deferring these costs, especially at 
installations impacted by base realignment and closure (BRAC) decisions 
and mission-related shifts.
    We applaud congressional support for military housing privatization 
initiatives. This has provided housing at a much faster pace than would 
have been possible through military construction alone.
    AFSA urges Congress to fully fund appropriate accounts to ensure 
our installations eliminate substandard housing and work centers as 
quickly as possible. Those devoted to serving this Nation deserve 
better.
    Tremendous strides have been made to improve access to quality 
child care and fitness centers on military installations, and we are 
grateful to the Department of Defense and Congress for these collective 
efforts. However, there is still much more work to be done. I have 
personally visited over 125 Air Force installations in the states and 
overseas these past three years and I can assure you that the demand 
for adequate child care is a top priority among our Airmen and their 
families. The importance of this is directly reflected in the military 
members' family decision to remain in the service or exit.

                  VETERANS AFFAIRS HEALTHCARE FUNDING

    AFSA believes that the healthcare portion of Veterans Affairs (VA) 
funding should be moved to mandatory annual spending. One of this 
Nation's highest obligations is the willingness to fully fund VA health 
care, facilities, and other programs for those who have served in the 
past, are serving today and will serve in the future.
    There are many challenges facing veterans and we are encouraged by 
the initiatives centered on improving access for all veterans 
regardless of their VA designated category. Much more emphasis has to 
be focused on continuity of care and addressing the scars of war, some 
obvious and others not so, such as traumatic brain injuries and post 
traumatic stress disorders. We are particularly pleased by the 
tremendous support of Congress and this Committee to implement and fund 
Wounded Warrior programs across America. The outpouring of support from 
civilian communities and volunteer support has been truly amazing and 
very much appreciated.

                    WOMEN VETERANS HEALTHCARE ISSUES

    The Air Force Sergeants Association applauds the actions of this 
committee, other committees and sub-committees to directly address the 
issue of the unique health challenges faced by women veterans. Between 
1990 and 2000, the women veteran population increased by over 33 
percent from 1.2 million to 1.6 million, and women now represent 
approximately 9 percent of the total veteran population. By next year, 
the VA estimates women veterans will comprise well over 10 percent of 
the veteran population. Currently women make up more than 20 percent of 
the active duty Air Force, Air National Guard 19 percent, and 
approximately 26 percent of the Air Force Reserves with thousands 
serving, or having already returned from serving, in Iraq, Afghanistan 
and other places a long way from our shores. AFSA urges an increase to 
the VA budget so they can appropriately care for these veterans now and 
in the future.

                               IMPACT AID

    Military leaders often use the phrase, ``we recruit the member, but 
we retain the family'' when talking about quality of life and 
retention. Impact Aid is a program at the very core of this premise, 
because it directly affects the quality of educational programs 
provided to the children of military service members. In the Department 
of Defense Dependent Schools, there are over 79,000 children of our 
active duty force scattered all over the globe.
    These children lead unique lives, fraught with challenges 
associated with frequent changes in schools, repeatedly being uprooted 
and having to readjust to new communities and friends. Many of these 
school children are in other countries in either the DODDS system or 
host nation schools that are not affected by Impact Aid funding. 
Worrying about what resources might or might not be available to school 
administrators should not be yet another concern heaped upon them and 
their parents.
    The Impact Aid program provides Federal funding to public school 
districts in the United States with enrollment of students that have a 
parent who is a member of the Armed Forces, living on and/or assigned 
to a military installation.
    The budget proposed by the administration is identical to the 
approved funding in 2009 in spite of increased financial obligations by 
the servicing local school districts. It has a completely detrimental 
effect on the military member and their decision to take that next 
assignment or opt to get out for the good of his or her family. The 
implicit statement in this action is military children are a lower 
priority than others in our Nation. We ask this committee to take the 
steps necessary to show our military men and women that the education 
of their children is as important at the next child.
    AFSA is grateful that Congress funded Impact Aid with 1.265.7 
million this past fiscal year. We strongly urge increased funding of 
this important family quality of life area that has a direct bearing on 
reenlistment rates and military families quality of life. We urge 
Congress restore this program to its rightful full funding.

                           BASIC MILITARY PAY

    Tremendous progress has been made over the last 15+ years to close 
the gap between civilian sector and military compensation. AFSA 
appreciates these steady efforts and we encourage further steps. We 
believe linking pay raises to the employment cost index (ECI) is 
essential to recruiting and retaining the very best and brightest 
volunteers. AFSA urges the formula for determining annual pay increases 
to be ECI + 0.5 percent until the gap is completed eliminated. If we 
want to continue having an all volunteer force then we must continue on 
the path to close the aforementioned pay gap. Enrollment in food stamps 
rose 25 percent in the military last year. Our junior enlisted are all 
volunteers serving our Nation, yet they remain on monthly use of food 
stamps.

                     TRANSITION ASSISTANCE PROGRAMS

    The all-volunteer military force repeatedly answers this Nation's 
call to duty and at the end of their tours of duty, whether a few years 
or after decades of service, all transition to civilian life.
    Section 502 of the National Defense Authorization Act of Fiscal 
Year 1991 codified in sections 1141-1143 and 1144-1150 of title 10, 
United States Code, authorized comprehensive assistance benefits and 
services for separating service members and their spouses.
    From that legislation, grew a valuable partnership between the 
Department of Labor and the Departments of Defense, Veterans Affairs 
and Homeland Security to provide Transition Assistance Program (TAP) 
employment workshops, VA Benefits Briefings and the Disabled Transition 
Assistance Program (DTAP). These programs and briefings provide service 
members valuable job placement assistance, training opportunities, and 
education on veteran benefits so they make informed choices about post-
service opportunities.
    We urge the committee to continue fully funding transition 
assistance programs at a level that serves our deserving volunteer 
veterans.
    In addition, we ask you to support the initiatives in this Congress 
to pass legislation and fund a program that would create hiring 
preferences across the Federal Government for military spouses. Under 
current law, veterans of America's Armed Forces are entitled to 
preferences over others in competitive hiring positions in Federal 
Government. We believe the sacrifice of family members warrant this 
consideration as well.

                      VETERANS EDUCATION BENEFITS

    There's no escaping the fact that college costs are rising. As the 
gap between the cost of an education and value of the MGIB widens, the 
significance of the benefit becomes less apparent. For that reason, the 
Post 9-11 GI Bill was a giant step forward. However, we must make sure 
that the new post 9-11 stays current at all times, so that this benefit 
will not lose its effectiveness when it comes to recruiting this 
Nation's finest young men and women into service. As a member of The 
Military Coalition and the Partnership for Veterans' Education, we 
strongly recommend you make the technical corrections to the Post 9-11 
Veterans GI Bill that need to be done prior to its implementation this 
August 1st.
    When young enlisted men and women opt for military service, they 
should know that this Nation will provide them with a no-cost, complete 
education, as do numerous companies in the private industry. We, as a 
Government, give them a one-time chance to enroll in the MGIB during 
basic training. The Department of Defense charges them $1,200 to enroll 
at a time when they can least afford it. Service-members are even 
offered an opportunity to increase their education benefit by paying an 
additional $600.
    Now that the new Post 9-11 GI bill is coming on board for free, 
those who already paid for but who have not yet utilized the Montgomery 
GI Bill, will now have to wait until their chapter 33 entitlements are 
exhausted before they will be allowed to receive a refund on their 
Montgomery GI bill contributions. Under current law, those who have 
contributed the additional $600, will not have that money returned to 
them at all.
    This is unacceptable.
    In good faith and trusting their Government-funded education will 
be provided in their best interest, service-members now find a program 
that does not require further investment in their education. However 
the Government will withhold the service-member's Montgomery GI Bill 
initial investment and not refund it. Our recommendation is that the 
service-members who chose to enroll in the chapter 33 benefit, and who 
bought the additional benefit for $600, should be given their 
investment back or granted an additional 2 years of chapter 30 benefits 
to roll their $600 education investment into the new education bill. 
The latest shortfall with the new bill is that all active duty will not 
receive the $1,000 book allowance. We urge the appropriate committees 
to make the necessary corrections to ensure those on active duty 
receive this allowance.
    Mr. Chairman, we appreciate your efforts and thank you for this 
opportunity to share our perspective. AFSA realizes the many difficult 
decisions this committee must make and hope the information presented 
today proves helpful. As always, the Air Force Sergeants Association 
remains ready to support you in matters of mutual concern.

    Chairman Inouye. And our next witness represents the 
American Psychological Association, Dr. Gavin O'Shea.

STATEMENT OF GAVIN O'SHEA, Ph.D., ON BEHALF OF THE 
            AMERICAN PSYCHOLOGICAL ASSOCIATION
    Dr. O'Shea. Good morning Mr. Chairman and members of the 
subcommittee. I'm Dr. Gavin O'Shea from HumRRO, the Human 
Resources Research Organization. I'm submitting testimony on 
behalf of the American Psychological Association, or APA, a 
scientific and professional organization of more than 148,000 
psychologists.
    For decades, clinical and research psychologists have used 
their unique and critical expertise to meet the needs of our 
military and its personnel, playing a vital role within the 
Department of Defense. My own military-oriented research and 
consulting focuses on organizational commitment, personnel 
selection, and leadership assessment.
    This morning, I focus on APA's request that Congress 
reverse disturbing administration cuts to DOD's science and 
technology budget and maintain support for important behavioral 
sciences research on counterterrorism and counterintelligence 
operations.
    In terms of the overall DOD S&T budget, the President's 
request for fiscal year 2010 represents a dramatic step 
backward for defense research. Defense S&T would fall from the 
current fiscal year 2009 level of $13.6 billion to $11.6 
billion, with cuts across the board. With very few exceptions, 
all basic and applied research accounts within military labs 
would face cuts, some as high as 50 percent.
    This is not the time to reduce support for research that is 
vital to our Nation's continued security in a global atmosphere 
of uncertainty and asymmetric threats. APA urges the 
subcommittee to reverse this cut to the critical defense 
science program by providing $14 billion for defense S&T in 
fiscal year 2010.
    Finally, APA is also concerned about the potential loss of 
invaluable human-centered research programs related to 
counterintelligence and counterterrorism due to the 
reorganization of the CIFA office into the Defense Intelligence 
Agency (DIA). APA urges the subcommittee to provide ongoing 
funding in fiscal year 2010 for DIA's behavioral research 
programs on cyberdefense, insider threat, credibility 
assessment, detection of deception, and other operational 
challenges.
    As noted in a recent National Research Council report, 
``People are the heart of all military efforts. People operate 
the available weaponry and technology, and they constitute a 
complex military system composed of teams and groups at 
multiple levels. Scientific research on human behavior is 
crucial to the military, because it provides knowledge about 
how people work together, and use weapons and technology to 
extend and amplify their forces.''
    The defense research programs need your help more than ever 
this year, and we look forward to your support.
    Thank you.
    Chairman Inouye. I thank you very much, Dr. O'Shea.
    [The statement follows:]

                   Prepared Statement of Gavan O'Shea

    The American Psychological Association (APA) is a scientific and 
professional organization of more than 148,000 psychologists and 
affiliates.
    For decades, psychologists have played vital roles within the 
Department of Defense (DOD), as providers of clinical services to 
military personnel and their families, and as scientific researchers 
investigating mission-targeted issues ranging from airplane cockpit 
design to human intelligence-gathering. More than ever before, 
psychologists today bring unique and critical expertise to meeting the 
needs of our military and its personnel. APA's testimony will focus on 
reversing Administration cuts to the overall DOD Science and Technology 
(S&T) budget and maintaining support for important behavioral sciences 
research within DOD.

                              DOD RESEARCH

    ``People are the heart of all military efforts. People operate the 
available weaponry and technology, and they constitute a complex 
military system composed of teams and groups at multiple levels. 
Scientific research on human behavior is crucial to the military 
because it provides knowledge about how people work together and use 
weapons and technology to extend and amplify their forces.''----Human 
Behavior in Military Contexts, Report of the National Research Council, 
2008.
    Just as a large number of psychologists provide high-quality 
clinical services to our military service members stateside and abroad, 
psychological scientists within DOD conduct cutting-edge, mission-
specific research critical to national defense.
    In terms of the overall DOD S&T budget, the President's request for 
fiscal year 2010 represents a dramatic step backward for defense 
research. Defense S&T would fall from the estimated fiscal year 2009 
level of $13.6 billion to $11.6 billion with cuts across the board. 
With the exception of a less-than-1-percent increase in Air Force basic 
(6.1) research and an increase in basic research in the Office of the 
Secretary of Defense, all military labs would see cuts to their 6.1, 
6.2 and 6.3 accounts, some as high as 50 percent.
    The President's budget request for basic and applied research at 
DOD in fiscal year 2010 is $11.6 billion, which represents a stunning 
decrease of almost $2 billion or 15 percent from the enacted fiscal 
year 2009 level of $13.6 billion. APA urges the Subcommittee to reverse 
this cut to the critical defense science program by providing a total 
of $14 billion for Defense S&T in fiscal year 2010. This is not the 
time to cut back on research vital to our Nation's continued security 
in a global atmosphere of uncertainty and asymmetric threats.
      behavioral research within the military service labs and dod
    Within DOD, the majority of behavioral, cognitive and social 
science is funded through the Army Research Institute (ARI) and Army 
Research Laboratory (ARL); the Office of Naval Research (ONR); and the 
Air Force Research Laboratory (AFRL), with additional, smaller human 
systems research programs funded through the Office of the Secretary of 
Defense, the Defense Advanced Research Projects Agency (DARPA), and 
DOD's Defense Intelligence Agency (DIA).
    The military service laboratories provide a stable, mission-
oriented focus for science, conducting and sponsoring basic (6.1), 
applied/exploratory development (6.2) and advanced development (6.3) 
research. These three levels of research are roughly parallel to the 
military's need to win a current war (through products in advanced 
development) while concurrently preparing for the next war (with 
technology ``in the works'') and the war after next (by taking 
advantage of ideas emerging from basic research). All of the services 
fund human-related research in the broad categories of personnel, 
training and leader development; warfighter protection, sustainment and 
physical performance; and system interfaces and cognitive processing.

National Academies Report Calls for Doubling Behavioral Research
    The 2008 National Academies report on Human Behavior in Military 
Contexts recommended doubling the current budgets for basic and applied 
behavioral and social science research ``across the U.S. military 
research agencies.'' It specifically called for enhanced research in 
six areas:
  --intercultural competence;
  --teams in complex environments;
  --technology-based training;
  --nonverbal behavior;
  --emotion; and
  --behavioral neurophysiology.
    Behavioral and social science research programs eliminated from the 
mission labs due to cuts or flat funding are extremely unlikely to be 
picked up by industry, which focuses on short-term, profit-driven 
product development. Once the expertise is gone, there is absolutely no 
way to ``catch up'' when defense mission needs for critical human-
oriented research develop. As DOD noted in its own Report to the Senate 
Appropriations Committee: ``Military knowledge needs are not 
sufficiently like the needs of the private sector that retooling 
behavioral, cognitive and social science research carried out for other 
purposes can be expected to substitute for service-supported research, 
development, testing, and evaluation . . . our choice, therefore, is 
between paying for it ourselves and not having it.''

Defense Science Board Calls for Priority Research in Social and 
        Behavioral Sciences: Mapping the Human Terrain
    This emphasis on the importance of social and behavioral research 
within DOD is echoed by the Defense Science Board (DSB), an independent 
group of scientists and defense industry leaders whose charge is to 
advise the Secretary of Defense and the Chairman of the Joint Chiefs of 
Staff on ``scientific, technical, manufacturing, acquisition process, 
and other matters of special interest to the Department of Defense.''
    In its 2007 report on 21st Century Strategic Technology Vectors, 
the DSB identified a set of four operational capabilities and the 
''enabling technologies'' needed to accomplish major future military 
missions (analogous to winning the Cold War in previous decades). In 
identifying these capabilities, DSB specifically noted that ``the 
report defined technology broadly, to include tools enabled by the 
social sciences as well as the physical and life sciences.'' Of the 
four priority capabilities and corresponding areas of research 
identified by the DSB for priority funding from DOD, the first was 
defined as ``mapping the human terrain.''
         maintaining behavioral research on counterintelligence
    In addition to strengthening the DOD S&T account, and behavioral 
research within the military labs in particular, APA also is concerned 
with maintaining invaluable human-centered research programs formerly 
within DOD's Counterintelligence Field Activity (CIFA) now that staff 
and programming have been transferred to the Defense Intelligence 
Agency. Within this DIA program, psychologists lead intramural and 
extramural research programs on counterintelligence issues ranging from 
models of ``insider threat'' to cybersecurity and detection of 
deception. These psychologists also consult with the three military 
services to translate findings from behavioral research directly into 
enhanced counterintelligence operations on the ground.
    APA urges the Subcommittee to provide ongoing funding in fiscal 
year 2010 for counterintelligence behavioral science research programs 
at DIA in light of their direct support for military intelligence 
operations.

                                SUMMARY

    On behalf of APA, I would like to express my appreciation for this 
opportunity to present testimony before the Subcommittee. Clearly, 
psychological scientists address a broad range of important issues and 
problems vital to our national security, with expertise in modeling 
behavior of individuals and groups, understanding and optimizing 
cognitive functioning, perceptual awareness, complex decision-making, 
stress resilience, recruitment and retention, and human-systems 
interactions. We urge you to support the men and women on the front 
lines by reversing another round of cuts to the overall defense S&T 
account and the human-oriented research projects within the military 
laboratories and CIFA.
    As our Nation rises to meet the challenges of current engagements 
in Iraq and Afghanistan as well as other asymmetric threats and 
increased demand for homeland defense and infrastructure protection, 
enhanced battlespace awareness and warfighter protection are absolutely 
critical. Our ability to both foresee and immediately adapt to changing 
security environments will only become more vital over the next several 
decades. Accordingly, DOD must support basic Science and Technology 
(S&T) research on both the near-term readiness and modernization needs 
of the department and on the long-term future needs of the warfighter.
    Below is suggested appropriations report language for fiscal year 
2010 which would encourage the Department of Defense to fully fund its 
behavioral research programs within the military laboratories and 
protect counterintelligence research:

Department of Defense
            Research, Development, Test, and Evaluation
    Behavioral Research in the Military Service Laboratories.--The 
Committee notes the increased demands on our military personnel, 
including high operational tempo, leadership and training challenges, 
new and ever-changing stresses on decision-making and cognitive 
readiness, and complex human-technology interactions. To help address 
these issues vital to our national security, the Committee has provided 
increased funding to reverse cuts to psychological research through the 
military research laboratories: the Air Force Office of Scientific 
Research and Air Force Research Laboratory; the Army Research Institute 
and Army Research Laboratory; and the Office of Naval Research.
    Human-Centered Counterintelligence Research.--The Committee urges 
the Department of Defense to continue supporting human-centered 
research, formerly coordinated through the Counterintelligence Field 
Activity, at the Defense Intelligence Agency.

    Chairman Inouye. And now may I call upon the chair of the 
Extremities War Injuries Project Team of the American Academy 
of Orthopaedic Surgeons, Dr. Andrew Pollak.

STATEMENT OF ANDREW N. POLLAK, M.D., CHAIR, EXTREMITY 
            WAR INJURIES AND DISASTER PREPAREDNESS 
            PROJECT TEAM, AMERICAN ACADEMY OF 
            ORTHOPAEDIC SURGEONS
    Dr. Pollak. Good morning, Senators. I'm Dr. Andy Pollak, 
and I chair the Extremity War Injuries Project Team for the 
American Academy of Orthopaedic Surgeons. During the day, I 
serve as chief of orthopaedic surgery at the Shock Trauma 
Center at the University of Maryland in Baltimore.
    On behalf of military and civilian orthopaedic surgeons and 
researchers throughout the country, I take this opportunity to 
urge the subcommittee to continue to provide significant 
resources for peer-reviewed medical research in the area of 
extremity war injuries, injuries arising from trauma to the 
bones, joints, muscles, and tendons of the arms and legs.
    We thank you for providing the DOD with the funding for 
this purpose since fiscal year 2006, including $117 million 
total in fiscal year 2009, and we urge you to consider 
increasing funding for this program, in fiscal year 2010, to 
$150 million.
    Chairman Inouye, we know of your personal experience 
involving extremity trauma during war, and appreciate the fact 
that you have both personal and professional perspectives from 
which to address this issue.
    We're very grateful for the dedicated work of Senators 
Harkin and Hutchison, both members of the subcommittee. They 
worked together in support of last year's appropriation, and 
have both expressed support for growing this program to $150 
million for fiscal year 2010.
    Mr. Chairman, I've had the privilege of performing surgery 
in military facilities in Balad, Iraq, and Landstuhl, Germany. 
I can assure this subcommittee of the outstanding quality of 
trauma care being delivered by the military health system 
there. The problem facing surgeons emanates from limitations in 
medical knowledge and techniques in the management of these 
horrific injuries. We need your help to advance the state of 
the art. We also need your help to improve our ability to treat 
consequences of severe injury to the extremities, such as 
arthritis, nerve damage, infection, and failure of bones to 
heal properly.
    I'll keep the statistics short. Extremity injury is the 
most common type of injury sustained in battle, affecting over 
80 percent of wounded warriors. Extremity wounds are the 
greatest source of expense related to hospitalization of 
wounded warriors after combat injury. Extremity war wounds are 
the greatest source of war-related disability expense for the 
military, expected to total $1.8 billion, lifetime, for 
payments related to injuries sustained to American warriors in 
Iraq and Afghanistan, exclusive of costs associated with their 
medical care. And conditions analogous to arthritis were the 
most common reason for disability-related retirement from the 
Army in 2008.
    The peer-reviewed orthopaedic research programs were 
designed to help military surgeons find new, limb-sparing 
techniques, with the goals of avoiding amputations, and 
preserving and restoring the function of injured extremities, 
limiting disability and suffering, and, whenever possible, 
allowing our warriors to return to duty as soon as it's safely 
possible.
    The interest and capacity of the U.S. research community is 
very strong. This past year, as a result of funding made 
available in the fiscal year 2008 supplemental appropriation, 
the DOD accepted applications for development of a consortium 
of military and civilian trauma centers to begin work on the 
critically important clinical studies necessary to understand 
the best ways to treat extremity injuries, and to translate 
recent scientific advances in bone growth and tissue 
regeneration to the real world, where these advances can help 
improve the lives of our injured heroes.
    Mr. Chairman, Mr. Vice Chairman, you've recognized the 
urgent need to finance extremity research over the past 4 
years, and we're extremely grateful for that support. Based on 
the level of scientific need, our goal is to see the Defense 
Department programs achieve an operating level of $150 million 
per year.
    Thank you and the entire subcommittee for your vision and 
leadership in responding to this appeal. We strongly urge your 
continued action.
    Chairman Inouye. All right, thank you very much, Dr. 
Pollak.
    [The statement follows:]

                 Prepared Statement of Andrew N. Pollak

    Chairman Inouye, Vice Chairman Cochran, Members of the Senate 
Defense Appropriations Subcommittee, thank you for the opportunity to 
testify today. I am Andrew N. Pollak, M.D., and I speak today on behalf 
of the American Academy of Orthopaedic Surgeons (AAOS), of which I am 
an active member, as well as my military and civilian orthopaedic 
surgery colleagues who are involved in extremity trauma research and 
care.
    I am Chair of the Academy's Extremity War Injuries and Disaster 
Preparedness Project Team, past-chair of its Board of Specialty 
Societies, and a subspecialist in orthopaedic traumatology. I am 
Associate Director of Trauma and Head of the Division of Orthopaedic 
Traumatology at the R Adams Cowley Shock Trauma Center and the 
University of Maryland School of Medicine. My Division at Shock Trauma 
is responsible for providing education and training in orthopaedic 
traumatology to residents from eight separate training programs 
nationally, including the Bethesda Naval, Walter Reed Army and Tripler 
Army military orthopaedic residency programs. In addition, Shock Trauma 
serves as the home for the Air Force Center for the Sustainment of 
Trauma and Readiness Skills (CSTARS) program. I also serve as Second 
Vice President of the Orthopaedic Trauma Association.
    Senators, on behalf of all the military and civilian members of the 
American Academy of Orthopaedic Surgeons, please allow me to take this 
opportunity today to thank you both, as well as the Members of this 
Subcommittee, for your vision and leadership in providing funding in 
fiscal years 2006 through 2009 for the peer reviewed medical research 
program on orthopaedic and extremity war injuries. In particular, we 
thank you for providing $66 million in your fiscal year 2009 Conference 
Bill and for creating the Peer Reviewed Orthopedic Research Program to 
cover the full range of research--from basic to clinical trials.
    We also thank you most sincerely for your consideration of 
providing funding in the fiscal year 2009 Supplemental Appropriations 
Bill. Your commitment to building this research enterprise and enabling 
the Department of Defense to pursue answers to its critical medical 
needs must be recognized. Clearly this effort by the Congress will 
provide medical benefit through improved treatments and procedures to 
help our Wounded Warriors heal better and quicker.
    We are very grateful for the dedicated work of Senators Tom Harkin 
and Kay Bailey Hutchison--both Members of this Subcommittee--in 
sponsoring a ``Dear Colleague'' letter this year supporting the 
ultimate goal of achieving an annual operating level of $150 million 
per year for this critical peer reviewed research program.
    It really cannot be overstated: the level and consistency of 
appropriations you are providing are ``game-changing.'' It provides the 
Department with the ability to move rapidly in developing the full 
research continuum, especially clinical trials--an essential form of 
investigation that has not existed in the extremity injury field 
previously because of a lack of significant and sustained resources. 
Just last month because of your support the U.S. Army's Medical 
Research and Materiel Command accepted applications in response to its 
first ever call for the formation of network for clinical research into 
these challenges. In addition because of this critical funding, in 
April the Command hosted a 2-day scientific conference to further 
examine needs, and prioritize areas for its broadened research agenda.
    Mr. Chairman, our message is straightforward:
  --Extremity trauma and its sequelae represent the single most common 
        injury class our wounded warriors suffer, the greatest source 
        of inpatient medical care expense for the DOD, the single 
        greatest source of injury related disability expense for the 
        military, and the most common cause for disability retirement 
        from all branches of the armed services;
  --the state of the science must be advanced to provide better 
        treatment options for our wounded service members who suffer 
        extremity trauma and other injuries to their bone and muscles 
        with a goal of limiting the profound long-term disability 
        associated with these injuries;
  --the current peer reviewed research program has great potential to 
        address a wide range of bone and muscle injuries and conditions 
        that are sidelining our troops at increasing rates; and
  --the Defense Department must be convinced to proactively budget for 
        research on military-related orthopaedic injuries, including 
        extremity trauma, but until that occurs, we believe that the 
        Congress has an obligation to ensure--as you have done--that 
        the necessary resources are appropriated and directed to the 
        task.
    As the Iraq and Afghanistan conflicts enter their seventh year, the 
Nation continues to face a profound need for focused medical research 
to help military surgeons find new limb-sparing techniques with the 
goal of avoiding amputations and preserving and restoring the function 
of injured extremities.
    Chairman Inouye, we know of your experience with extremity trauma 
during war and appreciate the fact that you have both personal and 
professional perspectives from which to address this issue and we honor 
your service as well as that of Vice Chairman Cochran.
    U.S. military researchers have documented that approximately 82 
percent of war injuries suffered fighting the global war on terror 
involve the extremities--often severe and multiple injuries to the arms 
and legs.
    The evidence is also reflected in legislative documents. House 
Report 111-105 accompanying the recent fiscal year 2009 Supplemental 
Appropriations Bill, H.R. 2346, correctly states that ``. . . extremity 
injuries are the most prevalent injury, and amputations following 
battlefield injury now occur as twice the rate as in past wars. 
Understanding how to treat and facilitate rapid recovery from 
orthopedic injuries should be one of the top priorities for the 
Military Health System.''
    The Report accompanying the fiscal year 2009 House Appropriations 
Bill made similar points and added: ``. . . the committee believes that 
every aspect of research shall be considered during a time when unique 
and dynamic research and treatment is necessary to provide the soldiers 
the greatest ability to recover from injuries sustained on the 
battlefield.''
    House Report 110-279 accompanying the fiscal year 2008 Defense 
Appropriations Bill stated that ``Extremity injuries are the number one 
battlefield injury . . . dynamic research and treatment is necessary to 
provide service members the greatest ability to recover from injuries 
sustained on the battlefield.''
    A recent U.S. Army analysis of soldiers injured in Iraq and 
Afghanistan from 2001 through 2005 shows that extremity injuries 
account for the greatest proportion of medical resource utilization and 
cause the greatest number of disabled soldiers. In fact, soldiers with 
extremity injuries had the longest average inpatient stays, accounted 
for 65 percent of total inpatient resource utilization and 64 percent 
of projected disability benefits costs in the future. The projected 
disability cost for extremity injuries sustained in this conflict to 
date--exclusive of ANY short or long-term medical costs--is estimated 
to be approximately $1.2 billion.
    In addition, muscle and bone injuries are sidelining a growing 
number of troops in our current conflicts. Data from the U.S. Army 
reported 257,000 acute orthopaedic injuries in 2007--an increase of 
10,000 over the previous year. Increasing numbers of troops are listed 
as ``non-deployable'' as a result of injuries related to carrying heavy 
combat gear in repeated deployments, and, in the case of Afghanistan, 
carrying those loads in high altitude settings.
    A February 1, 2009 Washington Post article on this challenge stated 
that ``Army leaders and experts say the injuries--linked to the stress 
of bearing heavy loads during repeated 12- or 15-month combat tours--
have increased the number of soldiers categorized as ``non 
deployable.''
    The article goes on to quote General Peter W. Chiarelli, the Army 
Vice Chief of Staff: ``You can't hump a rucksack at 8,000 to 11,000 
feet for 15 months, even at a young age, and not have that have an 
impact on your body, and we are seeing an increase in muscular-skeletal 
issues.''

             THE PEER REVIEWED ORTHOPAEDIC RESEARCH PROGRAM

    Chairman Inouye, the AAOS and military and civilian orthopaedic 
surgeons and researchers are very grateful for your Subcommittee's 
vision in providing support for Peer Reviewed Orthopedic Research. This 
is the first program created in the Department of Defense dedicated 
exclusively to funding peer-reviewed intramural and extramural 
orthopaedic research. Having the program administered on behalf of the 
Defense Health Program by the U.S. Army Medical Research and Materiel 
Command, Fort Dietrick, ensures that the funding closely follows the 
research priorities established by the Armed Forces. With the 
assistance of the Army's Institute of Surgical Research, MRMC has 
extensive experience administering military-related research grant 
programs. Military orthopaedic surgeons have also had significant input 
into the creation of this program and fully support its goals.
    The design of the program fosters collaboration between civilian 
and military orthopaedic surgeons and researchers and various 
facilities. Civilian researchers have the expertise and resources to 
assist their military colleagues with the growing number of patients 
and musculoskeletal injuries and war wound challenges in building the 
military research program. As can been seen in extensive numbers of 
research applications submitted under each RFP, civilian investigators 
are extremely interested in advancing this research and have responded 
enthusiastically to engage in this important work which will also 
provide wide ranging spin-off benefits to civilian trauma patients.
    The program is growing to encompass the full spectrum of research, 
from basic and translational studies to clinical trials. It focuses on 
targeted, competitively-awarded research where peer reviewers score 
proposals on the degree of (1) military relevance, (2) military impact, 
and (3) scientific merit. Military and civilian orthopaedic surgeons 
are highly involved in defining the research topics and in evaluating 
and scoring the proposals. This unique process ensures that projects 
selected for funding have the highest chance for improving treatment of 
battlefield injuries and deployment related musculoskeletal injuries.
    Significant new funding from the Congress will allow for more 
robust numbers of grants, a broader scope of work and increased multi-
institutional collaboration. As mentioned earlier, clinical trials and 
more in-depth tracking of long term outcomes are in the planning 
stages--important components in rapidly advancing the state of the 
science.
    By funding the Peer Reviewed Orthopedic Research Program--operated 
on behalf of all services by the Army's Medical Research and Materiel 
Command--your committee is advancing the state of the science in this 
field to the benefit of our current servicemen and women--and those who 
will step forward in the future to defend our Nation. Your action will 
directly result in improved treatments for our Wounded Warriors and 
injured troops now and in future conflicts.
    It is important to point out that unique to the current conflicts 
is a new type of patient, a war fighter with multiple and severely 
mangled extremities who is otherwise free of life-threatening injury to 
the torso or whose life-threatening injuries have been successfully 
addressed because of improvements in protective body armor and the 
excellent care quickly delivered through the echelon treatment system. 
Such injuries are rarely seen in civilian surgical hospitals, even in 
Level 1 trauma centers like my own at Shock Trauma in Baltimore. 
Current challenges that often compound the battlefield injuries include 
serious infections due to the nature of the injuries and the 
environment in which they are sustained, and the need for immediate 
transport for more complex surgery.
    The Academy's interest in this effort began in the very early days 
of Operation Enduring Freedom when our deployed military Academy 
members began to report the great clinical needs that were emerging as 
they went about their work in surgery to save injured servicemen and 
women. Soon studies on the nature of injuries in Iraq and Afghanistan 
documented the high proportion of extremity injuries as well as the 
severity of injuries.
    I have been fortunate to travel to and operate in the U.S. Army 
Hospital in Landstuhl, Germany several times and to the Air Force 
Theater Hospital in Balad, Iraq to initiate the Academy's Distinguished 
Visiting Scholars Program. This program is a joint initiative between 
the AAOS and the Orthopaedic Trauma Association. The activity allows 
civilian orthopaedic trauma specialists with demonstrated clinical 
expertise and national recognition for their teaching abilities to 
volunteer two weeks at a time to be away from their practices 
performing surgery and teaching at Landstuhl Regional Medical Center. I 
also had the privilege of operating in Balad, Iraq as part of a request 
by Air Force Surgeon General James Roudebush to evaluate the trauma 
care being delivered at the Air Force Theater Hospital and to 
investigate the feasibility and value of extending the Distinguished 
Visiting Scholars Program into Iraq and Afghanistan. Based on my 
experiences in Balad, I can assure this committee of the outstanding 
quality of trauma care being delivered there by the military health 
system. I believe the quality of medical care being delivered to our 
injured warriors in Balad is at or above the care being delivered in 
our finest trauma centers within the United States.
    On January 21-23 of this year, the fourth annual Extremity War 
Injuries Scientific Symposium was held in Washington, DC, sponsored by 
our Academy, along with the Society of Military Orthopaedic Surgeons, 
The Orthopaedic Research Society and the Orthopaedic Trauma 
Association. This combined effort of three major associations and the 
United States military began in 2006 in an initiative to examine the 
nature of extremity injuries sustained during Operation Enduring 
Freedom and Operation Iraqi Freedom and to plan for advancing the state 
of the science and treatment of these injuries. Each year the meetings 
are attended by over 175 military and civilian leaders in orthopaedic 
and extremity medical research and treatment from around the world. We 
have been very fortunate to have had many outstanding leaders speak to 
the conference audiences in the past about their perspectives on 
injuries being sustained by our armed forces. These speakers have 
included Joint Chiefs Chairman Adm. Michael Mullen, Senator Tom Harkin, 
Representatives John Murtha, Dutch Ruppersberger, and Tom Latham, and 
the previous Assistant Secretary of Defense for Health Affairs, Ward 
Casscells. This conference series has produced widely referenced 
scientific publications describing the clinical challenges posed by 
extremity war injuries, and a research agenda to guide the scientific 
community and the managers of the Peer Reviewed Orthopedic Research 
Program in planning and executing the program.

ORTHOPAEDIC TRAUMA FROM OPERATION IRAQI FREEDOM AND OPERATION ENDURING 
                                FREEDOM

    The likelihood of surviving wounds on the battlefield was 69.7 
percent in WWII and 76.4 percent in Vietnam. Now, thanks in part to the 
use of body armor, ``up-armored'' vehicles, intense training of our 
combat personnel and surgical capability within minutes of the 
battlefield, survivability has increased dramatically to 90.2 percent 
as of February 2007.
    The Armed Forces are attempting to return significantly injured 
warriors to full function or limit their disabilities to a functional 
level in the case of the most severe injuries. The ability to provide 
improved recovery of function moves toward the goal of keeping injured 
warriors part of the military team. Moreover, when they do leave the 
Armed Forces, these rehabilitated warriors have a greater chance of 
finding worthwhile occupations outside of the service to contribute 
positively to society. The military believes that it has a duty and 
obligation to provide the highest level of care and rehabilitation to 
those men and women who have suffered the most while serving the 
country and our Academy fully supports those efforts.
    It comes as no surprise that the vast majority of trauma 
experienced in Iraq and Afghanistan is orthopaedic-related, especially 
upper and lower extremity and spine. A recent article in the Journal of 
Orthopaedic Trauma reports on wounds sustained in Operation Iraqi 
Freedom (OIF) and Operation Enduring Freedom (OEF) based on data from 
the Joint Theater Trauma Registry, a database of medical treatment 
information from theater of combat operations at U.S. Army medical 
treatment facilities. From October, 2001 through January, 2005, of 
1,566 soldiers who were injured by hostile enemy action, 1,281 (82 
percent) had extremity injuries, with each solider sustaining, on 
average, 2.28 extremity wounds. These estimates do not include non-
American and civilians receiving medical care through U.S. military 
facilities. (Owens, Kragh, Macaitis, Svoboda and Wenke. 
Characterization of Extremity Wounds in Operation Iraqi Freedom and 
Operation Enduring Freedom. J Orthopaedic Trauma. Vol. 21, No. 4, April 
2007. 254-257.)
    An earlier article reported on 256 battle casualties treated at the 
Landstuhl Regional Medical Center in Germany during the first 2 months 
of OIF, finding 68 percent sustained an extremity injury. The reported 
mechanism of injury was explosives in 48 percent, gun-shot wounds in 30 
percent and blunt trauma in 21 percent. As the war has moved from an 
offensive phase to the current counter-insurgency campaign, higher 
rates of injuries from explosives have been experienced. (Johnson BA. 
Carmack D, Neary M, et al. Operation Iraqi Freedom: the Landstuhl 
Regional Medical Center experience. J Foot Ankle Surg. 2005; 44:177-
183.) According to the JTTR, between 2001 and 2005, explosive 
mechanisms accounted for 78 percent of the war injuries compared to 18 
percent from gun shots.
    While medical and technological advancements, as well as the use of 
fast-moving Forward Surgical Teams, have dramatically decreased the 
lethality of war wounds, wounded soldiers who may have died in previous 
conflicts from their injuries are now surviving and have to learn to 
recover from devastating injuries. While body armor is very effective 
in protecting a soldier's torso, his or her extremities are 
particularly vulnerable during attacks.
Characteristics of Military Orthopaedic Trauma
    At this point there have been almost 40,000 warriors evacuated to 
Landstuhl Regional Medical Center in the Global War on Terror. Of 
these, almost 16,000 have been wounded in action. As mentioned earlier, 
the vast majority have injuries to their extremities--often severe and 
multiple injuries to the arms and legs. Most wounds are caused by 
exploding ordinance--frequently, improvised explosive devices (IEDs), 
rocket-propelled grenades (RPGs), as well as high-velocity gunshot 
wounds. Military surgeons report an average of 3 wounds per casualty.
    According to the New England Journal of Medicine, blast injuries 
are producing an unprecedented number of ``mangled extremities''--limbs 
with severe soft-tissue and bone injuries. (``Casualties of War--
Military Care for the Wounded from Iraq and Afghanistan,'' NEJM, 
December 9, 2004). The result of such trauma is open, complex wounds 
with severe bone fragmentation. Often there is nerve damage, as well as 
damage to tendons, muscles, vessels, and soft-tissue. In these types of 
wounds, infection is often a problem. According to the JTTR, 53 percent 
of the extremity wounds are classified as penetrating soft-tissue 
wounds, while fractures compose 26 percent of extremity wounds. Other 
types of extremity wounds composing less than 5 percent each are burns, 
sprains, nerve injuries, abrasions, amputations, contusions, 
dislocations, and vascular injuries.
    The sheer number of extremity injuries represents a staggering 
health burden. Between January 2003, and February 2009, over 15,000 
U.S. Warriors have been wounded-in-action severely enough to require 
evacuation out of theater. In addition, 780 American patients have lost 
at least one limb.
Military Versus Civilian Orthopaedic Trauma
    While there are similarities between military orthopaedic trauma 
and the types of orthopaedic trauma seen in civilian settings, there 
are several major differences that must be noted.
    With orthopaedic military trauma, there are up to five echelons of 
care, unlike in civilian settings when those injured are most likely to 
receive initial treatment at the highest level center. Instead, wounded 
warriors get passed from one level of care to the next, with physicians 
and other health care providers rendering the most appropriate type of 
care possible in the context of the limitations of a battlefield 
environment in order to ensure the best possible outcome. The surgeon 
in each subsequent level of care must try to recreate what was 
previously done. In addition, a majority of injured soldiers have to be 
``med-evaced'' to receive care and transportation is often delayed due 
to weather or combat conditions. It has been our experience that over 
65-percent of the trauma is urgent and requires immediate attention.
    Injuries from IEDs and other explosive ordnance in Iraq and 
Afghanistan differ markedly from those of gunshot wounds sustained in 
civilian society. The contamination, infection and soft-tissue injury 
caused by exploding ordnance requires more aggressive treatment and new 
techniques, especially when the wounded warrior was in close proximity 
to the blast radius.
    Warriors are usually in excellent health prior to injury. However, 
through the evacuation process they may not be able to eat due to 
medical considerations resulting in impaired body nitrogen stores and 
decreased ability to heal wounds and fight infections. This presents 
many complicating factors when determining the most appropriate care.
    The setting in which care is initially provided to wounded soldiers 
is less than ideal, to say the least, especially in comparison to a 
sterile hospital setting. The environment, such as that seen in Iraq 
and Afghanistan, is dusty and hot, leading to concerns about secondary 
contamination of wounds in the hospital setting. For example, infection 
from acinetobacter baumanni, a ubiquitous organism found in the desert 
soil of Afghanistan and Iraq, is extremely common. In addition, the 
surgical environment is under constant threat of attack by insurgents. 
Imagine teams of medical specialists working in close quarters to save 
an injured serviceman while mortars or rockets are raining down on the 
hospital. Finally, the forward-deployed surgical team is faced with 
limited resources that make providing the highest level of care 
difficult.
    While, as I have stated, there are many unique characteristics of 
orthopaedic military trauma, there is no doubt that research done on 
orthopaedic military trauma also benefits trauma victims in civilian 
settings. Many of the great advancements in orthopaedic trauma care 
have been made during times of war, including principles of debridement 
of open wounds, utilization of external fixation and use of tourniquets 
for control of hemorrhage which has been used extensively during the 
current conflict.
    Research Needs.--With such strong research interest and capacity, 
and the great need for medical breakthroughs in this field, the 
scientific community believes that a sustained, multi-year program 
funded at $150 million per year is justified. Such significant funding 
is required allow the Defense Department to conduct multi-center 
clinical trials--research projects that would greatly advance the field 
and significantly benefit the battlefield injured warriors. In 
addition, basic and translational research also must be sustained, as 
in any major research undertaking, to provide the underpinnings for 
advancing clinical breakthroughs. Research in the management of 
extremity injuries and other disabling orthopaedic conditions will lead 
to quicker recovery times, improved function of limbs, better response 
rates to infection, and new advances in rehabilitation benefiting both 
military and civilian patients. General areas of research need include 
bone regeneration, improved healing of massive soft tissue damage, 
prevention of wound infection, techniques to improve irrigation and 
debridement of blast injuries, prevention of bone reformation 
abnormalities, and epidemiology of current battle-related injuries.
    Specific areas of research need include:
  --Prevention and treatment of post-traumatic arthritis;
  --Prevention and treatment of infections following high-energy 
        extremity war injury;
  --Management of segmental bone defects;
  --Establishment of tissue viability markers--this would assist 
        surgeons in better understanding the ideal frequency and 
        techniques of debridement wound cleaning);
  --Timing of treatment--early versus late surgical treatment;
  --Prevention and treatment of chronic neck and low back arthritic 
        conditions resulting from combat associated stress and overuse 
        injury;
  --Treatment of severe muscle, nerve, ligament and other soft-tissue 
        injury associated with combat trauma; and
  --Rehabilitation of high-performance warriors after significant 
        combat related injury.

Future Needs of Orthopaedic Research
    As mentioned earlier, an important development in this scientific 
effort has been the convening of the annual Extremity War Injury 
Symposia, which began in January of 2006. These widely attended medical 
conferences in Washington, D.C. bring together leading military and 
civilian clinicians and researchers to focus on the immediate needs of 
personnel sustaining extremity injuries. Discussions at the conferences 
have confirmed that there is tremendous interest and much untapped 
research capacity in the Nation's military and civilian research 
community.
    These extraordinary scientific meetings were a partnership effort 
between organized orthopaedic surgery, military surgeons and 
researchers. They were attended by key military and civilian physicians 
and researchers committed to the care of extremity injuries. The first 
conference addressed current challenges in the management of extremity 
trauma associated with recent combat in Iraq and Afghanistan. The major 
focus was to identify opportunities to improve care for the sons and 
daughters of America who have been injured serving our Nation. The 
second focused on the best way to deliver care within the early 
echelons of treatment. The third explored the wide spectrum of needs in 
definitive reconstruction of injuries. Scientific proceedings from the 
symposia have been published by our Academy and made available to the 
military and civilian research community. Each conference has continued 
to refine the list of prioritized research needs which I will 
summarize:
            Timing of Treatment
    Better data are necessary to establish best practices with regard 
to timing of debridement, timing of temporary stabilization and timing 
of definitive stabilization. Development of animal models of early 
versus late operative treatment of open injuries may be helpful. 
Prospective clinical comparisons of treatment groups will be helpful in 
gaining further understanding of the relative role of surgical timing 
on outcomes.
            Techniques of Debridement
    More information is necessary about effective means of 
demonstrating adequacy of debridement. Current challenges, particularly 
for surgeons with limited experience in wound debridement, exist in 
understanding how to establish long-term tissue viability or lack 
thereof at the time of an index operative debridement. Since patients 
in military settings are typically transferred away from the care of 
the surgeon performing the initial debridement prior to delivery of 
secondary care, opportunities to learn about the efficacy of initial 
procedures are lost. Development of animal models of blast injury could 
help establish tissue viability markers. Additional study is necessary 
to understand ideal frequencies and techniques of debridement.
            Transport Issues
    Clinical experience suggests that current air evacuation techniques 
are associated with development of complications in wound and extremity 
management although the specific role of individual variables in the 
genesis of these complications is unclear. Possible contributing 
factors include altitude, hypothermia and secondary wound 
contamination. Clinical and animal models are necessary to help develop 
an understanding of transport issues.
            Coverage Issues
    Controlled studies defining the role of timing of coverage in 
outcome following high-energy extremity war injuries are lacking. Also 
necessary is more information about markers and indicators to help 
assess the readiness of a wound and host for coverage procedures. 
Additional animal modeling and clinical marker evaluation are necessary 
to develop understanding in this area.
            Antibiotic Treatments
    Emergence of resistant organisms continues to provide challenges in 
the treatment of infection following high-energy extremity war 
injuries. Broader prophylaxis likely encourages development of 
antibiotic resistance. In the context of a dwindling pipeline of new 
antibiotics, particularly those directed toward gram-negative 
organisms, development of new technologies to fight infection is 
necessary. This patient population offers opportunity to assess 
efficacy of vaccination against common pathogens. Partnerships with 
infectious disease researchers currently involved in addressing similar 
questions warrants further development.
            Management of Segmental Bone Defects
    A multitude of different techniques for management of segmental 
bone defects is available. These include bone transport, massive onlay 
grafting with and without use of recombinant proteins, delayed 
allograft reconstruction, and acute shortening. While some techniques 
are more appropriate than others after analysis of other clinical 
variables, controlled trials comparing efficacy between treatment 
methods are lacking. Variables that may affect outcome can be grouped 
according to patient characteristics including co-morbidities, injury 
characteristics including severity of bony and soft-tissue wounds, and 
treatment variables including method of internal fixation selected. 
Evaluation of new technologies for treatment of segmental bone defects 
should include assessment of efficacy with adequate control for 
confounding variables and assessment of cost-effectiveness. 
Partnerships with other military research programs may be particularly 
effective in improving clinical capabilities in this area.
            Development of an Animal Model
    A large animal survival military blast injury model is necessary to 
serve as a platform for multiple research questions including: negative 
pressure wound therapy v. bead pouch v. dressing changes; wound 
debridement strategy; effect of topical antibiotics; modulation of 
inflammatory response; timing of wound closure; and vascular shunt 
utilization.
            Prevention of Post-Traumatic Arthritis
    More research is necessary to better understand how to address 
traumatic injuries to articular cartilage with associated articular 
loss. Current treatment options include artificial joint replacement 
and joint fusion. Regeneration of cartilage and re-growth of joint 
surfaces is poorly understood and warrants further investigation. 
Similarly, the role of cadaver joint surfaces in replacing injured 
joints in soldiers warrants further consideration and investigation. 
Initial research has been exciting in this area, particularly in the 
area of allograft hand transplantation.
            Amputee Issues
    Development and validation of ``best practice'' guidelines for 
multidisciplinary care of the amputee is essential. Treatment protocols 
should be tested clinically. Studies should be designed to allow for 
differentiation between the impacts of the process versus the device on 
outcome. Failure mode analysis as a tool to evaluate efficacy of 
treatment protocols and elucidate shortcomings should be utilized. 
Clinically, studies should focus on defining requirements for the 
residual limb length necessary to achieve success without proceeding to 
higher level amputation. Outcomes based comparisons of amputation 
techniques for similar injuries and similar levels should be performed. 
Use of local tissue lengthening and free tissue transfer techniques 
should be evaluated. In the context of current results and increasing 
levels of expectation for function following amputation, development of 
more sensitive and military appropriate outcomes monitors is necessary.
            Heterotopic Ossification
    This condition, known as ``H.O.'' by the many soldiers who 
experience it, is abnormal and uncontrolled bone growth that often 
occurs following severe bone destruction or fracture. Animal models of 
heterotopic ossification should be utilized to develop early markers 
for heterotopic ossification that could identify opportunities for 
early treatment and prevention. Better information is needed about 
burden of disease including prevalence following amputation for 
civilian versus military trauma and frequency with which symptoms 
develop. Treatment methods such as surgical debridement, while 
effective, necessarily interrupt rehabilitation. Prevention could 
expedite recovery and potentially improve outcome.

                               CONCLUSION

    With extremity trauma injuries being the most common form of injury 
seen in current military conflicts and musculoskeletal injuries 
becoming an increasing factor in sidelining our troops, it is crucial 
that significant funding be directed specifically to the advancement of 
research. The AAOS has worked closely with the top military orthopaedic 
surgeons and medical leaders, at world-class facilities such as the 
U.S. Army Institute of Surgical Research, Brooke Army Medical Center, 
Bethesda Naval Hospital, Landstuhl Regional Medical Center, the Medical 
Research and Materiel Command and Walter Reed Army Medical Center to 
identify the gaps in research and clinical treatment--and the 
challenges are many.
    Orthopaedic research currently being carried out at those and other 
facilities, and at civilian medical centers, is vital to the health of 
our soldiers and to the Armed Forces' objective to return injured 
soldiers to full function in hopes that they can continue to be 
contributing soldiers and active members of society.
    The 17,000 members of our Academy thank you for sustaining the Peer 
Reviewed Orthopedic Research Program. While Congress funds an extensive 
array of medical research through the Department of Defense, with over 
80 percent of military trauma being extremity-related, I can assure you 
that this type of medical research will greatly benefit our men and 
women serving in the Global War on Terror and in future conflicts.
    Mr. Chairman and Mr. Vice Chairman, the American Academy of 
Orthopaedic Surgeons, as well as the entire orthopaedic trauma 
community, stands ready to work with this Subcommittee to identify and 
prioritize research opportunities for the advancement in the care of 
extremity and orthopaedic injuries. Military and civilian orthopaedic 
surgeons and researchers are committed to pursuing scientific inquiry 
that will benefit the unfortunately high number of soldiers afflicted 
with such conditions and return them to the highest level of function 
possible. This investment to improve treatment for our soldiers will be 
well spent. It is imperative that the Federal Government--when 
establishing its defense health research priorities in the future--
continues to ensure that research on treating orthopaedic and extremity 
war injuries remains a top priority. We appreciate your consideration 
of our perspective on this critical issue and urge your continued 
action on behalf of our Nation's servicemen and women.

    Chairman Inouye. And we'd like to thank the whole panel and 
now call upon the new panel.
    Thank you very much.
    The next panel consists of Ms. Frances Visco, Ms. Jackie S. 
Rowles, Mr. Rick Jones, Ms. Cara Tenenbaum, Colonel William 
Holahan, and Ms. Elizabeth Cochran.
    I've been advised that Mr. Wicks will be substituting for 
Ms. Jackie Rowles.
    And our next witness is the president of the National 
Breast Cancer Coalition, Ms. Frances Visco.

STATEMENT OF FRAN VISCO, J.D., PRESIDENT, NATIONAL 
            BREAST CANCER COALITION
    Ms. Visco. Thank you, Chairman Inouye, Senator Cochran.
    I'm here as a 22-year breast cancer survivor, a wife, a 
mother, and the president of the National Breast Cancer 
Coalition. As you know, NBCC is a coalition of more than 600 
organizations from across the country whose mission is to end 
breast cancer.
    I want to thank you, as I do every year, for your continued 
support of this program. And I want to report to you that this 
program continues to be incredibly successful. It continues to 
create new models of science, new models of research, through a 
competitive, peer-reviewed process that releases funding to 
scientists around the world.
    This program has funded innovative research, it has filled 
the gaps in the traditional funding mechanisms. It has also 
been copied by the National Institutes of Health, by private 
foundations. The models that this program has launched have now 
changed science in many different areas within the Department 
of Defense, collaborations within the Defense Department, and 
without. It has resulted in bringing many new young scientists 
into the field of research, and biomedical research. And I'm 
very proud to say--very proud of the military--that this 
program has incredibly low administrative costs, so that 90 
percent--more than 90 percent of the appropriations go directly 
to research funding.
    There's an incredibly high return on the investment of 
these funds. And, most importantly, this program is 
transparent, and it is accountable to the taxpayers. It is 
possible to see where every dollar of these funds has gone. And 
the public gets a report of the results of the research that 
has been funded with these dollars.
    It has made an incredible difference to women with breast 
cancer, to their families, but really to all disease research. 
And I want to take my last moments to say how grateful we are 
to the members of the military, to--who administer this 
program. They are passionately committed to this mission, and 
they do an incredible job. And I want to thank you very much 
for continuing and allowing this program to proceed.
    Thank you.
    Chairman Inouye. Thank you very much, Ms. Visco.
    [The statement follows:]

                    Prepared Statement of Fran Visco

    Thank you, Mr. Chairman and members of the Appropriations 
Subcommittee on Defense, for the opportunity to submit testimony today 
about a Program that has made a significant difference in the lives of 
women and their families.
    I am Fran Visco, a 21-year breast cancer survivor, a wife and 
mother, a lawyer, and President of the National Breast Cancer Coalition 
(NBCC). My testimony represents the hundreds of member organizations 
and thousands of individual members of the Coalition. NBCC is a 
grassroots organization dedicated to ending breast cancer through 
action and advocacy. The Coalition's main goals are to increase Federal 
funding for breast cancer research and collaborate with the scientific 
community to implement new models of research; improve access to high 
quality health care and breast cancer clinical trials for all women; 
and expand the influence of breast cancer advocates wherever breast 
cancer decisions are made.
    You and your Committee have shown great determination and 
leadership in funding the Department of Defense (DOD) peer-reviewed 
Breast Cancer Research Program (BCRP) at a level that has brought us 
closer to eradicating this disease. Chairman Inouye and Ranking Member 
Cochran, we appreciate your longstanding personal support for this 
Program. I am hopeful that you and your Committee will continue that 
determination and leadership.
    I know you recognize the importance of this Program to women and 
their families across the country, to the scientific and health care 
communities and to the Department of Defense. Much of the progress in 
the fight against breast cancer has been made possible by the 
Appropriations Committee's investment in breast cancer research through 
the DOD BCRP. This Program has launched new models of biomedical 
research that have benefited other agencies and both public and private 
institutions. It has changed for the better the way research is 
performed and has been replicated by programs focused on other 
diseases, by other countries and states. To support this unprecedented 
progress moving forward, we ask that you support a separate $150 
million appropriation for fiscal year 2010. In order to continue the 
success of the Program, you must ensure that it maintain its integrity 
and separate identity, in addition to the requested level of funding. 
This is important not just for breast cancer, but for all biomedical 
research that has benefited from this incredible government Program. In 
addition, as Institute of Medicine (IOM) reports concluded in 1997 and 
2004, there continues to be excellent science that would go unfunded 
without this Program. It is only through a separate appropriation that 
this Program is able to continue to focus on breast cancer yet impact 
all other research. The separate appropriation of $150 million will 
ensure that this Program can rapidly respond to changes and new 
discoveries in the field and fill the gaps in traditional funding 
mechanisms.
    Since its inception, this Program has matured into a broad-reaching 
influential voice forging new and innovative directions for breast 
cancer research and science. Breast cancer is an extraordinarily 
complex disease. Despite the enormous successes and advancements in 
breast cancer research made through funding from the DOD BCRP, we still 
do not know what causes breast cancer, how to prevent it, or how to 
cure it. It is critical that innovative research through this unique 
Program continues so that we can move forward toward eradicating this 
disease.

           OVERVIEW OF THE DOD BREAST CANCER RESEARCH PROGRAM

    The DOD peer-reviewed Breast Cancer Research Program has 
established itself as a model medical research program, respected 
throughout the cancer and broader medical community for its innovative, 
transparent and accountable approach. The pioneering research performed 
through the Program has the potential to benefit not just breast 
cancer, but all cancers, as well as other diseases. Biomedical research 
is being transformed by the DOD BCRP's success.
    This Program is both innovative and incredibly streamlined. It 
continues to be overseen by an Integration Panel including 
distinguished scientists and advocates, as recommended by the IOM. 
Because there is little bureaucracy, the Program is able to respond 
quickly to what is currently happening in the research community. 
Because of its specific focus on breast cancer, it is able to rapidly 
support innovative proposals that reflect the most recent discoveries 
in the field. It is responsive, not just to the scientific community, 
but also to the public. The flexibility of the Program has allowed the 
Army to administer it with unparalleled efficiency and effectiveness.
    An integral part of this Program has been the inclusion of consumer 
advocates at every level. Breast cancer is not just a problem of 
scientists; it is a problem of people. Advocates bring a necessary 
perspective to the table, ensuring that the science funded by this 
Program is not only meritorious, but it is also meaningful and will 
make a difference in people's lives. The consumer advocates bring 
accountability and transparency to the process. Many of the scientists 
who have participated in the Program have said that working with the 
advocates has changed the way they approach research. Let me quote Dr. 
Michael Diefenbach of Mount Sinai School of Medicine:

    ``I have served as a reviewer for the Department of Defense's 
Breast and Prostate Cancer Review programs and I am a member of the 
behavioral study section for the National Cancer Institute . . . I find 
survivors or advocate reviewers as they are sometimes called bring a 
sense of realism to the review process that is very important to the 
selection and ultimately funding process of important research . . . 
Both sides bring important aspects to the review process and the 
selected projects are ultimately those that can fulfill scientific 
rigor and translatability from the research arena to clinical practice. 
I urge that future review panels include advocate reviewers in the 
review process.''

    Since 1992, nearly 600 breast cancer survivors have served on the 
BCRP peer review panels. As a result of this inclusion of consumers, 
the Program has created an unprecedented working relationship between 
the public, scientists, and the military, and ultimately has led to new 
avenues of research in breast cancer. The vital role of the advocates 
in the success of the BCRP has led to consumer inclusion in other 
biomedical research programs at DOD. This Program now serves as an 
international model.
    It is important to note that the Integration Panel that designs 
this Program has a strategic plan for how best to spend the funds 
appropriated. This plan is based on the state of the science--both what 
scientists know now and the gaps in our knowledge--as well as the needs 
of the public. While this plan is mission driven, and helps ensure that 
the science keeps that mission--eradicating breast cancer--in mind, it 
does not restrict scientific freedom, creativity or innovation. The 
Integration Panel carefully allocates these resources, but it does not 
predetermine the specific research areas to be addressed.

                      UNIQUE FUNDING OPPORTUNITIES

    The DOD BCRP research portfolio includes many different types of 
projects, including support for innovative ideas, networks to 
facilitate clinical trials, and training of breast cancer researchers.
    Developments in the past few years have begun to offer breast 
cancer researchers fascinating insights into the biology of breast 
cancer and have brought into sharp focus the areas of research that 
hold promise and will build on the knowledge and investment we have 
made. The Innovative Developmental and Exploratory Awards (IDEA) grants 
of the DOD Program have been critical in the effort to respond to new 
discoveries and to encourage and support innovative, risk-taking 
research. Concept Awards support funding even earlier in the process of 
discovery. These grants have been instrumental in the development of 
promising breast cancer research by allowing scientists to explore 
beyond the realm of traditional research and unleash incredible new 
ideas. IDEA and Concept grants are uniquely designed to dramatically 
advance our knowledge in areas that offer the greatest potential. IDEA 
and Concept grants are precisely the type of grants that rarely receive 
funding through more traditional programs such as the National 
Institutes of Health and private research programs. They therefore 
complement, and do not duplicate, other Federal funding programs. This 
is true of other DOD award mechanisms also.
    Innovator awards invest in world renowned, outstanding individuals 
rather than projects, by providing funding and freedom to pursue highly 
creative, potentially groundbreaking research that could ultimately 
accelerate the eradication of breast cancer. The Era of Hope Scholar 
Award supports the formation of the next generation of leaders in 
breast cancer research, by identifying the best and brightest 
scientists early in their careers and giving them the necessary 
resources to pursue a highly innovative vision of ending breast cancer.
    These are just a few examples of innovative funding opportunities 
at the DOD BCRP that are filling gaps in breast cancer research. 
Scientists have lauded the Program and the importance of these award 
mechanisms. In 2005, Zelton Dave Sharp wrote about the importance of 
the Concept award mechanism:

    ``Our Concept grant has enabled us to obtain necessary data to 
recently apply for a larger grant to support this project. We could 
have never gotten to this stage without the Concept award. Our eventual 
goal is to use the technology we are developing to identify new 
compounds that will be effective in preventing and/or treating breast 
cancer . . . Equally important, however, the DOD BCRP does an 
outstanding job of supporting graduate student trainees in breast 
cancer research, through training grants and pre-doctoral fellowships . 
. . The young people supported by these awards are the lifeblood of 
science, and since they are starting their training on projects 
relevant to breast cancer, there is a high probability they will devote 
their entire careers to finding a cure. These young scientists are by 
far the most important `products' that the DOD BCRP produces.''----
Zelton Dave Sharp, Associate Professor, Interim Director/Chairman, 
Institute of Biotechnology/Dept. Molecular Medicine, University of 
Texas Health Science Center (August 2005).

    The DOD BCRP also focuses on moving research from the bench to the 
bedside. DOD BCRP awards are designed to fill niches that are not 
addressed by other Federal agencies. The BCRP considers translational 
research to be the application of well-founded laboratory or other pre-
clinical insight into a clinical trial. To enhance this critical area 
of research, several research opportunities have been offered. Clinical 
Translational Research Awards have been awarded for investigator-
initiated projects that involve a clinical trial within the lifetime of 
the award. The BCRP has expanded its emphasis on translational research 
by also offering five different types of awards that support work at 
the critical juncture between laboratory research and bedside 
applications.
    The Centers of Excellence award mechanism brings together the 
world's most highly qualified individuals and institutions to address a 
major overarching question in breast cancer research that could make a 
significant contribution towards the eradication of breast cancer. Many 
of these Centers are working on questions that will translate into 
direct clinical applications. These Centers include the expertise of 
basic, epidemiology and clinical researchers, as well as consumer 
advocates.
    Dr. John Niederhuber, now the Director of the National Cancer 
Institute (NCI), said the following about the Program when he was 
Director of the University of Wisconsin Comprehensive Cancer Center in 
April, 1999:

    ``Research projects at our institution funded by the Department of 
Defense are searching for new knowledge in many different fields 
including: identification of risk factors, investigating new therapies 
and their mechanism of action, developing new imaging techniques and 
the development of new models to study [breast cancer] . . . Continued 
availability of this money is critical for continued progress in the 
Nation's battle against this deadly disease.''

    Scientists and consumers agree that it is vital that these grants 
continue to support breast cancer research. To sustain the Program's 
momentum, $150 million for peer-reviewed research is needed in fiscal 
year 2010.

                        SCIENTIFIC ACHIEVEMENTS

    One of the most promising outcomes of research funded by the DOD 
BCRP was the development of the first monoclonal antibody targeted 
therapy that prolongs the lives of women with a particularly aggressive 
type of advanced breast cancer. This drug could not have been developed 
without first researching and understanding the gene known as HER-2/
neu, which is involved in the progression of some breast cancers. 
Researchers found that over-expression of HER-2/neu in breast cancer 
cells results in very aggressive biologic behavior. The same 
researchers demonstrated that an antibody directed against HER-2/neu 
could slow the growth of the cancer cells that over-expressed the gene. 
This research, which led to the development of the targeted therapy, 
was made possible in part by a DOD BCRP-funded infrastructure grant. 
Other researchers funded by the DOD BCRP are identifying similar kinds 
of genes that are involved in the initiation and progression of cancer.
    Another example of innovation in the Program is in the area of 
imaging. One DOD BCRP awardee developed a new use for medical 
hyperspectral imaging (MHSI) technology. This work demonstrated the 
usefulness of MHSI as a rapid, noninvasive, and cost-effective 
evaluation of normal and tumor tissue during a real-time operating 
procedure. Application of MHSI to surgical procedures has the potential 
to significantly reduce local recurrence of breast tumors and may 
facilitate early determination of tumor malignancy.
    Studies funded by the DOD BCRP are examining the role of estrogen 
and estrogen signaling in breast cancer. For example, one study 
examined the effects of the two main pathways that produce estrogen. 
Estrogen is often processed by one of two pathways; one yields 
biologically active substances while the other does not. It has been 
suggested that women who process estrogen via the biologically active 
pathway may be at higher risk of developing breast cancer. This 
research will yield insights into the effects of estrogen processing on 
breast cancer risk in women with and without family histories of breast 
cancer.
    Another example of success from the Program is a study of sentinel 
lymph nodes (SLNs). This study confirmed that SLNs are indicators of 
metastatic progression of disease. The resulting knowledge from this 
study and others has led to a new standard of care for lymph node 
biopsies. If the first lymph node is negative for cancer cells, then it 
is unnecessary to remove all the lymph nodes. This helps prevent 
lymphodema which can be painful and have lasting complications.

                        FEDERAL MONEY WELL SPENT

    The DOD BCRP is as efficient as it is innovative. In fact, 90 
percent of funds go directly to research grants. The flexibility of the 
Program allows the Army to administer it in such a way as to maximize 
its limited resources. The Program is able to quickly respond to 
current scientific advances and fulfills an important niche by focusing 
on research that is traditionally under-funded. This was confirmed and 
reiterated in two separate IOM reports released in 1997 and 2004. The 
areas of focus of the DOD BCRP span a broad spectrum and include basic, 
clinical, behavioral, environmental sciences, and alternative therapy 
studies, to name a few. The BCRP benefits women and their families by 
maximizing resources and filling in the gaps in breast cancer research.
    The Program is responsive to the scientific community and to the 
public. This is evidenced by the inclusion of consumer advocates at 
both the peer and programmatic review levels. The consumer perspective 
helps the scientists understand how the research will affect the 
community and allows for funding decisions based on the concerns and 
needs of patients and the medical community.
    The outcomes of the BCRP-funded research can be gauged, in part, by 
the number of publications, abstracts/presentations, and patents/
licensures reported by awardees. To date, there have been more than 
12,241 publications in scientific journals, more than 12,000 abstracts 
and nearly 550 patents/licensure applications. The American public can 
truly be proud of its investment in the DOD BCRP. Scientific 
achievements that are the direct result of the DOD BCRP grants are 
undoubtedly moving us closer to eradicating breast cancer.

               INDEPENDENT ASSESSMENTS OF PROGRAM SUCCESS

    The success of the DOD peer-reviewed Breast Cancer Research Program 
has been illustrated by several unique assessments of the Program. The 
IOM, which originally recommended the structure for the Program, 
independently re-examined the Program in a report published in 1997. 
They published another report on the Program in 2004. Their findings 
overwhelmingly encouraged the continuation of the Program and offered 
guidance for program implementation improvements.
    The 1997 IOM review of the DOD peer-reviewed Breast Cancer Research 
Program commended the Program, stating, ``the Program fills a unique 
niche among public and private funding sources for cancer research. It 
is not duplicative of other programs and is a promising vehicle for 
forging new ideas and scientific breakthroughs in the Nation's fight 
against breast cancer.'' The 2004 report spoke to the importance of the 
program and the need for its continuation.

               TRANSPARENT AND ACCOUNTABLE TO THE PUBLIC

    The DOD peer-reviewed Breast Cancer Research Program not only 
provides a funding mechanism for high-risk, high-return research, but 
also reports the results of this research to the American people every 
2 to 3 years at a public meeting called the Era of Hope. The 1997 
meeting was the first time a federally-funded program reported back to 
the public in detail not only on the funds used, but also on the 
research undertaken, the knowledge gained from that research and future 
directions to be pursued.
    Sixteen hundred and consumers and researchers met for the fifth Era 
of Hope meeting in June, 2008. As MSNBC.com's Bob Bazell wrote, this 
meeting ``brought together many of the most committed breast cancer 
activists with some of the Nation's top cancer scientists. The 
conference's directive is to push researchers to think `out of the box' 
for potential treatments, methods of detection and prevention in 
ways.'' He went on to say ``the program . . . has racked up some 
impressive accomplishments in high-risk research projects . . .''
    One of the topics reported on at the meeting was the development of 
more effective breast imaging methods. An example of the important work 
that is coming out of the DOD BCRP includes a new screening method 
called molecular breast imaging, which helps detect breast cancer in 
women with dense breasts--which can be difficult using a mammogram 
alone. I invite you to log on to NBCC's new website http://
influence.stopbreastcancer.org/ to learn more about the exciting 
research reported at the 2008 Era of Hope.
    The DOD peer-reviewed Breast Cancer Research Program has attracted 
scientists across a broad spectrum of disciplines, launched new 
mechanisms for research and facilitated new thinking in breast cancer 
research and research in general. A report on all research that has 
been funded through the DOD BCRP is available to the public. 
Individuals can go to the Department of Defense website and look at the 
abstracts for each proposal at http://cdmrp.army.mil/bcrp/.

           COMMITMENT OF THE NATIONAL BREAST CANCER COALITION

    The National Breast Cancer Coalition is strongly committed to the 
DOD BCRP in every aspect, as we truly believe it is one of our best 
chances for finding cures for and ways to prevent breast cancer. The 
Coalition and its members are dedicated to working with you to ensure 
the continuation of funding for this Program at a level that allows 
this research to forge ahead. From 1992, with the launch of our ``300 
Million More Campaign'' that formed the basis of this Program, until 
now, NBCC advocates have appreciated your support.
    Over the years, our members have shown their continuing support for 
this Program through petition campaigns, collecting more than 2.6 
million signatures, and through their advocacy on an almost daily basis 
around the country asking for support of the DOD BCRP.
    There are 3 million women living with breast cancer in this country 
today. This year, more than 40,000 will die of the disease and more 
than 240,000 will be diagnosed. We still do not know how to prevent 
breast cancer, how to diagnose it truly early or how to cure it. It is 
an incredibly complex disease. We simply cannot afford to walk away 
from this program.
    Since the very beginning of this Program in 1992, Congress has 
stood with us in support of this important investment in the fight 
against breast cancer. In the years since, Chairman Inouye and Ranking 
Member Cochran, you and this entire Committee have been leaders in the 
effort to continue this innovative investment in breast cancer 
research.
    NBCC asks you, the Defense Appropriations Subcommittee, to 
recognize the importance of what has been initiated by the 
Appropriations Committee. You have set in motion an innovative and 
highly efficient approach to fighting the breast cancer epidemic. We 
ask you now to continue your leadership and fund the Program at $150 
million and maintain its integrity. This is research that will help us 
win this very real and devastating war against a cruel enemy.
    Thank you again for the opportunity to submit testimony and for 
giving hope to all women and their families, and especially to the 3 
million women in the United States living with breast cancer.

    Chairman Inouye. And now may I call upon Mr. Wicks, 
representing the American Association of Nurse Anesthetists.

STATEMENT OF TERRY WICKS, PAST PRESIDENT, ON BEHALF OF 
            THE AMERICAN ASSOCIATION OF NURSE 
            ANESTHETISTS (AANA)
    Mr. Wicks. Chairman Inouye, Senator Cochran, and members of 
the subcommittee, good morning.
    My name is Terry Wicks, and I am a past president of the 
40,000-member American Association of Nurse Anesthetists. The 
quality of healthcare America provides our servicemen and women 
and their dependents has long been this subcommittee's high 
priority. Today, I report to you the contributions that 
certified registered nurse anesthetists, or CRNAs, make toward 
our services' mission. I will also provide you our 
recommendations to further improve military healthcare for 
these challenging times.
    I also ask that--unanimous consent that my written 
statement be entered into the record.
    Chairman Inouye. So ordered.
    Mr. Wicks. America's CRNAs provide some 30 million 
anesthetics annually, in every healthcare setting requiring 
anesthesia care. And we provide that care safely. The Institute 
of Medicine reported, in 2000, that anesthesia care is 50 times 
safer than it was in the early 1980s.
    For the United States Armed Forces, CRNAs are particularly 
critical. In 2005, 493 active duty and 790 reservist nurse 
anesthetists provided anesthesia care indispensable to our 
Armed Forces' current mission. Not long ago one CRNA, Major 
General Gail Pollock, served as Acting Surgeon General of the 
Army.
    Today, CRNAs serve in major military hospitals, in 
educational institutions, aboard ships, and in isolated bases 
abroad and at home, and as members of forward surgical teams, 
and they are as close to the tip of the spear as they can be. 
In most of these environments, CRNAs provide anesthesia 
services, alone, with anesthesiologists, enabling surgeons and 
other clinicians to safely deliver lifesaving care to our 
soldiers.
    In recent years, however, the number of CRNAs needed in the 
Armed Forces has fallen below--the number of CRNAs in the 
services has fallen below the number needed. The private market 
for nurse anesthetists is extremely strong, and the military 
has struggled to compete. The services, this subcommittee, and 
the authorizing committees have responded with increased 
benefits to CRNAs, incentive specialty pay, and the health 
professions loan repayment program, focusing on incentives for 
multiyear agreements.
    The profession of nurse anesthesia has likewise responded. 
Our Council on Certification of Nurse Anesthetists reports 
that, in 2008, our schools produced 2,161 graduates, double the 
number since the year 2000, and 2,100 nurse anesthetists were 
certified. That growth is expected to continue, and the Council 
on Accreditation of Nurse Anesthesia Educational Programs 
projects that nurse anesthesia programs will produce over 2,400 
graduates in 2009.
    These combined actions have helped strengthen the services' 
readiness and the quality of healthcare available to our 
servicemen and women.
    So, our first recommendation to you is to extend and 
strengthen this successful incentive service pay program for 
CRNAs. The authorizing committee has extended the ISP program, 
and we encourage this subcommittee to continue funding ISP 
levels sufficient for the services to recruit and retain CRNAs 
needed for the mission.
    Our second recommendation is for the subcommittee to 
encourage all the services to adopt the joint scope of 
practice. Standard practice across the services enhances 
patient safety and the quality of healthcare of our servicemen 
and women. The Navy, in particular, has made a great deal of 
progress toward adopting the joint scope of practice of 
independent practitioners. We encourage its adoption in all the 
services.
    Like our military CRNAs that serve each and every day, the 
American Association of Nurse Anesthetists stands ready to work 
with Congress to ensure that all our Nation's military men and 
women get the care they need and deserve.
    Thank you, and I'll be happy to answer any question that 
you may have.
    Chairman Inouye. All right. Thank you very much, Mr. Wicks.
    [The statement follows:]

     Prepared Statement of Jackie S. Rowles, CRNA, MBA, MA, FAAPM, 
      President, American Association of Nurse Anesthetists (AANA)

    Chairman Inouye, Ranking Member Cochran, and Members of the 
Subcommittee: The American Association of Nurse Anesthetists (AANA) is 
the professional association that represents over 40,000 Certified 
Registered Nurse Anesthetists (CRNAs) across the United States, 
including more than 500 active duty and over 750 reservists in the 
military reported in 2009. The AANA appreciates the opportunity to 
provide testimony regarding CRNAs in the military. We would also like 
to thank this committee for the help it has given us in assisting the 
Department of Defense (DOD) and each of the services to recruit and 
retain CRNAs.

           CRNAS AND THE ARMED FORCES: A TRADITION OF SERVICE

    Let us begin by describing the profession of nurse anesthesia, and 
its history and role with the Armed Forces of the United States.
    In the administration of anesthesia, CRNAs perform the same 
functions as anesthesiologists and work in every setting in which 
anesthesia is delivered including hospital surgical suites and 
obstetrical delivery rooms, ambulatory surgical centers, health 
maintenance organizations, and the offices of dentists, podiatrists, 
ophthalmologists, and plastic surgeons. Today, CRNAs administer some 30 
million anesthetics given to patients each year in the United States. 
Nurse anesthetists are also the sole anesthesia providers in the vast 
majority of rural hospitals, assuring access to surgical, obstetrical 
and other healthcare services for millions of rural Americans.
    Our tradition of service to the military and our Veterans is 
buttressed by our personal, professional commitment to patient safety, 
made evident through research into our practice. In our professional 
association, we state emphatically ``our members' only business is 
patient safety.'' Safety is assured through education, high standards 
of professional practice, and commitment to continuing education. 
Having first practiced as registered nurses, CRNAs are educated to the 
master's degree level, and some to the doctoral level, and meet the 
most stringent continuing education and recertification standards in 
the field. Thanks to this tradition of advanced education and clinical 
practice excellence, we are humbled and honored to note that anesthesia 
is 50 times safer now than in the early 1980s (National Academy of 
Sciences, 2000). Research further demonstrates that the care delivered 
by CRNAs, physician anesthesiologists, or by both working together 
yields similar patient safety outcomes. In addition to studies 
performed by the National Academy of Sciences in 1977, Forrest in 1980, 
Bechtoldt in 1981, the Minnesota Department of Health in 1994, and 
others, Dr. Michael Pine, MD, MBA, recently concluded once again that 
among CRNAs and physician anesthesiologists, ``the type of anesthesia 
provider does not affect inpatient surgical mortality'' (Pine, 2003). 
Thus, the practice of anesthesia is a recognized specialty in nursing 
and medicine. Most recently, a study published in Nursing Research 
confirmed obstetrical anesthesia services are extremely safe, and that 
there is no difference in safety between hospitals that use only CRNAs 
compared with those that use only anesthesiologists (Simonson et al, 
2007). Both CRNAs and anesthesiologists administer anesthesia for all 
types of surgical procedures from the simplest to the most complex, 
either as single providers or together.

                   NURSE ANESTHETISTS IN THE MILITARY

    Since the mid-19th century, our profession of nurse anesthesia has 
been proud and honored to provide anesthesia care for our past and 
present military personnel and their families. From the Civil War to 
the present day, nurse anesthetists have been the principal anesthesia 
providers in combat areas of every war in which the United States has 
been engaged.
    Military nurse anesthetists have been honored and decorated by the 
U.S. and foreign governments for outstanding achievements, resulting 
from their dedication and commitment to duty and competence in managing 
seriously wounded casualties. In World War II, there were 17 nurse 
anesthetists to every one anesthesiologist. In Vietnam, the ratio of 
CRNAs to physician anesthetists was approximately 3:1. Two nurse 
anesthetists were killed in Vietnam and their names have been engraved 
on the Vietnam Memorial Wall. During the Panama strike, only CRNAs were 
sent with the fighting forces. Nurse anesthetists served with honor 
during Desert Shield and Desert Storm.
    Military CRNAs also provide critical anesthesia support to 
humanitarian missions around the globe in such places as Bosnia and 
Somalia. In May 2003, approximately 364 nurse anesthetists had been 
deployed to the Middle East for the military mission for ``Operation 
Iraqi Freedom'' and ``Operation Enduring Freedom.'' When President 
George W. Bush initiated ``Operation Enduring Freedom,'' CRNAs were 
immediately deployed. With the new special operations environment new 
training was needed to prepare our CRNAs to ensure military medical 
mobilization and readiness. Brigadier General Barbara C. Brannon, 
Assistant Surgeon General, Air Force Nursing Services, testified before 
this Senate Committee on May 8, 2002, to provide an account of CRNAs on 
the job overseas. She stated, ``Lt. Col Beisser, a certified registered 
nurse anesthetist (CRNA) leading a Mobile Forward Surgical Team (MFST), 
recently commended the seamless interoperability he witnessed during 
treatment of trauma victims in Special Forces mass casualty incident.''
    Data gathered from the U.S. Armed Forces anesthesia communities 
reveal that CRNAs have often been the sole anesthesia providers at 
certain facilities, both at home and while forward deployed. For 
decades CRNAs have staffed ships, isolated U.S. Bases, and forward 
surgical teams without physician anesthesia support. The U.S. Army 
Joint Special Operations Command Medical Team and all Army Forward 
Surgical Teams are staffed solely by CRNAs. Military CRNAs have a long 
proud history of providing independent support and quality anesthesia 
care to military men and women, their families and to people from many 
nations who have found themselves in harm's way.
    In the current mission, CRNAs are deployed all over the world, on 
land and at sea. This committee must ensure that we retain and recruit 
CRNAs for now and in the future to serve in these military deployments 
overseas. This committee must ensure that we retain and recruit CRNAs 
now and in the future to serve in these military overseas deployments 
and humanitarian efforts, and to ensure the maximum readiness of 
America's armed services.

NURSE ANESTHESIA PROVIDER SUPPLY AND DEMAND: SOLUTIONS FOR RECRUITMENT 
                             AND RETENTION

    In all of the Services, maintaining adequate numbers of active duty 
CRNAs is of utmost concern. For several years, the number of CRNAs 
serving in active duty fell short of the number authorized by the 
Department of Defense (DOD). This is further complicated by strong 
demand for CRNAs in both the public and private sectors.
    It is essential to understand that while there is strong demand for 
CRNA services in the public and private healthcare sectors, the 
profession of nurse anesthesia is working effectively to meet this 
workforce challenge. The AANA anticipates growing demand for CRNAs. Our 
evidence suggests that while vacancies exist, the demand for anesthesia 
professionals can be met if appropriate actions are taken. As of 
January 2009, there are 108 accredited CRNA schools to support the 
profession of nurse anesthesia. The number of qualified registered 
nurses applying to CRNA schools continues to climb. The growth in the 
number of schools, the number of applicants, and in production 
capacity, has yielded significant growth in the number of nurse 
anesthetists graduating and being certified into the profession, while 
absolutely maintaining and strengthening the quality and competence of 
these clinicians. The Council on Certification of Nurse Anesthetists 
reports that in 2008, our schools produced 2,161 graduates, double the 
number since 2000, and 2,110 nurse anesthetists were certified. The 
growth is expected to continue. The Council on Accreditation of Nurse 
Anesthesia Educational Programs (COA) projects that CRNA schools will 
produce over 2,417 graduates in 2009.
    This Committee can greatly assist in the effort to attract and 
maintain essential numbers of nurse anesthetists in the military by 
their support to increase special pays.

                    INCENTIVE SPECIAL PAY FOR NURSES

    According to a March 1994 study requested by the Health Policy 
Directorate of Health Affairs and conducted by DOD, a large pay gap 
existed between annual civilian and military pay in 1992. This study 
concluded, ``this earnings gap is a major reason why the military has 
difficulty retaining CRNAs.'' In order to address this pay gap, in the 
fiscal year 1995 Defense Authorization bill Congress authorized the 
implementation of an increase in the annual Incentive Special Pay (ISP) 
for nurse anesthetists from $6,000 to $15,000 for those CRNAs no longer 
under service obligation to pay back their anesthesia education. Those 
CRNAs who remained obligated receive the $6,000 ISP.
    Both the House and Senate passed the fiscal year 2003 Defense 
Authorization Act Conference report, H. Rept. 107-772, which included 
an ISP increase to $50,000. The report included an increase in ISP for 
nurse anesthetists from $15,000 to $50,000. The AANA is requesting that 
this committee fund the ISP at $50,000 for all the branches of the 
armed services to retain and recruit CRNAs now and into the future. Per 
the testimony provided in 2006 from the three services' Nurse Corps 
leaders, the AANA is aware that there is an active effort with the 
Surgeons General to closely evaluate and adjust ISP rates and policies 
needed to support the recruitment and retention of CRNAs. In 2006, 
Major General Gale Pollock, MBA, MHA, MS, CRNA, FACHE, Deputy Surgeon 
General, Army Nurse Corps of the U.S. Army stated in testimony before 
this Subcommittee, ``I am particularly concerned about the retention of 
our certified registered nurse anesthetists (CRNAs). Our inventory of 
CRNAs is currently at 73 percent. The restructuring of the incentive 
special pay program for CRNAs last year, as well as the 180 (day)-
deployment rotation policy were good first steps in stemming the loss 
of these highly trained providers. We are working closely with the 
Surgeon General's staff to closely evaluate and adjust rates and 
policies where needed.''
    There have been positive results from the Nurse Corps and Surgeons 
General initiatives to increase incentive special pays for CRNAs. In 
testimony before the House Armed Services Committee in 2007, Gen. 
Pollock stated, ``We have . . . increased the Incentive Special Pay 
(ISP) Certified Registered Nurse Anesthetist, and expanded use of the 
Health Professions Loan Repayment Program (HPLRP). The . . . Nurse 
Anesthetist bonuses have been very successful in retaining these 
providers who are critically important to our mission on the 
battlefield.'' She also stated in that same statement, ``In 2004, we 
increased the multi-year bonuses we offer to Certified Registered Nurse 
Anesthetists with emphasis on incentives for multi-year agreements. A 
year's worth of experience indicates that this increased bonus, 180-day 
deployments, and a revamped Professional Filler system to improve 
deployment equity is helping to retain CRNAs.''
    There still continues to be high demand for CRNAs in the healthcare 
community leading to higher incomes widening the gap in pay for CRNAs 
in the civilian sector compared to the military. However, the ISP and 
other incentives the services are providing CRNAs has helped close that 
gap the past 3 years, according to the most recent AANA membership 
survey data. In civilian practice, all additional skills, experience, 
duties and responsibilities, and hours of work are compensated for 
monetarily. Additionally, training (tuition and continuing education), 
healthcare, retirement, recruitment and retention bonuses, and other 
benefits often equal or exceed those offered in the military. 
Therefore, it is vitally important that the Incentive Special Pay (ISP) 
be supported to ensure retention of CRNAs in the military.
    AANA thanks this Committee for its support of the annual ISP for 
nurse anesthetists. AANA strongly recommends the continuation in the 
annual funding for ISP at $50,000 or more for fiscal year 2010, which 
recognizes the special skills and advanced education that CRNAs bring 
to the DOD healthcare system, and supports the mission of our U.S. 
Armed Forces.

                   BOARD CERTIFICATION PAY FOR NURSES

    Included in the fiscal year 1996 Defense Authorization bill was 
language authorizing the implementation of a board certification pay 
for certain clinicians who are not physicians, including advanced 
practice nurses.
    AANA is highly supportive of board certification pay for all 
advanced practice nurses. The establishment of this type of pay for 
nurses recognizes that there are levels of excellence in the profession 
of nursing that should be recognized, just as in the medical 
profession. In addition, this pay may assist in closing the earnings 
gap, which may help with retention of CRNAs.
    While many CRNAs have received board certification pay, some remain 
ineligible. Since certification to practice as a CRNA does not require 
a specific master's degree, many nurse anesthetists have chosen to 
diversify their education by pursuing an advanced degree in other 
related fields. But CRNAs with master's degrees in education, 
administration, or management are not eligible for board certification 
pay since their graduate degree is not in a clinical specialty. Many 
CRNAs who have non-clinical master's degrees either chose or were 
guided by their respective services to pursue a degree other than in a 
clinical specialty. The AANA encourages DOD and the respective services 
to reexamine the issue of restricting board certification pay only to 
CRNAs who have specific clinical master's degrees.

     DOD/VA RESOURCE SHARING: U.S. ARMY-VA JOINT PROGRAM IN NURSE 
             ANESTHESIA, FORT SAM HOUSTON, SAN ANTONIO, TX

    The establishment of the joint U.S. Army-VA program in nurse 
anesthesia education at the U.S. Army Graduate Program in Anesthesia 
Nursing, Fort Sam Houston, in San Antonio, TX holds the promise of 
making significant improvements in the VA CRNA workforce, as well as 
improving retention of DOD registered nurses in a cost effective 
manner. The current program utilizes existing resources from both the 
Department of Veterans Affairs Employee Incentive Scholarship Program 
(EISP) and VA hospitals to fund tuition, books, and salary 
reimbursement for student registered nurse anesthetists (SRNAs). This 
joint program also serves the interests of the Army.
    This VA nurse anesthesia program started in June 2004 with three 
openings for VA registered nurses to apply to and earn a Master of 
Science in Nursing (MSN) in anesthesia granted through the University 
of Texas Houston Health Science Center. In the future, the program is 
granting degrees through the Northeastern University Bouve College of 
Health Sciences nurse anesthesia educational program in Boston, Mass. 
At a time of increased deployments in medical military personnel, this 
type of VA-DOD partnership is a cost-effective model to fill these gaps 
in the military healthcare system. At Fort Sam Houston, the VA faculty 
director has covered her Army colleagues' didactic classes when they 
are deployed at a moments notice. This benefits both the VA and the DOD 
to ensure the nurse anesthesia students are trained and certified in a 
timely manner to meet their workforce obligation to the Federal 
Government as anesthesia providers. We are pleased to note that the 
Department of Veterans' Affairs Acting Deputy Under Secretary for 
Health and the U.S. Army Surgeon General approved funding to start this 
VA nurse anesthesia school in 2004. In addition, the VA director has 
been pleased to work under the direction of the Army program director 
LTC Thomas Ceremuga, CRNA, PhD to further the continued success of this 
U.S. Army-VA partnership. With modest levels of additional funding in 
the VA EISP, this joint U.S. Army-VA nurse anesthesia education 
initiative can grow and thrive, and serve as a model for meeting other 
VA workforce needs, particularly in nursing.

                               CONCLUSION

    In conclusion, the AANA believes that the recruitment and retention 
of CRNAs in the armed services is of critical concern. By Congress 
supporting these efforts to recruit and retain CRNAS, the military is 
able to meet the mission to provide benefit care and deployment care--a 
mission that is unique to the military.
    The AANA would also like to thank the Surgeons General and Nurse 
Corp leadership for their support in meeting the needs of the 
profession within the military workforce. Last, we commend and thank 
this committee for their continued support for CRNAs in the military.

    Chairman Inouye. Our next witness is the legislative 
director of the National Association for Uniformed Services, 
Mr. Rick Jones.

STATEMENT OF RICHARD A. ``RICK'' JONES, LEGISLATIVE 
            DIRECTOR, NATIONAL ASSOCIATION FOR 
            UNIFORMED SERVICES
    Mr. Jones. Chairman Inouye, Ranking Member Cochran, it's a 
privilege to be invited before your subcommittee.
    My association is very proud of the job our young 
generation is doing overseas. They risk their lives every day, 
and what we do for them is vital for the debt we owe them and 
the vital job they do for security.
    Mr. Chairman, quality healthcare is a strong incentive for 
a military career. My association asks that you ensure full 
funding is provided to maintain the value of the healthcare 
benefit that has been earned by these men and women who have 
served a career in our military.
    Mr. Chairman, the war on terror is fought by an 
overstretched force. There are signs of wear; simply too many 
missions and too few troops. We must increase troop strength; 
it must be resourced. We ask that you give priority to funding 
operation and maintenance accounts to reset, recapitalize, and 
renew the force.
    My association asks, also, that you maintain the Walter 
Reed facility. Its operations support and medical services 
require an uninterrupted care for those who are 
catastrophically wounded. We request that funds be in place to 
ensure that Walter Reed remain open, fully operational, fully 
functional, until the planned facilities at Bethesda and Fort 
Belvoir are in place and ready to give appropriate care to 
these young servicemen and women.
    Our wounded warriors deserve the Nation's best quality 
treatment. They earned it the hard way. With proper resources, 
we know our Nation will continue to hold the well-being of 
these troops in hand.
    Traumatic brain injury is the signature injury of the war 
overseas. We request that the subcommittee fund a full spectrum 
of traumatic brain injury care. The approach to this problem 
requires resources for hiring doctors, nurses, clinicians, 
general caregivers. And we must meet the needs of these men and 
women and their families. They have given so much for our 
Nation.
    We encourage the subcommittee to ensure funding for the 
Defense Department prosthetic research, to make sure that that 
is adequately funded. We support the Uniformed Service 
University Healthcare. That Federal school has the--provides 
medical instruction to all active duty troops who provide for 
wartime casualties, for national disasters, for emerging 
diseases. And we support the Armed Forces Retirement Home in 
Washington, DC, and in Gulfport, Mississippi.
    Mr. Chairman, regarding the supplemental, NAUS received a 
message from one of our members who wanted us to assure that we 
support a strong, timely action on the emergency supplemental. 
The bill will assure that, as our sons and daughters go into 
harm's way under the flag of the United States, they will have 
the vital wherewithal to carry out their mission. He's 
concerned, however, that when he sees not one dime, one penny, 
nor a shadow of concern is given to our military survivors, yet 
$1 billion will be spent on a program to replace older cars--
cash for clunkers--he says he's concerned about our survivors.
    Thank you very much for the opportunity to testify.
    Chairman Inouye. Thank you very much, Director Jones.
    [The statement follows:]

                    Prepared Statement of Rick Jones

    Chairman Inouye, Ranking Member Cochran, and members of the 
Subcommittee, it is a pleasure to appear before you today to present 
the views of the National Association for Uniformed Services on the 
fiscal year 2010 Defense Appropriations Bill.
    My name is Richard ``Rick'' Jones, Legislative Director of the 
National Association for Uniformed Services (NAUS). And for the record, 
NAUS has not received any Federal grant or contract during the current 
fiscal year or during the previous 2 years in relation to any of the 
subjects discussed today.
    As you know, the National Association for Uniformed Services, 
founded in 1968, represents all ranks, branches and components of 
uniformed services personnel, their spouses and survivors. The 
Association includes all personnel of the active, retired, Reserve and 
National Guard, disabled veterans, veterans community and their 
families. We love our country, believe in a strong national defense, 
support our troops, and honor their service.
    Mr. Chairman, the first and most important responsibility of our 
government is the protection of our citizens. As we all know, we are at 
war. That is why the defense appropriations bill is so very important. 
It is critical that we provide the resources to those who fight for our 
protection and our way of life. We need to give our courageous men and 
women everything they need to prevail. And we must recognize as well 
that we must provide priority funding to keep the promises made to the 
generations of warriors whose sacrifice has paid for today's freedom.
    At the start, I want to express NAUS concern about the amount of 
our investment in our national defense. At the height of the War on 
Terror, our current defense budget represents only a little more than 4 
percent of the gross national product, as opposed to the average of 5.7 
percent of GNP in the peacetime years between 1940 and 2000.
    We cannot look the other way in a time when we face such serious 
threats. Resources are required to ensure our military is fully 
staffed, trained, and equipped to achieve victory against our enemies. 
Leaders in Congress and the administration need to balance our 
priorities and ensure our defense in a dangerous world.
    Here, I would like to make special mention of the leadership and 
contribution this panel has made in providing the resources and support 
our forces need to complete their mission. Defending the United States 
homeland and the cause of freedom means that the dangers we face must 
be confronted. And it means that the brave men and women who put on the 
uniform must have the very best training, best weapons, best care and 
wherewithal we can give them.
    The members of this important panel have taken every step to give 
our fighting men and women the funds they need, despite allocations we 
view as insufficient for our total defense needs. You have made 
difficult priority decisions that have helped defend America and taken 
special care of one of our greatest assets, namely our men and women in 
uniform.
    And the National Association for Uniformed Services is very proud 
of the job this generation of Americans is doing to defend America. 
Every day they risk their lives, half a world away from loved ones. 
Their daily sacrifice is done in today's voluntary force. What they do 
is vital to our security. And the debt we owe them is enormous.
    Our Association does, however, have some concerns about a number of 
matters. Among the major issues that we will address today is the 
provision of a proper health care for the military community and 
recognition of the funding requirements for TRICARE for retired 
military. Also, we will ask for adequate funding to improve the pay for 
members of our armed forces and to address a number of other challenges 
including TRICARE Reserve Select and the Survivor Benefit Plan.
    We also have a number of related priority concerns such as the 
diagnosis and care of troops returning with Post Traumatic Stress 
Disorder (PTSD) and Traumatic Brain Injury (TBI), the need for enhanced 
priority in the area of prosthetics research, and providing improved 
seamless transition for returning troops between the Department of 
Defense (DOD) and the Department of Veterans Affairs (VA). In addition, 
we would like to ensure that adequate funds are provided to defeat 
injuries from the enemy's use of Improvised Explosive Devices (IEDs).

           TRICARE AND MILITARY QUALITY OF LIFE: HEALTH CARE

    Quality health care is a strong incentive to make military service 
a career. The provision of quality, timely care is considered one of 
the most important benefits afforded the career military. The TRICARE 
benefit, earned through a career of service in the uniformed services, 
reflects the commitment of a Nation, and it deserves your wholehearted 
support.
    It should also be recognized that discussions have once again begun 
on increasing the retiree-paid costs of TRICARE earned by military 
retirees and their families. We remember the outrageous statement of 
Dr. Gail Wilensky, a co-chair of the Task Force on the Future of 
Military, calling congressional passage of TRICARE for Life ``a big 
mistake.''
    And more recently, we heard Admiral Mike Mullen, the current 
Chairman of Joint Chiefs of Staff, call for an increase in TRICARE 
fees. Mullen said, ``It's a given as far as I'm concerned.''
    Fortunately, President Obama has taken fee increases off the table 
this year in the administration budget recommendation. However, with 
comments like these from those in leadership positions, there is little 
wonder that retirees and active duty personnel are upset.
    Seldom has NAUS seen such a lowing in confidence about the 
direction of those who manage the program. Faith in our leadership 
continues, but it is a weakening faith. And unless something changes, 
it is bound to affect recruiting and retention.
    criminal activity costs medicare and tricare billions of dollars
    Recent testimony and studies from the Government Accountability 
Office (GAO), the investigative arm of the United States Congress, 
shows us that at least $80 billion worth of Medicare money is being 
ripped off every year. Frankly, it demonstrates that criminal activity 
costs Medicare and TRICARE billions of dollars.
    Here are a couple of examples. GAO reports that one company billed 
Medicare for $170 million for HIV drugs. In truth, the company 
dispensed less than a million dollars. In addition, the company billed 
$142 million for nonexistent delivery of supplies and parts and medical 
equipment.
    In another example, fake Medicare providers billed Medicare for 
prosthetic arms on people who already have two arms. The fraud amounted 
to $1.4 billion of bills for people who do not need prosthetics.
    TRICARE is closely tied to Medicare and its operations are not 
immune. According to Rose Sabo, Director of the TRICARE Program 
Integrity Office, the Government Accountability Office says that 10 
percent of all health care expenditures are fraudulent. With a military 
health system annual cost of $47 billion, fraudulent purchase of care 
in the military health system would amount to $4.7 billion.
    Last year a Philippine corporation was ordered to pay back more 
than $100 million following a TRICARE fraud conviction. But despite 
TRICARE efforts to uncover this type of criminal activity, money 
continues to go out the door with insufficient resources dedicated to 
its recovery.
    Regarding TRICARE efforts to uncover fraud problems, it should be 
noted that documents by the Department of Defense Inspector General 
(DODIG) reported the fraud as early as 1998 to TRICARE Management 
Activity (TMA). But it wasn't until 2005 that TMA stopped paying the 
fraudulent claims reported 7 years earlier by DODIG.
    NAUS urges the Subcommittee to challenge DOD and TRICARE 
authorities to put some guts behind efforts to drive fraud down and out 
of the system. If left unchecked, fraud will increasingly strip away 
resources from government programs like TRICARE. And unless Congress 
directs the administration to take action, you know who will be left in 
the breach, holding the bag--the law abiding retiree and family.
    We recently learned of an incident of clear outright healthcare 
fraud involving a Medicare/TRICARE provider. The patient was a member 
of a veterans-related survivor organization and a TRICARE for Life 
beneficiary. She went to visit a doctor for the first time but was not 
content with the provider so she did not see him again. But bills 
against TRICARE continued to roll in for visits and services that were 
never provided. The beneficiary reported this suspicious activity to 
the TRICARE Management Activity. TRICARE officials were reticent to 
talk to the individual when she called them again to report additional 
fraudulent bills. When the individual's survivor organization became 
involved, it was told by TRICARE not to worry about the billings 
because the bogus charges only added up to about $2,500, which fell 
below the level of investigative action. The TMA rational is 
troublesome on many levels. It is, of course, quite possible that the 
same doctor charged TRICARE for the ``care'' of other patients.
    A fair portion of the cost of controlling Medicare and TRICARE 
fraud can be directly attributed to the detection of it. In this 
instance, a beneficiary attempted to perform her civic duty by 
``sounding the alarm'' only to be ignored by the agency that claims to 
be committed to preventing, identifying, and assisting in the 
prosecution of healthcare fraud, not only to save valuable benefit 
dollars but also to ensure that eligible beneficiaries receive 
appropriate medical care. Deceitful schemes can adversely impact the 
quality of the care received. NAUS believes that criminal activity 
should be identified and prosecuted to the fullest extent of the law, 
whether it is for $2,500 or $250,000.
    America expects its government to move courageously and tackle the 
real problems of issues like fraud in the TRICARE system and the 
Medicare system. The government should direct and resource its 
investigative teams to root out criminal activity, rather than looking 
to take money out of the pockets of military retirees. With hard work 
and honest public service, we are confident Congress will have more 
than enough money to pay for earned benefits like TRICARE.
    The National Association for Uniformed Services urges increased 
funding for the Defense Criminal Investigative Service (DCIS), the 
criminal investigative arm of the DOD Inspector General, and for the 
TRICARE Program Integrity Office, responsible for anti-fraud activity 
in the military health system.
    We urge the Subcommittee to take the actions necessary for honoring 
our obligation to those men and women who have worn the Nation's 
military uniform. Root out the corruption, fraud and waste. And confirm 
America's solemn, moral obligation to support our troops, our military 
retirees, and their families. They have kept their promise to our 
Nation, now it's time for us to keep our promise to them.

                     MILITARY QUALITY OF LIFE: PAY

    For fiscal year 2010, the administration recommends a 2.9 percent 
across-the-board pay increase for members of the Armed Forces. The 
proposal is designed, according to the Pentagon, to keep military pay 
in line with civilian wage growth.
    The National Association for Uniformed Services calls on you to put 
our troops and their families first. Our forces are stretched thin, at 
war, yet getting the job done. We ask you to express the Nation's 
gratitude for their critical service, increase basic pay and drill pay 
one-half percent above the administration's request to 3.4 percent.
    Congress and the administration have done a good job over the 
recent past to narrow the gap between civilian-sector and military pay. 
The differential, which was as great as 14 percent in the late 1990s, 
has been reduced to just under 4 percent with the January 2009 pay 
increase.
    However, we can do better than simply maintaining a rough measure 
of comparability with the civilian wage scale. To help retention of 
experience and entice recruitment, the pay differential is important. 
We have made significant strides. But we are still below the private 
sector.
    In addition, we urge the appropriations panel to never lose sight 
of the fact that our DOD manpower policy needs a compensation package 
that is reasonable and competitive. Bonuses have a role in this area. 
Bonuses for instance can pull people into special jobs that help supply 
our manpower for critical assets, and they can also entice ``old 
hands'' to come back into the game with their skills.
    The National Association for Uniformed Services asks you to do all 
you can to fully compensate these brave men and women for being in 
harm's way, we should clearly recognize the risks they face and make 
every effort to appropriately compensate them for the job they do.
         military quality of life: basic allowance for housing
    The National Association for Uniformed Services strongly supports 
revised housing standards within the Basic Allowance for Housing (BAH). 
We are most grateful for the congressional actions reducing out-of-
pocket housing expenses for servicemembers over the last several years. 
Despite the many advances made, many enlisted personnel continue to 
face steep challenge in providing themselves and their families with 
affordable off-base housing and utility expenses. BAH provisions must 
ensure that rates keep pace with housing costs in communities where 
military members serve and reside. Efforts to better align actual 
housing rates can reduce unnecessary stress and help those who serve 
better focus on the job at hand, rather than the struggle with meeting 
housing costs for their families.

           MILITARY QUALITY OF LIFE: FAMILY HOUSING ACCOUNTS

    The National Association for Uniformed Services urges the 
Subcommittee to provide adequate funding for military construction and 
family housing accounts used by DOD to provide our service members and 
their families quality housing. The funds for base allowance and 
housing should ensure that those serving our country are able to afford 
to live in quality housing whether on or off the base. The current 
program to upgrade military housing by privatizing Defense housing 
stock is working well. We encourage continued oversight in this area to 
ensure joint military-developer activity continues to improve housing 
options. Clearly, we need to be particularly alert to this challenge as 
we implement BRAC and related rebasing changes.
    The National Association for Uniformed Services also asks special 
provision be granted the National Guard and Reserve for planning and 
design in the upgrade of facilities. Since the terrorist attacks of 
Sept. 11, 2001, our Guardsmen and reservists have witnessed an upward 
spiral in the rate of deployment and mobilization. The mission has 
clearly changed, and we must recognize they account for an increasing 
role in our national defense and homeland security responsibilities. 
The challenge to help them keep pace is an obligation we owe for their 
vital service.

                     INCREASE FORCE READINESS FUNDS

    The readiness of our forces is in decline. The long war fought by 
an overstretched force tells us one thing: there are simply too many 
missions and too few troops. Extended and repeated deployments are 
taking a human toll. Back-to-back deployments means, in practical 
terms, that our troops face unrealistic demands. To sustain the service 
we must recognize that an increase in troop strength is needed and it 
must be resourced.
    In addition, we ask you to give priority to funding for the 
operations and maintenance accounts where money is secured to reset, 
recapitalize and renew the force. The National Guard, for example, has 
virtually depleted its equipment inventory, causing rising concern 
about its capacity to respond to disasters at home or to train for its 
missions abroad.
    The deficiencies in the equipment available for the National Guard 
to respond to such disasters include sufficient levels of trucks, 
tractors, communication, and miscellaneous equipment. If we have 
another overwhelming storm, hurricane or, God forbid, a large-scale 
terrorist attack, our National Guard is not going to have the basic 
level of resources to do the job right.

                    WALTER REED ARMY MEDICAL CENTER

    Another matter of great interest to our members is the plan to 
realign and consolidate military health facilities in the National 
Capital Region. The proposed plan includes the realignment of all 
highly specialized and sophisticated medical services currently located 
at Walter Reed Army Medical Center in Washington, DC, to the National 
Naval Medical Center in Bethesda, MD, and the closing of the existing 
Walter Reed by 2011.
    While we herald the renewed review of the adequacy of our hospital 
facilities and the care and treatment of our wounded warriors that 
result from last year's news reports of deteriorating conditions at 
Walter Reed Army Medical Center, the National Association for Uniformed 
Services believes that Congress must continue to provide adequate 
resources for WRAMC to maintain its base operations' support and 
medical services that are required for uninterrupted care of our 
catastrophically wounded soldiers and marines as they move through this 
premier medical center.
    We request that funds be in place to ensure that Walter Reed 
remains open, fully operational and fully functional, until the planned 
facilities at Bethesda or Fort Belvoir are in place and ready to give 
appropriate care and treatment to the men and women wounded in armed 
service.
    Our wounded warriors deserve our Nation's best, most compassionate 
healthcare and quality treatment system. They earned it the hard way. 
And with application of the proper resources, we know the Nation will 
continue to hold the well-being of soldiers and their families as our 
number one priority.
   department of defense, seamless transition between the dod and va
    The development of electronic medical records remains a major goal. 
It is our view that providing a seamless transition for recently 
discharged military is especially important for servicemembers leaving 
the military for medical reasons related to combat, particularly for 
the most severely injured patients.
    The National Association for Uniformed Services is pleased to 
receive the support of President Obama and the forward movement of 
Secretaries Gates and Shinseki toward this long-supported goal of 
providing a comprehensive e-health record.
    The National Association for Uniformed Services calls on the 
appropriations committee to continue the push for DOD and VA to follow 
through on establishing a bi-directional, interoperable electronic 
medical record. Since 1982, these two departments have been working on 
sharing critical medical records, yet to date neither has effectively 
come together in coordination with the other.
    The time for foot dragging is over. Taking care of soldiers, 
sailors, airmen, and marines is a national obligation, and doing it 
right sends a strong signal to those currently in military service as 
well as to those thinking about joining the military.
    DOD must be directed to adopt electronic architecture including 
software, data standards, and data repositories that are compatible 
with the system used at the Department of Veterans Affairs. It makes 
absolute sense and it would lower costs for both organizations.
    If our seriously wounded troops are to receive the care they 
deserve, the departments must do what is necessary to establish a 
system that allows seamless transition of medical records. It is 
essential if our Nation is to ensure that all troops receive timely, 
quality health care and other benefits earned in military service.
    To improve the DOD/VA exchange, the hand-off should include a 
detailed history of care provided and an assessment of what each 
patient may require in the future, including mental health services. No 
veteran leaving military service should fall through the bureaucratic 
cracks.

                  DEFENSE DEPARTMENT FORCE PROTECTION

    The National Association for Uniformed Services urges the 
Subcommittee to provide adequate funding to rapidly deploy and acquire 
the full range of force protection capabilities for deployed forces. 
This would include resources for up-armored high mobility multipurpose 
wheeled vehicles and add-on ballistic protection to provide force 
protection for soldiers in Iraq and Afghanistan, ensure increased 
activity for joint research and treatment effort to treat combat blast 
injuries resulting from improvised explosive devices (IEDs), rocket 
propelled grenades, and other attacks; and facilitate the early 
deployment of new technology, equipment, and tactics to counter the 
threat of IEDs.
    We ask special consideration be given to counter IEDs, defined as 
makeshift or ``homemade'' bombs, often used by enemy forces to destroy 
military convoys and currently the leading cause of casualties to 
troops deployed in Iraq. These devices are the weapon of choice and, 
unfortunately, a very efficient weapon used by our enemy. The Joint 
Improvised Explosive Device Defeat Organization (JIEDDO) is established 
to coordinate efforts that would help eliminate the threat posed by 
these IEDs. We urge efforts to advance investment in technology to 
counteract radio-controlled devices used to detonate these killers. 
Maintaining support is required to stay ahead of our enemy and to 
decrease casualties caused by IEDs.

             DEFENSE HEALTH PROGRAM--TRICARE RESERVE SELECT

    Mr. Chairman, another area that requires attention is reservist 
participation in TRICARE. As we are all aware, National Guard and 
Reserve personnel have seen an upward spiral of mobilization and 
deployment since the terrorist attacks of Sept. 11, 2001. The mission 
has changed and with it our reliance on these forces has risen. 
Congress has recognized these changes and begun to update and upgrade 
protections and benefits for those called away from family, home, and 
employment to active duty. We urge your commitment to these troops to 
ensure that the long overdue changes made in the provision of their 
heath care and related benefits is adequately resourced. We are one 
force, all bearing a critical share of the load.

               DEPARTMENT OF DEFENSE, PROSTHETIC RESEARCH

    Clearly, care for our troops with limb loss is a matter of national 
concern. The global war on terrorism in Iraq and Afghanistan has 
produced wounded soldiers with multiple amputations and limb loss who 
in previous conflicts would have died from their injuries. Improved 
body armor and better advances in battlefield medicine reduce the 
number of fatalities, however injured soldiers are coming back 
oftentimes with severe, devastating physical losses.
    In order to help meet the challenge, Defense Department research 
must be adequately funded to continue its critical focus on treatment 
of troops surviving this war with grievous injuries. The research 
program also requires funding for continued development of advanced 
prosthesis that will focus on the use of prosthetics with 
microprocessors that will perform more like the natural limb.
    The National Association for Uniformed Services encourages the 
Subcommittee to ensure that funding for Defense Department's prosthetic 
research is adequate to support the full range of programs needed to 
meet current and future health challenges facing wounded veterans. To 
meet the situation, the Subcommittee needs to focus a substantial, 
dedicated funding stream on Defense Department research to address the 
care needs of a growing number of casualties who require specialized 
treatment and rehabilitation that result from their armed service.
    We would also like to see better coordination between the 
Department of Defense Advanced Research Projects Agency and the 
Department of Veterans Affairs in the development of prosthetics that 
are readily adaptable to aid amputees.
 post traumatic stress disorder (ptsd) and traumatic brain injury (tbi)
    The National Association for Uniformed Services supports a higher 
priority on Defense Department care of troops demonstrating symptoms of 
mental health disorders and traumatic brain injury.
    It is said that Traumatic Brain Injury (TBI) is the signature 
injury of the Iraq war. Blast injuries often cause permanent damage to 
brain tissue. Veterans with severe TBI will require extensive 
rehabilitation and medical and clinical support, including neurological 
and psychiatric services with physical and psycho-social therapies.
    We call on the Subcommittee to fund a full spectrum of TBI care and 
to recognize that care is also needed for patients suffering from mild 
to moderate brain injuries, as well. The approach to this problem 
requires resources for hiring caseworkers, doctors, nurses, clinicians, 
and general caregivers if we are to meet the needs of these men and 
women and their families.
    The mental condition known as Post Traumatic Stress Disorder (PTSD) 
has been well known for over a hundred years under an assortment of 
different names. For example more than 60 years ago, Army psychiatrists 
reported, ``That each moment of combat imposes a strain so great that . 
. . psychiatric casualties are as inevitable as gunshot and shrapnel 
wounds in warfare.''
    PTSD is a serious psychiatric disorder. While the government has 
demonstrated over the past several years a higher level of attention to 
those military personnel who exhibit PTSD symptoms, more should be done 
to assist service members found to be at risk.
    Pre-deployment and post-deployment medicine is very important. Our 
legacy of the Gulf War demonstrates the concept that we need to 
understand the health of our service members as a continuum, from pre- 
to post-deployment.
    The National Association for Uniformed Services applauds the extent 
of help provided by the Defense Department, however we encourage that 
more resources be made available to assist. Early recognition of the 
symptoms and proactive programs are essential to help many of those who 
must deal with the debilitating effects of mental injuries, as 
inevitable in combat as gunshot and shrapnel wounds.
    We encourage the Members of the Subcommittee to provide for these 
funds and to closely monitor their expenditure and to see they are not 
redirected to other areas of defense spending.

                      ARMED FORCES RETIREMENT HOME

    The National Association for Uniformed Services encourages the 
Subcommittee's continued interest in providing funds for the Armed 
Forces Retirement Home (AFRH).
    We urge the Subcommittee to continue its help in providing adequate 
funding to alleviate the strains on the Washington home. Also, we 
remain concerned about the future of the Gulfport home, so we urge your 
continued close oversight on its re-construction. And we thank the 
subcommittee for the construction of a new Armed Forces Retirement Home 
at its present location in Gulfport.
    The National Association for Uniformed Services also asks the 
Subcommittee to closely review administration plans to sell great 
portions of the Washington AFRH to developers. The AFRH home is a 
historic national treasure, and we thank Congress for its oversight of 
this gentle program and its work to provide for a world-class quality-
of-life support system for these deserving veterans.
   improved medicine with less cost at military treatment facilities
    The National Association for Uniformed Services is also seriously 
concerned over the consistent push to have Military Health System 
beneficiaries age of 65 and over moved into the civilian sector from 
military care. That is a very serious problem for the Graduate Medical 
Education (GME) programs in the MHS; the patients over 65 are required 
for sound GME programs, which, in turn, ensure that the military can 
retain the appropriate number of physicians who are board certified in 
their specialties.
    TRICARE/HA policies are pushing out those patients not on active 
duty into the private sector where the cost per patient is at least 
twice as expensive as that provided within Military Treatment 
Facilities (MTFs). We understand that there are many retirees and their 
families who must use the private sector due to the distance from the 
closest MTF; however, where possible, it is best for the patients 
themselves, GME, medical readiness, and the minimizing the cost of 
TRICARE premiums if as many non-active duty beneficiaries are taken 
care of within the MTFs. As more and more MHS beneficiaries are pushed 
into the private sector, the cost of the MHS rises. The MHS can provide 
better medicine, more appreciated service and do it at improved medical 
readiness and less cost to the taxpayers.

          UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCES

    As you know, the Uniformed Services University of the Health 
Sciences (USUHS) is the Nation's Federal school of medicine and 
graduate school of nursing. The medical students are all active-duty 
uniformed officers in the Army, Navy, Air Force, and U.S. Public Health 
Service who are being educated to deal with wartime casualties, 
national disasters, emerging diseases, and other public health 
emergencies.
    The National Association for Uniformed Services supports the USUHS 
and requests adequate funding be provided to ensure continued 
accredited training, especially in the area of chemical, biological, 
radiological, and nuclear response. In this regard, it is our 
understanding that USUHS requires funding for training and educational 
focus on biological threats and incidents for military, civilian, 
uniformed first responders, and healthcare providers across the Nation.

                JOINT POW/MIA ACCOUNTING COMMAND (JPAC)

    We also want the fullest accounting of our missing servicemen and 
ask for your support in DOD dedicated efforts to find and identify 
remains. It is a duty we owe to the families of those still missing as 
well as to those who served or who currently serve. And as President 
Bush said, ``It is a signal that those who wear our country's military 
uniform will never be abandoned.''
    In recent years, funding for the Joint POW/MIA Accounting Command 
(JPAC) has fallen short, forcing the agency to scale back and even 
cancel many of its investigative and recovery operations. NAUS supports 
the fullest possible accounting of our missing servicemen. It is a duty 
we owe the families, to ensure that those who wear our country's 
uniform are never abandoned. We request that appropriate funds be 
provided to support the JPAC mission for fiscal year 2010.

              APPRECIATION FOR THE OPPORTUNITY TO TESTIFY

    As a staunch advocate for our uniformed service men and women, the 
National Association for Uniformed Services recognizes that these brave 
men and women did not fail us in their service to country, and we, in 
turn, must not fail them in providing the benefits and services they 
earned through honorable military service.
    Mr. Chairman, the National Association for Uniformed Services 
appreciates the Subcommittee's hard work. We ask that you continue to 
work in good faith to put the dollars where they are most needed: in 
strengthening our national defense, ensuring troop protection, 
compensating those who serve, providing for DOD medical services 
including TRICARE, and building adequate housing for military troops 
and their families, and in the related defense matters discussed today. 
These are some of our Nation's highest priority needs and we ask that 
they be given the level of attention they deserve.
    The National Association for Uniformed Services is confident you 
will take special care of our Nation's greatest assets: the men and 
women who serve and have served in uniform. We are proud of the service 
they give to America every day. They are vital to our defense and 
national security. The price we pay as a Nation for their earned 
benefits is a continuing cost of war, and it will never cost more nor 
equal the value of their service.
    We thank you for your efforts, your hard work. And we look forward 
to working with you to ensure we continue to provide sufficient 
resources to protect the earned benefits for those giving military 
service to America every day.
    Again, the National Association for Uniformed Services deeply 
appreciates the opportunity to present the Association's views on the 
issues before the Defense Appropriations Subcommittee.

    Chairman Inouye. Our next witness represents the Ovarian 
Cancer National Alliance, Ms. Cara Tenenbaum.

STATEMENT OF CARA TENENBAUM, SENIOR POLICY DIRECTOR, 
            OVARIAN CANCER NATIONAL ALLIANCE
    Ms. Tenenbaum. Good morning, Mr. Chairman, Vice Chairman. I 
want to thank you and all the members of the subcommittee for 
the opportunity to testify today. I'm here to talk about the 
Department of Defense's Ovarian Cancer Research Program, one of 
the congressionally directed medical research programs.
    For more than 10 years, the Ovarian Cancer National 
Alliance has worked with you to fund groundbreaking research 
that will help women diagnosed with, and women at high risk 
for, ovarian cancer. The ovarian cancer community is so 
grateful for the money you've appropriated in the past and last 
year, and we respectfully request further funding for this 
year, fiscal year 2010.
    Simply put, the ovarian cancer research program's mission 
is to eliminate ovarian cancer. It's the only Federal research 
program with that mission, conquering the disease. Of course, 
that's a complicated effort. It requires understanding the 
cause of the disease, its development, how the disease spreads, 
and recurrence.
    The Ovarian Cancer Research Program has a two-tiered peer-
review system that chooses the best potential research. Much of 
this research has been published, patented, granted further 
Federal funding by the National Cancer Institute, and/or gone 
into commercial development.
    Ovarian cancer is rarely diagnosed in early stages, when 
survival is best. There is no reliable early-detection test, 
but the Ovarian Cancer Research Program has made progress on 
this front. There is one early-detection test that's currently 
looking at commercialization--it's a urine biomarker test--and 
another you may have read about in the newspaper, the cancer-
sniffing dogs.
    The Ovarian Cancer Research Program has also developed two 
working models--animal models of ovarian cancer--for ovarian 
cancer: the mouse model, which is commonly used in research, 
but also the chicken model, which is the only other known 
animal to get ovarian cancer.
    I'm here, not only as an employee of the Ovarian Cancer 
National Alliance, but as someone with a personal interest in 
ovarian cancer. I'm an Ashkenazi Jew, my family is from Eastern 
Europe, and I have a strong family history of cancer. My 
mother, a breast cancer survivor, is here with me. And I know 
that I'm at high risk for both breast cancer and ovarian 
cancer. Because there is no early-detection test, I know that 
I, and so many other women, have to remain vigilant about our 
health.
    I'm here, and I'm honored to be here, on behalf of the 
ovarian cancer community. And I ask, on behalf of all of these 
daughters, mothers, and sisters, like my own--my sister is also 
here--that you continue to support the Ovarian Cancer Research 
Program, so that we all have a better chance at detecting 
ovarian cancer early. We ask you to continue supporting the 
Ovarian Cancer Research Program's mission to eliminate this 
deadly disease.
    Thank you for your time.
    Chairman Inouye. All right. Thank you very much, Ms. 
Tenenbaum.
    [The statement follows:]

                  Prepared Statement of Cara Tenenbaum

    Mr. Chairman, Ranking Member, and Members of the Committee, thank 
you for the opportunity to testify before you today about the 
Department of Defense's Ovarian Cancer Research Program, one of the 
Congressionally Directed Medical Research Programs.
    My name is Cara Tenenbaum, and I'm the Senior Policy Director at 
the Ovarian Cancer National Alliance. For more than 10 years, we have 
worked with you to fund ground breaking research that will help women 
diagnosed with, and women at high risk for, ovarian cancer. The ovarian 
cancer community is so grateful for the $20 million you appropriated to 
the Ovarian Cancer Research Program for fiscal year 2009. This year we 
respectfully request $30 million for this program.
    Simply put, the Ovarian Cancer Research Program's mission is to 
eliminate ovarian cancer. It is the only Federal research program that 
seeks to conquer this disease, rather than explore it. Of course, 
conquering ovarian cancer is a complicated effort that requires 
understanding the causes of the disease, its development, how it 
spreads and recurrence. The Ovarian Cancer Research Program has a two 
tiered peer review system that chooses the best potential research. 
Much of this research has been published, patented, granted further 
Federal funding by the National Cancer Institute and/or gone into 
commercial development.
    Ovarian cancer is rarely diagnosed in the early stages when 
survival is best. There is no reliable early detection test, which is 
an urgent priority for the ovarian cancer community. The Ovarian Cancer 
Research Program has funded two early detection tests that are in 
development: one in progress is the discovery and commercialization of 
a urine biomarker test; the second is a breath test, which you may have 
read about in the popular press under headlines like ``Cancer Sniffing 
Dogs.''
    The Ovarian Cancer Research Program has also developed working 
animal models of ovarian cancer: the mouse model, which is commonly 
used in medical research; and the chicken model, which is the only 
other animal known to get ovarian cancer.
    What makes this program unique is not just its use of ovarian 
cancer survivors as patient reviewers, and its transparency and low 
overhead, but the numerous grant mechanisms that provide a flexible 
model that funds innovative research.
    I am here, not only as an employee of the Ovarian Cancer National 
Alliance, but as someone with a personal interest in ovarian cancer. As 
an Ashkenazi Jew with a strong family history of cancer--my mother, a 
breast cancer survivor is here with me--I know that I am at high risk 
for both breast and ovarian cancer. As there is no reliable early 
detection test for ovarian cancer, I, like so many others, have to rely 
on my own vigilance for early detection of ovarian cancer.
    As a single woman who hopes to have children one day, I'm not ready 
for prophylactic surgery, although many of the patients I speak with 
have urged me to consider it. I am not even interested in genetic 
testing at this point, because without any action steps, I'm left with 
more worry than solutions. And so, on behalf of the millions of 
daughters, mothers, and sisters, like my own who has joined me here, I 
ask that you continue to support funding the Ovarian Cancer Research 
Program so that we all have a better chance of detecting ovarian cancer 
early, fighting it with better treatments and fulfilling the Ovarian 
Cancer Research Program's mission to eliminate this deadly disease.
    I am honored to be here representing the ovarian cancer community 
in respectfully requesting that Congress provide $30 million for the 
Ovarian Cancer Research Program (OCRP) in fiscal year 2010 as part of 
the Federal Government's investment in the Department of Defense's 
Congressionally Directed Medical Research Programs (CDMRP).

                  THE OVARIAN CANCER RESEARCH PROGRAM

    The Ovarian Cancer Research Program was created in 1997 to address 
a lack of ovarian cancer research, which remains the deadliest 
gynecologic cancer. The program uses a two tier peer review system, 
including patient advocates in both levels of review. Reviews are made 
not only on scientific rigor, but on the impact the proposed research 
will have on the disease and patients.
    To date, accomplishments reported by awardees include 371 
publications, 431 abstracts/presentations, and 15 patents applied for/
obtained. The Ovarian Cancer Research Program meets each year to 
evaluate the science and determine funding priorities for the upcoming 
year. This flexibility, along with input from patient advocates and 
leading researchers, allows the Ovarian Cancer Research Program to fill 
current research gaps. Much of the research funded by the Ovarian 
Cancer Research Program continues to get larger grants from this seed 
money, including four Ovarian Cancer Specialized Programs of Research 
Excellence (SPORES) funded by the National Cancer Institute.
    The program provides awards in the following categories: 
Collaborative Translational Research Award, Consortium Development 
Award, Idea Development Award, Ovarian Cancer Academy Award, Career 
Development Award, Translational Research Partnership Award, 
Historically Black Colleges and Universities/Minority Institution 
Collaborative Research Awards, Pilot Awards, and the New Investigator 
Research Award. From 1997 to 2009 more than $140 million has been 
awarded through these mechanisms.
    In fiscal year 2009 alone:
  --A New Investigator Award funded a research project using 
        immunotherapy, rather than chemotherapy or surgery, to fight 
        tumors;
  --An Idea Development award funded a research project on biomarkers, 
        including the discovery of a biomarker that is elevated 3 years 
        prior to clinical diagnosis of ovarian cancer;
  --An Idea Development award to explore the use of a new drug as a 
        single agent and in combination with existing chemotherapy 
        regimens to shrink tumors;
  --An Idea Development Award to fund preclinical studies of DNA 
        therapies that induce ovarian cancer cell death without any 
        toxicity to normal cells;
  --Phase II research in angiogenisis inhibitors, which stop new blood 
        vessels from forming in a tumor.

                   OVARIAN CANCER'S DEADLY STATISTICS

    According to the American Cancer Society, in 2009, more than 21,000 
American women will be diagnosed with ovarian cancer, and more than 
15,000 will lose their lives to this terrible disease. Ovarian cancer 
is the fifth leading cause of cancer death in women. Currently, more 
than half of the women diagnosed with ovarian cancer will die within 5 
years. When detected early, the 5-year survival rate increases to more 
than 90 percent, but when detected in the late stages, the 5-year 
survival rate drops to less than 29 percent.
    In the more than 30 years since the War on Cancer was declared, 
ovarian cancer mortality rates have not significantly improved. A valid 
and reliable screening test--a critical tool for improving early 
diagnosis and survival rates--still does not exist for ovarian cancer. 
Behind the sobering statistics are the lost lives of our loved ones, 
colleagues, and community members. While we have been waiting for the 
development of an effective early detection test, thousands of our 
wives, mothers, daughters, and sisters have lost their battle with 
ovarian cancer.
    More than three-quarters of women diagnosed with ovarian cancer 
will have at least one recurrence. These recurrences may indicate that 
the tumor cells are no longer responsive to some therapies, leaving 
women with fewer treatment options. The Ovarian Cancer Research Program 
spends almost 20 percent of its grant money studying recurrence. Almost 
a third is spent on understanding ovarian cancer cell biology, 
genetics, and molecular biology, areas that we hope will lead to a more 
reliable early detection test.
    In 2007, a number of prominent cancer organizations released a 
consensus statement identifying the early warning symptoms of ovarian 
cancer. Without a reliable diagnostic test, we can rely only on this 
set of vague symptoms of a deadly disease, and trust that both women 
and the medical community will identify these symptoms and act promptly 
and quickly. Unfortunately, we know that this does not always happen. 
Too many women are diagnosed late due to the lack of a test; too many 
women and their families endure life-threatening and debilitating 
treatments to kill cancer; too many women are lost to this horrible 
disease.

                                SUMMARY

    The Ovarian Cancer National Alliance has made commitments to work 
with Congress, the Administration, and other policymakers and 
stakeholders to improve the survival rate from ovarian cancer through 
education, public policy, research, and communication. Please know that 
we appreciate and understand that our Nation faces many challenges and 
that Congress has limited resources to allocate; however, we are 
concerned that without increased funding to bolster and expand ovarian 
cancer research efforts, the Nation will continue to see growing 
numbers of women losing their battle with this terrible disease.
    On behalf of the entire ovarian cancer community--patients, family 
members, clinicians, and researchers--we thank you for your leadership 
and support of Federal programs that seek to reduce and prevent 
suffering from ovarian cancer. Thank you in advance for your support of 
$30 million in fiscal year 2010 funding for the Ovarian Cancer Research 
Program.

    Chairman Inouye. You know, I just can't resist this 
temptation but if you'll forgive me, the Ovarian Cancer 
Treatment Program and the Breast Cancer Treatment Program are 
earmarks. They were not suggested by the administration or by 
experts. The Congress did that. And today we're being condemned 
for earmarks. But----
    The next witness represents the Reserve Officers 
Association, Colonel William Holahan.

STATEMENT OF COLONEL WILLIAM HOLAHAN, UNITED STATES 
            MARINE CORPS (RET.), DIRECTOR, MEMBER 
            SERVICES, RESERVE OFFICERS ASSOCIATION OF 
            THE UNITED STATES
    Colonel Holahan. Mr. Chairman, Senator Cochran, we ask the 
subcommittee that our submitted written testimony, particularly 
with regard to the unfunded equipment and priorities of those 
Reserve components noted therein, be accepted for the record.
    Chairman Inouye. It will be made part of the record.
    Colonel Holahan. Thank you for the opportunity to speak 
once again on the issue of funding for our Nation's Reserve 
components.
    Today the United States cannot conduct extended military 
operations without the augmentation and reinforcement of its 
active component. That reinforcement must come from one of two 
sources: a draft, or the National Guard and Reserve.
    The 700,000 men and women of our Nation's Reserve 
components have provided that reinforcing and augmenting force 
since 2001. They have saved the country from a draft. Every 
indication I see and hear is that they can and will continue to 
do so, if they are properly trained, equipped, and supported. 
The Congress has made great strides in increasing the funding 
for these important needs, but realism demands that we 
recognize the armed services frequently push the needs of their 
Reserve components to a lower priority in times when funding is 
tight.
    The Reserve Officers Association--and I have been 
authorized to speak on this subject for the Reserve Enlisted 
Association, as well--urges this subcommittee to specifically 
identify appropriations for resetting of both the National 
Guard and the Reserve, such that it must be spent to train and 
re-equip the Reserve components for both their homeland defense 
mission and any overseas contingency operations that they may 
be assigned.
    Each Reserve component has shared with ROA that there is a 
continued problem of tracking equipment specifically 
appropriated to the Reserves from manufacturers to a service's 
Reserve component. Frustrations continue with the belief that 
the active component either pushes out Reserve items during 
production, or actually redirects equipment in distribution 
channels before it reaches their reserve.
    At the end of the day, the Nation wants an All-Volunteer 
Force, and it does not want a draft. The only way to achieve 
both of these objectives is to ensure that the Reserve and the 
National Guard continue to be filled with the same type of 
great American patriots who serve, today. To do that, you must 
ensure that they are fully trained, properly re-equipped, and 
that their families are adequately supported. And you ensure 
that your appropriations get where you intend that they go.
    Thank you for your consideration.
    Chairman Inouye. Thank you very much, Colonel Holahan.
    [The statement follows:]

                 Prepared Statement of William Holahan

                               PRIORITIES

    CY 2009 Legislative Priorities are:
    Providing adequate resources and authorities to support the current 
recruiting and retention requirements of the Reserves and National 
Guard.
    Reset the whole force to include fully funding equipment and 
training for the National Guard and Reserves.
    Support citizen warriors, families and survivors.
    Assure that the Reserve and National Guard continue in a key 
national defense role, both at home and abroad.
Issues To Help Fund, Equip, and Train
    Advocate for adequate funding to maintain National Defense during 
overseas contingency operations.
    Regenerate the Reserve Components (RC) with field compatible 
equipment.
    Fence RC dollars for appropriated Reserve equipment.
    Fully fund Military Pay Appropriation to guarantee a minimum of 48 
drills and 2 weeks training.
    Sustain authorization and appropriation to National Guard and 
Reserve Equipment Account (NGREA) to permit flexibility for Reserve 
Chiefs in support of mission and readiness needs.
    Optimize funding for additional training, preparation and 
operational support.
    Keep Active and Reserve personnel and Operation & Maintenance 
funding separate.
    Equip Reserve Component members with equivalent personnel 
protection as Active Duty.
Issues To Assist Recruiting and Retention
    Support continued incentives for affiliation, reenlistment, 
retention and continuation in the Reserve Component.
            Pay and Compensation
    Provide permanent differential pay for Federal employees.
    Offer Professional pay for RC medical professionals.
    Eliminate the 1/30th rule for Aviation Career Incentive Pay, Career 
Enlisted Flyers Incentive Pay, Diving Special Duty Pay, and Hazardous 
Duty Incentive Pay.
            Education
    Continued funding for the GI Bill for the 21st Century.
            Health Care
    Provide Medical and Dental Readiness through subsidized preventive 
health care.
    Extend military coverage for restorative dental care for up to 180 
days following deployment.
            Spouse Support
    Repeal the SBP-Dependency Indemnity Clause (DIC) offset.
        national guard & reserve equipment & personnel accounts
    It is important to maintain separate equipment and personnel 
accounts to allow Reserve Component Chiefs the ability to direct 
dollars to needs.
Key Issues Facing the Armed Forces Concerning Equipment
    Developing the best equipment for troops fighting in overseas 
contingency operations.
    Procuring new equipment for all U.S. Forces.
    Maintaining or upgrading the equipment already in the inventory.
    Replacing the equipment deployed from the homeland to the war.
    Making sure new and renewed equipment gets into the right hands, 
including the Reserve Component.
Reserve Component Equipping Sources
    Procurement.
    Cascading of equipment from Active Component.
    Cross-leveling.
    Recapitalization and overhaul of legacy (old) equipment.
    Congressional adds.
    National Guard and Reserve Appropriations (NGREA).
    Supplemental appropriation.

                    CONTINUED RESETTING OF THE FORCE

    Resetting or reconstitution of the force is the process to restore 
people, aircraft and equipment to a high state of readiness following a 
period of higher-than-normal, or surge, operations.
    Some equipment goes through recapitalization: stripping down and 
rebuilding equipment completely. Recapitalization is one of the fastest 
ways to get equipment back to units for use, and on some equipment, 
such as trucks, recapitalization costs only 75 percent of replacement 
costs. A second option is to upgrade equipment, such as adding armor. A 
third option is to simply extend the equipment's service life through a 
maintenance program.
    Theater operations in Iraqi and Afghanistan are consuming the 
Reserve Component force's equipment. Wear and tear is at a rate many 
times higher then planned. Battle damage expends additional resources. 
New equipment suited for mountain warfare will be needed with the shift 
back into Afghanistan.
    In addition to dollars already spent to maintain this well-worn 
equipment for ongoing operations, the Armed Forces will likely incur 
large expenditures in the future to repair or replace (reset) a 
significant amount of equipment when hostilities cease. It is still 
unknown how much equipment will be left in Afghanistan.

                           PERSONNEL TRAINING

    When Reserve Component personnel participate in an operation they 
are focused on the needs of the particular mission, which may not 
include everything required to maintain qualification status in their 
military occupation specialty (MOS, AFSC, NEC).
  --There are many different aspects of training that are affected:
    --Skills that must be refreshed for specialty;
    --Training needed for upgrade but delayed by mission;
    --Ancillary training missed;
    --Professional military education needed to stay competitive;
    --Professional continuing education requirements for single-managed 
            career fields and other certified or licensed specialties 
            required annually;
    --Graduate education in business related areas to address force 
            transformation and induce officer retention.
  --Loss, training a replacement: There are particular challenges that 
        occur to the force when a loss occurs during a mobilization or 
        operation and depending on the specialty this can be a 
        particularly critical requirement that must be met:
    --Recruiting may require particular attention to enticing certain 
            specialties or skills to fill critical billets;
    --Minimum levels of training (84 days basic, plus specialty 
            training);
    --Retraining may be required due to force leveling as emphasis is 
            shifted within the service to meet emerging requirements.

                              END STRENGTH

    The ROA would like to place a moratorium on reductions to the Guard 
and Reserve manning levels. Manpower numbers need to include not only 
deployable assets, but individuals in the accession pipeline. ROA urges 
this subcommittee to fund to support:
  --Army National Guard of the United States, 358,200.
  --Army Reserve, 206,000.
  --Navy Reserve, 66,700.
  --Marine Corps Reserve, 39,600.
  --Air National Guard of the United States, 106,756.
  --Air Force Reserve, 69,900.
  --Coast Guard Reserve, 10,000.
    In a time of war and the highest OPTEMPO in recent history, it is 
wrong to make cuts to the end strength of the Reserve Components. We 
need to pause to permit force planning and strategy to catch-up with 
budget reductions.
    With the Navy's requested increase by 2,500 sailors, corresponding 
increases need to be made in the Navy Reserve. The Navy Reserve is 
providing most of the individual augmentee support for the Navy in 
overseas operations. Five years ago was the last time the Navy 
evaluated its USNR requirements; such a study needs to be done again.

                               READINESS

    Readiness is a product of many factors, including the quality of 
officers and enlisted, full staffing, extensive training and exercises, 
well-maintained weapons and authorized equipment, efficient procedures, 
and the capacity to operate at a fast tempo.
    The Defense Department does not attempt to keep all Active units at 
the C-1 level. The risk is without resetting the force returning Active 
and Reserve units will be C-4 or lower because of missing equipment, 
and without authorized equipment their training levels will 
deteriorate.

               NONFUNDED ARMY RESERVE COMPONENT EQUIPMENT

    The Army National Guard and Army Reserve have made significant 
contributions to ongoing military operations, but equipment shortages 
and personnel challenges continue and if left unattended, may hamper 
the Reserves' preparedness for future overseas and domestic missions. 
To provide deployable units, the Army National Guard and the Army 
Reserve have cross-leveled large quantities of personnel and equipment 
to deploying units, an approach that has resulted in growing shortages 
in nondeployed units.
Army Reserve Unfunded Requirements
    The 21st Century Army Reserve mobilizes continuously with 12 
percent of its force consistently deployed in support of the current 
contingencies. However, the Army Reserve lacks the ability to fully 
train Army Reserve Soldiers on the same equipment the Army uses in the 
field. To prepare to perform a dangerous mission, soldiers must have 
modern equipment and state-of-the-art training facilities. The Army 
Reserve has 73 percent of its required equipment on hand. Under 
currently programmed funding, the Army Reserve should reach 85 percent 
equipment on hand by fiscal year 2016 with the goal of 100 percent on 
hand by fiscal year 2019.

            C-12 Huran Cargo Transport Airplane (7)--$63 Million
    Replace aircraft permanently transferred to Intelligence, 
Surveillance and Reconnaissance (ISR) mission. Seven below total 
authorized count. Capacity lift 5,185 lbs, distance 1,710 miles.
            Communications Security (COMSEC) AKMS/Computer Sets 
                    (3648)--$8.6 Million
    Provide secure communications to (4) companies with AN/GYK-49(V)1 
&AN/PYQ-10(C) sets.
            Cargo Bed, Demountable PLS 8 x20 (5498)--$109.7 Million
    Transportation Support: pacing item for Medium Truck Company, 360 
each.
            Optical Data Entry Reader (115)--$25.5 Million
    Imaging/Reader automation to fix trailer transfer and Inland Cargo 
units.
            Heavy/Medium Trailers (1760)--$115.8 Million
    Cargo--MTV with dropsides (M1095); flatbed--LMTV w/dropsides 
(M1086)
Army National Guard Unfunded Equipment Requirements
    Army National Guard (ARNG) units deployed overseas have the most 
up-to-date equipment available. However, a significant amount of 
equipment is currently unavailable to the Army National Guard in the 
States due to continuing rotational deployments and emerging 
modernization requirements. Many States have expressed concern about 
the resulting shortfalls of equipment for training as well as for 
domestic emergency response operations.
            Aviation Upgrade Kits--$100.5 Million
    UH-60A to UH-60L Upgrade Kits; LUH-72A S&S Mission Equipment 
Package.
            Homeland Security Command and Control Package--$168.4 
                    Million
    Joint Incident Site Communications and Interim Satcom Incident 
Site. (JISC & ISISCS); Wideband Imagery Satellite Terminals, and Full 
Motion Video (FMV) downlink to support state and local leaders during 
natural and manmade disasters.
            M777A2 Lightweight 155mm Howitzer (18)--$54 Million
    To ensure readiness of Army National Guard (ARNG) Fire Support, 
Field Artillery units.
            Transportation--$1.15 Billion
    FMTV/LMTV Cargo Trucks; HMMWV; HTV 8x8 Heavy Trucks; Tactical 
Trailers.
            Force XXI Battlefield Command Brigade and Below (FBCB2)--
                    $179 Million
    To ensure readiness of ARNG Combat Support and Combat Service 
Support (CS/CSS) units.
    Also needed: To organize a second Stryker Brigade Combat Team 
(SBCT)

            AIR FORCE RESERVE COMPONENT EQUIPMENT PRIORITIES

    ROA continues to support military aircraft Multi-Year Procurement 
(MYP) beginning with 15 for more C-17s and 8 more C-130Js for USAir 
Force and its Reserve. Further, ROA supports additional funding for 
continued Research and Development of the next generation bomber.
Air Force Reserve Unfunded Requirements
    The Air Force Reserve (AFR) mission is to be an integrated member 
of the Total Air Force to support mission requirements of the joint 
warfighter. To achieve interoperability in the future, the Air Force 
Reserve top priorities for nonfunded equipment are:
            C-40 D multi-role airlift (3)--$370 Million
    To replace aging C-9 C's at Scott Air Force Base: mission requests 
exceed aircraft availability.
            KC-130J Aircraft (2)--$148 Million
    These Aircraft are needed to fill the shortfall in Search and 
Rescue refueling capabilities.
            Cyber Systems Defense--$109 Million
    Upgrade Active Duty and AF Reserve network infrastructure to ensure 
overall A.F. mission.
            Helmet Mounted Cueing System--$38 Million
    Upgrade and enhancement to engagement systems.
Defensive Systems
    Airlift Defensive Systems (16) Install ADS systems onto (16) AFRC 
C-5As at Lackland Air Force Base against IR missile threats.
    Infra-Red Counter Measures (42) Procure and install (42) LAIRCM 
lite systems on AFRC C-5s. Protects high value national assets against 
advanced IR missile threats.
    Missile Warning System (MWS) Upgrade/replacement--Improve and 
integrate the existing Electronic Attack (EA) for A-10 and F-16 and 
Electronic Protection (EP) for A-10, F-16 and HC-130.
Air National Guard Unfunded Equipment Requirements
    Shortfalls in equipment will impact the Air National Guard's 
ability to support the National Guard's response to disasters and 
terrorist incidents in the homeland. Improved equipping strengthens 
readiness for both overseas and homeland missions and improves the ANG 
capability to train on mission-essential equipment.
            Infra-Red Counter Measures--$240.7 Million
    Procure and install LAIRCM systems on C-5, C-17, C-130, 130, HC-
130, EC-130, KC-135 a/c.
            Air Defensive Systems--$59.31 Million
    Install ADS systems onto C-5, C-17, F-15 aircraft.
            Missile Warning Systems--$22.48 Million
    Upgrade/replacement--Improve and integrate the existing Electronic 
Attack (EA) and Electronic Protection (EP) for A-10, C-130.
            Rear Aspect Visual Scan Capability/Safire--$57.2 Million
    Increase the field of view on C-5, C-17 transports and add a larger 
window in the C-130 paratroop doors.
            Personal Protective Equipment, M4 Rifles--$34.77 Million
            Force Protection Mobility Bag Upgrades/Replacements--
                    $113.72 Million

                    NAVY RESERVE UNFUNDED PRIORITIES

    Active Reserve Integration (ARI) aligns Active and Reserve 
component units to achieve unity of command. Navy Reservists are fully 
integrated into their Active component supported commands. Little 
distinction is drawn between Active component and Reserve component 
equipment, but unique missions remain.
            C-40 A Combo Cargo/Passenger Airlift (4)--$402 Million
    The Navy requires a Navy Unique Fleet Essential Airlift Replacement 
Aircraft. The C-40A is able to carry 121 passengers or 40,000 pounds of 
cargo, compared with 90 passengers or 30,000 pounds for the C-9.
            KC-130J Super Hercules Aircraft Tankers (4)--$160 Million
    These Aircraft are needed to fill the shortfall in Navy Unique 
Fleet Essential Airlift (NUFEA). Procurement price close to upgrading 
existing C-130Ts with the benefit of a long life span.
            P-3 Maritime Patrol Aircraft Fixes--$312 Million
    Due to the grounding of 39 airframes in December 2007, there is a 
shortage of maritime patrol and reconnaissance aircraft, which are 
flown in associate Active and Reserve crews. P-3 wing crack kits are 
still needed for fiscal year 2010.
            F-5 Radar/Electronic Attack Block-2--$148.3 Million
    Aircraft used in adversarial training of F-18 pilots. Heightens 
adversary competition conditions.
            C-40 Hangar, Oceana--$31.4 Million

                MARINE CORPS RESERVE UNFUNDED PRIORITIES

    The Marine Corps Reserve faces two primary equipping challenges, 
supporting and sustaining its forward deployed forces in the Long War 
while simultaneous resetting and modernizing the Force to prepare for 
future challenges. Only by equally equipping and maintaining both the 
Active and Reserve forces will an integrated Total Force be seamless.
            KC-130J Super Hercules Aircraft tankers (4)--$160 Million
    These Aircraft are needed to fill the shortfall in Marine Corps 
Essential Airlift. Procurement price close to upgrading existing C-
130Ts with the benefit of a long life span. Commandant, USMC, has 
testified that acquisition must be accelerated.
            Light Armored Vehicles--LAV (14)--$21 Million
    A shortfall in a USMCR light armor reconnaissance company, the LAV-
25 is an all-terrain, all-weather vehicle with night capabilities. It 
provides strategic mobility to reach and engage the threat, tactical 
mobility for effective use of fire power.
            Training Allowance (T/A) Shortfalls--$187.7 Million
    Shortfalls consist of over 300 items needed for individual combat 
clothing and equipment, including protective vests, poncho, liner, 
gloves, cold weather clothing, environmental test sets, took kits, 
tents, camouflage netting, communications systems, engineering 
equipment, combat and logistics vehicles and weapon systems.
            MCB Vehicle Maintenance Facility--$10.9 Million
    Additional vehicle storage and maintenance: routine preventive and 
corrective maintenance are still performed throughout the country by 
Marines. Ground equipment maintenance efforts have expanded over the 
past few years, leveraging contracted services and depot-level 
capabilities.

                      TRANSPARENCY OF PROCUREMENT

    Each Reserve Component has shared with ROA that there is a 
continued problem of tracking equipment specifically appropriated to 
the Reserves from manufacturer to a service's Reserve Component. 
Frustrations continue with a belief that the Active Component either 
pushes out Reserve items during production or actual misappropriates 
equipment in distribution before it reaches the Reserve.

           NATIONAL GUARD AND RESERVE EQUIPMENT APPROPRIATION

    Much-needed items not funded by the respective service budget are 
frequently purchased through this appropriation. In some cases it is 
used to bring unit equipment readiness to a needed State for 
mobilization. With the war, the Reserve and Guard are faced with 
mounting challenges. Funding levels, rising costs, lack of replacement 
parts for older equipment, etc. have made it difficult for the Reserve 
Components to maintain their aging equipment, not to mention 
modernizing and recapitalizing to support a viable legacy force. The 
Reserve Components benefit greatly from a National Military Resource 
Strategy that includes a National Guard and Reserve Equipment 
Appropriation.

                       CIOR/CIOMR FUNDING REQUEST

    The Interallied Confederation of Reserve Officers (CIOR) was 
founded in 1948, and its affiliate organization, The Interallied 
Confederation of Medical Reserve Officers (CIOMR) was founded in 1947. 
The organization is a nonpolitical, independent confederation of 
national reserve associations of the signatory countries of the North 
Atlantic Treaty (NATO). Presently there are 16 member nation 
delegations representing over 800,000 reserve officers. CIOR supports 
four programs to improve professional development and international 
understanding.
    Military Competition.--The CIOR Military Competition is a strenuous 
3-day contest on warfighting skills among Reserve Officers teams from 
member countries. These contests emphasize combined and joint military 
actions relevant to the multinational aspects of current and future 
Alliance operations.
    Language Academy.--The two official languages of NATO are English 
and French. As a non-government body, operating on a limited budget, it 
is not in a position to afford the expense of providing simultaneous 
translation services. The Academy offers intensive courses in English 
and French as specified by NATO Military Agency for Standardization, 
which affords international junior officer members the opportunity to 
become fluent in English as a second language.
    Partnership for Peace (PfP).--Established by CIOR Executive 
Committee in 1994 with the focus of assisting NATO PfP nations with the 
development of Reserve officer and enlisted organizations according to 
democratic principles. CIOR's PfP Committee, fully supports the 
development of civil-military relationships and respect for democratic 
ideals within PfP nations. CIOR PfP Committee also assists in the 
invitation process to participating countries in the Military 
Competition.
    Young Reserve Officers Workshop.--The workshops are arranged 
annually by the NATO International Staff (IS). Selected issues are 
assigned to joint seminars through the CIOR Defense and Security Issues 
(SECDEF) Commission. Junior grade officers work in a joint seminar 
environment to analyze Reserve concerns relevant to NATO.
    Dues do not cover the workshops and individual countries help fund 
the events. The Department of the Army as Executive Agent hasn't been 
funding these programs. Senate leadership support would be beneficial.

                               CONCLUSION

    DoD is in the middle of executing a war and operations in Iraq and 
Afghanistan. The impact of these operations is affecting the very 
nature of the Guard and Reserve, not just the execution of Roles and 
Missions. Without adequate funding, the Guard and Reserve may be viewed 
as a source to provide funds to the Active Component. It makes sense to 
fully fund the most cost efficient components of the Total Force, its 
Reserve Components.
    At a time of war, we are expending the smallest percentage of GDP 
in history on National Defense. Funding now reflects close to 4 percent 
of GDP including supplemental dollars. ROA has a resolution urging that 
defense spending should be 5 percent to cover both the war and homeland 
security. While these are big dollars, the President and Congress must 
understand that this type of investment is what it will take to equip, 
train and maintain an all-volunteer force for adequate National 
Security.
    The Reserve Officers Association, again, would like to thank the 
sub-committee for the opportunity to present our testimony. We are 
looking forward to working with you, and supporting your efforts in any 
way that we can.

    Chairman Inouye. Our next witness is the Secretary of the 
Associations for America's Defense, Ms. Elizabeth Cochran.

STATEMENT OF ELIZABETH COCHRAN, SECRETARY, ASSOCIATIONS 
            FOR AMERICA'S DEFENSE
    Ms. Cochran. Thank you, Mr. Chairman and Mr. Vice Chairman.
    The Associations for America's Defense is very grateful to 
testify today, and we'd like to submit written testimony at 
this time.
    We would like to thank this subcommittee for its 
stewardship on defense issues and setting an example by its 
nonpartisan leadership. The Associations for America's Defense 
is concerned that U.S. defense policy is sacrificing future 
security for near-term readiness. It's been suggested that the 
United States should focus on wars we're fighting today, not on 
future wars that may not occur. The Pentagon's priorities sound 
like money will be redirected to more immediate needs.
    Erosion in the capability in the force means added risk 
will be faced today and tomorrow. According to the Office of 
Management and Budget, base defense spending, projected at $534 
billion in 2010, will stay relatively flat for the next 5 
years. We disagree with placing such budgetary constraints on 
defense, because it can lead to readiness and effectiveness 
being subtly degraded, which won't be immediately evident. We 
support increasing defense spending to 5 percent of the gross 
domestic product during times of war to cover procurement, and 
prevent unnecessary personnel end-strength cuts.
    The Associations for America's Defense is alarmed about the 
fiscal year 2010 unfunded programs list, submitted by the 
military services, which is 87 percent lower than fiscal year 
2009's request. We're concerned the unfunded requests were 
driven by budgetary factors more than risk assessment, which 
will impact national security.
    As always, our military will do everything to accomplish 
its missions, but response time is measured by equipment 
readiness. Due to the DOD's tactical aircraft acquisition 
programs having been blunted by cost and schedule overruns, the 
Air Force has offered to retire 250 fighter jets in one year, 
which the Secretary of Defense has accepted. Until new systems 
are acquired in sufficient quantities to replace legacy fleets, 
those legacy systems must be sustained. Airlift contributions 
in moving cargo and passengers are indispensable to American 
warfighters. As the military continues to become more 
expeditionary, more airlifts in C-17 and C-130Js will be 
required. Procurement needs to be accelerated and modernized, 
and mobility requirements need to be reported upon.
    The need for air refueling is utilized worldwide in DOD 
operations. But, significant numbers of tankers are old and 
plagued with structural problems. The Air Force would like to 
retire as many as 131 of the Eisenhower-era KC-135E tankers by 
the end of the decade. These aircraft must be replaced.
    Finally, we ask this subcommittee to continue to provide 
appropriations for the National Guard and Reserve equipment 
requirements. The National Guard's goal is to make at least 
one-half the army and air assets available to Governors and 
adjutants general at any given time. Appropriating funds to 
Guard and Reserve equipment provides Reserve chiefs with 
flexibility prioritizing funding.
    Once again, I thank you for your ongoing support for the 
Nation's armed services and the fine men and women who defend 
our country. Please contact us with any questions.
    Thank you.
    Chairman Inouye. Thank you very much, Ms. Cochran.
    And I thank the panel.
    [The statement follows:]

                Prepared Statement of Elizabeth Cochran

                              INTRODUCTION

    Mister Chairman and distinguished members of the Committee, the 
Associations for America's Defense (A4AD) is again very grateful for 
the invitation to testify before you about our views and suggestions 
concerning current and future issues facing the defense appropriations.
    The Association for America's Defense is an adhoc group of 12 
military and veteran associations that have concerns about national 
security issues. Collectively, we represent armed forces members and 
their families, who are serving our Nation, or who have done so in the 
past.

              CURRENT VERSUS FUTURE: ISSUES FACING DEFENSE

    The Associations for America's Defense would like to thank this 
subcommittee for the on-going stewardship that it has demonstrated on 
issues of Defense. At a time of war, its pro-defense and non-partisan 
leadership continues to set the example.
Emergent Risks
    Members of this group are concerned that U.S. Defense policy is 
sacrificing future security for near term readiness. So focused are our 
efforts to provide security and stabilization in Afghanistan and a 
withdrawal from Iraq, that risk is being accepted as an element in 
future force planning. Force planning is being driven by current 
overseas contingency operations, and to allow for budget limitations. 
Careful study is needed to make the right choice. A4AD is pleased that 
Congress and this subcommittee continue oversight in these decisions.
    What seems to be overlooked is that the United States is involved 
in a Cold War as well as a Hot war. With the United States preoccupied 
with the Middle East, North Korea, China, Russia, and Iran are growing 
areas of risk.

Korean Peninsula
    Provocatively, North Korea successfully tested a nuclear weapon at 
full yield, unilaterally withdrew from that 1953 armistice, and 
continues to test-fire missiles from both its coasts. The South sent a 
high speed missile patrol boat into Western waters in response to a 
reported amphibious assault training staged by the North. South Korean 
and U.S. troops have been put on the highest alert level in 3 years, 
and the South Korean Coast Guard is escorting its fishing boats.
    North Korea has 1.2 million troops, with the 655,000 South Korean 
soldiers and 30,000 U.S. troops stationed to the South. While not an 
immediate danger to the United States, North Korea is still viewed as a 
threat by its neighbors, and represents a destabilizing factor in Asia. 
Recent events may be mere posturing, but North Korea is still a failed 
state, where misinterpretation clouded by hubris could start a war. The 
North has prepositioned and could fire up to 250,000 rounds of heavy 
artillery in the first 48 hours of war along the border and into Seoul.

China
    China remains the elephant in the war room. As the United States 
expends resources in the Middle East and continues to restructures the 
military to fight terrorism, China patiently waits for America's 
ability to project force to weaken.
    China's armed forces are the biggest in the world and have 
undergone double-digit increases in military spending since the early 
1990s. The Pentagon has reported that China's actual spending on 
military is up to 250 percent higher than figures reported by the 
Chinese government, and their cost of materials and labor is much 
lower. This year, China chose to increase its defense budget by almost 
15 percent. China's build-up of sea and air military power appears 
aimed at the United States, according to Admiral Michael Mullen, the 
chairman of the U.S. Joint Chiefs of Staff.
    The U.S. military strategy cannot be held hostage by international 
debts. While China is the biggest foreign holder of U.S. Treasuries 
with $768 billion at the end of the first quarter, we can't be lulled 
into a sense of complacency.

Russia
    Russian President Dmitry Medvedev has called for ``comprehensive 
rearmament.'' Last March, in televised remarks to defense ministry 
officials, Medvedev proclaimed the ``most important task is to re-equip 
the [Russian] armed forces with the newest weapons systems.'' Russia's 
defense budget could jump 30 percent this year, increasing Moscow's 
military might and preserving its arms-export industry, reports Peter 
Brookes of the Heritage Foundation. The country will aim for 70 percent 
of its weaponry to be ``modern'' by 2020, Defense Minister Anatoly 
Serdyukov said, according to RIA-Novosti, the state-run news agency.
    Following an April meeting with President Medvedev, the Obama 
administration is seeking a new start with Russia. Underlying U.S.-
Russian frictions are issues of NATO military expansion to countries 
like Georgia and Ukraine, and U.S. plans to base a missile defense 
system in Poland and the Czech Republic to defend against attacks from 
countries like Iran. Concerns have been voiced about a European 
military threat to Russian gas and oil fields.

Iran
    While Iran lobs petulant rhetoric towards the United States, the 
real international tension is between Israel and Iran. Israel views 
Tehran's atomic work as a threat, and would consider military action 
against Iran. If Iran was attacked, it has threatened to ``eliminate 
Israel.'' Israeli leadership has warned Iran that any attack on Israel 
would result in the ``destruction of the Iranian nation.'' Israel is 
believed to have between 75 to 200 nuclear warheads with a megaton 
capacity.

Force Structure: An Erosion in Capability
    Supporting the National Security Strategy requires that the United 
States to maintain robust and versatile military forces that can 
accomplish a wide variety of missions. The two major theater war (2MTW) 
approach was an innovation at the end of the Cold War. It was based on 
the proposition that the United States should prepare for the 
possibility that two regional conflicts could arise at the same time, 
so that if the United States were engaged in a conflict in one theater, 
an adversary in a second theater could be prevented from gaining his 
objectives in the other. In 1996, the United States adopted the ``win-
hold-win'' concept--a strategy to fight and win one major regional 
contingency, with enough force to hold another foe at a stalemate until 
the first battle is won, and then to move the forces to the second 
theater.
    The Bush Administration's ``1-4-2-1 strategy'' from the 2001 
Quadrennial Defense Review (QDR) called their new military strategy 
``1-4-2-1,'' which meant: ``1'' Defend the United States; ``4'' Deter 
aggression in four critical regions: Europe, Northeast Asia, Southwest 
Asia, the Middle East; ``2'' Maintain the capability to combat 
aggression in two of these regions simultaneously; and ``1'' Maintain a 
capability to ``win decisively'' up to and including forcing regime 
change and occupation in one of those two conflicts ``at a time and 
place of our choosing.''
    A top to bottom review in 2005, suggested change to the national 
strategy as to mount one conventional campaign while devoting more 
resources to defending American territory and antiterrorism efforts.
    In a speech announcing the fiscal year 2010 Defense Budget, 
Secretary of Defense Robert Gates stated ``Our conventional 
modernization goals should be tied to the actual and prospective 
capabilities of known future adversaries--not by what might be 
technologically feasible for a potential adversary given unlimited time 
and resources . . .''
    ``This budget is less about numbers than it is about how the 
military thinks about the nature of warfare and prepares for the 
future,'' Secretary of Defense Robert Gates testified before the Senate 
Armed Services Committee on May 14, 2009. Gates says that the United 
States should focus on the wars that we are fighting today, not on 
future wars that may never occur. He also asserts that U.S. 
conventional capabilities will remain superior for another 15 years. 
Anthony Cordesman, a national security expert for the Center for 
Strategic and International Studies, says that Gates' plan should be 
viewed as a set of short-term fixes aimed at helping ``a serious cost 
containment problem,'' not a new national security policy.
    War planners are often accused of planning for the last war. 
Secretary Gates speaks to enhancing the capabilities of fighting 
today's wars. A concern arises on whether the Pentagon's focus should 
be on irregular or conventional warfare, and whether it should be 
preparing for a full scale ``peer'' war. From his priorities, it sounds 
like Secretary Gates will be redirecting money to more immediate needs.
    Each strategy permitted change to resize a force that was 
originally oriented to global war to a smaller force focused on smaller 
regional contingencies. But the erosion in the capability and the force 
means added risks will be faced today and tomorrow than when the 2MTW 
standard was established. ``The danger is in the poverty of 
expectation, a routine obsession with danger that are familiar rather 
than likely,'' wrote Thomas Schelling, in the Forward to: Pearl Harbor: 
Decision and Warning (1962).

Funding for the Future
    Base defense spending, projected at $534 billion in 2010, will stay 
relatively flat for the next 5 years, counting inflation, according to 
spending outlines by the Office of Management and Budget. ``It is 
simply not reasonable to expect the defense budget to continue 
increasing at the same rate it has over the last number of years,'' 
Secretary Gates told the Senate committee. ``We should be able to 
secure our Nation with a base budget of more than half a trillion 
dollars.''

Hollow Force
    The Associations for America's Defense couldn't disagree more by 
placing such budgetary constraints on the defense. A4AD members 
question the spending priorities of the current administration. 
``Fiscal restraint for defense and fiscal largesse for everything 
else,'' commented Rep. John McHugh at a HASC hearing on the Defense 
Budget in May.
    The result of such budgetary policy could again lead to a hollow 
force whose readiness and effectiveness has been subtly degraded and 
whose lessened efficiency will not be immediately evident. This process 
which echoes of the past, raises no red flags and sounds no alarms, and 
the damage can go unnoticed and unremedied until a crisis arises that 
highlights just how much readiness has decayed.

Defense as a Factor of GDP
    Secretary Gates has warned that that each defense budget decision 
is ``zero sum,'' providing money for one program will take money away 
from another. A4AD encourages the appropriations subcommittee on 
defense to scrutinize the recommended spending amount for defense. Each 
member association supports increasing defense spending to 5 percent of 
Gross Domestic Product during times of war to cover procurement and 
prevent unnecessary personnel end strength cuts.

A Changing Manpower Structure
    Secretary Gates proposed spending an extra $11 billion to finish 
enlarging the Army and the Marine Corps and to halt reductions in the 
Air Force and the Navy. The Navy has asked for an increase in end 
strength of nearly 2,500 to 328,800 sailors. The Navy Reserve (USNR) on 
the other hand would be reduced to 65,506, a cut of 1,194. The Navy 
Reserve continues to be cut, and it is the main contributor to the 
Navy's individual augmentees (IA) force on the ground in Iraq and, now, 
Afghanistan. Of the requested dollars to support 4,400 by the Navy, the 
Navy Reserve supplies 3,000.
    A4AD supports a moratorium on further cuts including the Navy 
Reserve. We further suggest that a Zero Based Review (ZBR) be performed 
to evaluate the manning level of the USNR. The last review was done 
over 5 years ago, and much has changed since.

Maintaining a Surge Capability
    The armed forces need to provide critical surge capacity for 
homeland security, domestic and expeditionary support to national 
security and defense, and response to domestic disasters, both natural 
and man-made that goes beyond operational forces. A strategic surge 
construct includes manpower, airlift and air refueling, sealift 
inventory, logistics, and communication to provide a surge-to-demand 
operation. This requires funding for training, equipping and 
maintenance of a mission-ready strategic reserve composed of active and 
reserve units. An additional requirement is excess infrastructure which 
would permit the housing of additional forces that are called-up beyond 
the normal operational force.

Dependence on Foreign Partnership
    Part of the U.S. military strategy is to rely on long-term 
alliances to augment U.S. forces. ``To succeed in any efforts the 
Department must harness and integrate all aspects of national power and 
work closely with a wide range of allies, friends and partners,'' as 
stated in a DOD progress report. ``Our strategy emphasizes the 
capacities of a broad spectrum of partners . . . We must also seek to 
strengthen the resiliency of the international system . . . helping 
others to police themselves and their regions.'' It's been recommended 
in the budget to increase funding of global partnerships efforts by 
$500 million in the fiscal year 2010 base budget proposal, to support 
training and equipping foreign militaries to undertake counter 
terrorism and stability operations. Performances by allies have yet 
proven to be a good return on investment.
    The risk of basing a national security policy on foreign interests 
and good world citizenship is increasingly uncertain because the United 
States does not necessarily control our foreign partners; countries 
whose objectives may differ with from own. This is more an exercise of 
consensus building rather than security integration. Alliances should 
be viewed as a tool and a force multiplier, but not the foundation of 
National Security.

                         UNFUNDED REQUIREMENTS

    The fiscal year 2010 Unfunded Program Lists submitted by the 
military services to Congress was 87 percent less than was requested 
for fiscal year 2009 with requests for only $3.44 billion versus $29.9 
billion the year before. A4AD has concerns that the unfunded requests 
were driven more by budgetary factors than risk assessment which will 
impact national security. The following are lists submitted by A4AD 
including additional non-funded recommendations.

Tactical Aircraft
    DOD's efforts to recapitalize and modernize its tactical air forces 
have been blunted by cost and schedule overruns in its new tactical 
aircraft acquisition programs. The Air Force has offered a plan to 
retire 250 fighter jets in 1 year alone, which the Secretary of Defense 
has accepted.
    Until new systems are acquired in sufficient quantities to replace 
legacy fleets, legacy systems must be sustained and kept operationally 
relevant. The risk of the older aircraft and their crews and support 
personnel being eliminated before the new aircraft are on line could 
result in a significant security shortfall.

Airlift
    Hundreds of thousands of hours have been flown, and millions of 
passengers and tons of cargo have been airlifted. Their contributions 
in moving cargo and passengers are absolutely indispensable to American 
warfighters in the Global War on Terrorism. Both Air Force and Naval 
airframes and air crew are being stressed by these lift missions. As 
the U.S. military continues to become more expeditionary, it will 
require more airlift. Procurement needs to be accelerated and 
modernized, and mobility requirements need to be reported upon.
    DOD should buy an additional (35) C-17s above the current 205 to 
ensure an adequate airlift force for the future and allow for 
attrition--C-17s are being worn out at a higher rate than anticipated 
in the Global War on Terrorism. Given the C-5's advanced age, it makes 
more sense to retire the oldest and most worn out of these planes and 
use the upgrade funds to buy more C-17s. DOD should also continue with 
a joint multi-year procurement of C-130Js.
    The Navy and Marine Corps need C-40-A replacements for the C-9B 
aircraft. The Navy requires Navy Unique Fleet Essential Airlift. The C-
40A, a derivative of the 737-700C a Federal Aviation Administration 
(FAA) certified, while the aging C-9 fleet is not compliant with either 
future global navigation requirements or noise abatement standards that 
restrict flights into European airfields.

Tankers
    The need for air refueling is reconfirmed on a daily basis in 
worldwide DOD operations. A significant number of tankers are old and 
plagued with structural problems. The Air Force would like to retire as 
many as 131 of the Eisenhower-era KC-135E tankers by the end of the 
decade. DOD and Congress must work together to replace of these 
aircraft.
NGREA
    A4AD asks this committee to continue to provide appropriations for 
unfunded National Guard and Reserve Equipment Requirements. The 
National Guard's goal is to make at least half of Army and Air assets 
(personnel and equipment) available to the Governors and Adjutants 
General at any given time. To appropriate funds to Guard and Reserve 
equipment provides Reserve Chiefs with a flexibility of prioritizing 
funding.

                     UNFUNDED EQUIPMENT REQUIREMENTS
            [The services are not listed in priority order.]
------------------------------------------------------------------------
                                                              Amount
------------------------------------------------------------------------
Air Force:
    C-17 Globemaster III transport aircraft (15)........    $3.9 billion
    C-130J Super Hercules (5)...........................     395 million
    Battlefield Airborne Communications Node (2) lease     180.2 million
     and operation......................................
    Upgrade kits for the EC-130s/Compass Call                 78 million
     Modifications (4)..................................
    HH-60G Pave Hawk (3) Search and Rescue..............     120 million
    AAQ-29 Forward Looking Infra Red System--FLIR (81)        81 million
     HH-60G.............................................
Air Force Reserve:
    C-5A Airlift Defense system (ADS) (42)..............    17.3 million
    C-130H LAIRCM--Large Aircraft I/R Counter Measures      56.6 million
     (6)................................................
    C-130J LAIRCM (2)...................................      22 million
    Missile Warning Systems and Electronic Protection, A-   27.9 million
     10, F-16...........................................
    C-5 Structural repair...............................      22 million
Note: USAFR has a $1 billion MILCON backlog.

Air National Guard:
    C-40C pax aircraft, procurement (1) and avionics        98.6 million
     upgrade............................................
    C-38 aircraft, replacement program..................     110 million
    Radio, Beyond Line of Sight (BLOS) ADS TACSAT, F-15,   109.7 million
     F-16C..............................................
    Electronic Attack Pod, A-10, F-16C..................      44 million
    Helmet Mounted Cueing System, A -10, F-16C, HH-60G..      38 million
Note: Air National Guard faces a MILCON backlog of $2
 billion to recapitalize facilities.

Army:
    Aviation Support Equipment..........................    36.2 million
    Field Feeding.......................................    30.7 million
    Force XXI Battlefield Command Brigade and Below.....     179 million
    Information System Security COMSEC..................    44.8 million
    Liquid Logistics Storage and Distribution...........       2 million
Army Reserve:
    Palletized Load System (PLS) Trailer................    27.8 million
    Tactical Light Truck (Ambulance HMMWV, Armament        183.8 million
     Carrier HMMWV, Troop/Cargo Carrier HMMWV)..........
    Command Post (FBCB2/TOCS/UYK-128) computer set,        181.4 million
     shelter............................................
    Support (Antenna-OE-361(V)/Loudspeakers tactical)...    13.4 million
    HEMTT (Tactical Heavy wrecker)......................    55.9 million
Army National Guard:
    CH-47F Chinook helicopters (6) in fiscal year 10....      66 million
    UH-60M Black Hawk medium-lift helicopter (10) in         164 million
     fiscal year 10.....................................
    Warfighter Information Network-Tactical (WIN-T).....     1.2 billion
    Communication Systems (JNN, SINCGARS, HF)...........     1.5 billion
    Stryker combat vehicles, various configurations          1.4 billion
     (549)..............................................
Note: $280 million/year is the investment necessary to
 effectively recapitalize MILCON.

Navy:
    P-3 Repair/Recovery Plan, kit installation..........     462 million
    Aviation Depot Maintenance, to fund 86 deferred          195 million
     airframes and 314 engines..........................
    Ship Depot Maintenance, for 20 surface ship              200 million
     availabilities.....................................
    C-130J Super Hercules (1) to replace Blue Angels          64 million
     transport..........................................
Navy Reserve:
    C-40A Combo cargo/passenger airlift aircraft (4)....     402 million
    KC-130J Super Hercules aircraft (4).................     256 million
    Maritime Expeditionary Warfare Equipment............    35.5 million
    Maritime Prepositioning Force Utility Boats (RHIB)..     6.6 million
    Information Systems Security Program................     5.5 million
Marine Corps:
    MTVR trailers (buys 352) to cover shortfall.........    28.9 million
    Engineer Equipment for Logistics Support:
        TRAMs, bucket loader (93).......................      21 million
        Forklift, Light Rough Terrain--LRTF (96)........      13 million
        Forklift, Extended Boom (177)...................      24 million
    MV-22 Osprey Aircraft, Improvements, and Upgrades...    17.4 million
    Mountain Terrain Support Vehicles (10)..............    10.2 million
    Tier I UAS (146) Digital Data Link upgrade kits.....    10.5 million
Note: Military Construction requirements are $70.5
 million.

Marine Forces Reserves:
    KC-130Js Super Hercules tanker aircraft (2).........     128 million
    Light Armored Vehicles (14).........................      21 million
    Helmet Mounted Displays (SA-HMDs) Systems...........  ..............
    Theater Provided Equipment Sensors..................  ..............
------------------------------------------------------------------------

Conclusion
    A4AD is a working group of military and veteran associations 
looking beyond personnel issues to the broader issues of National 
Defense.
    This testimony is an overview, and expanded data on information 
within this document can be provided upon request.
    Thank you for your ongoing support of the Nation, the Armed 
Services, and the fine young men and women who defend our country. 
Please contact us with any questions.

    Chairman Inouye. Now we have our final panel, consisting of 
Dr. Philip Boudjouk; the president and CEO, Ms. Sandra Raymond, 
Dr. George Zitnay, Captain Ike Puzon, of the Navy, Ms. Mary 
Hesdorffer, Dr. Jonathan Berman, vice president--Mr. George 
Dahlman, and General Michael Dunn.
    Thank you very much.
    Representing the Coalition of EPSCoR/IDeA States, Dr. 
Philip Boudjouk. Is that the correct pronunciation?
    Dr. Boudjouk. Mr. Chairman, ``boo-jock'' is the correct 
pronunciation.
    Chairman Inouye. Boudjouk.
    Dr. Boudjouk. Boudjouk, thank you.

STATEMENT OF PHILIP BOUDJOUK, Ph.D., VICE PRESIDENT, 
            RESEARCH, CREATIVE ACTIVIES AND TECHNOLOGY 
            TRANSFER, NORTH DAKOTA STATE UNIVERSITY; 
            CHAIR, COALITION OF EPSCoR/IDeA STATES
    Dr. Boudjouk. Chairman Inouye, Ranking Member Cochran, 
members of the subcommittee, thank you for the opportunity to 
testify today on the importance of maintaining and adequately 
funding the Department of Defense DEPSCoR program.
    My name is Philip Boudjouk, and I serve as the vice 
president of research, creative activities, and technology 
transfer at North Dakota State University, and I also serve as 
chair of the Coalition of EPSCoR/IDeA States, a nonprofit 
organization representing the 21 States and two territories 
currently eligible to receive DOD DEPSCoR research awards.
    DEPSCoR was originally authorized by section 257 of the 
National Defense Authorization Act of 1995 to ensure a 
nationwide, multi-State infrastructure to support the 6.1 basic 
research needs of the Department of Defense. In recent years, 
Congress has generously provided funding for DEPSCoR between 
$15 and $17 million, and has affirmatively rejected efforts by 
the previous administration to reduce the size of the program.
    In the fiscal year 2009 National Defense Authorization Act, 
the Senate directed a federally funded Research and Development 
Center assessment of the DEPSCoR program to determine its value 
to the Department and to the American taxpayer. The Institute 
for Defense Analyses concluded that DEPSCoR has strengthened 
the nationwide basic research capacity. More importantly, the 
assessment determined that the DEPSCoR States' share of 
nondefense--non-DEPSCoR DOD science and engineering funding 
increased steadily from inception of the program to today.
    However, the administration's proposed 2010 DOD budget 
recommends no funding for DEPSCoR. The 23 eligible DEPSCoR 
jurisdictions must therefore rely on Congress to ensure the 
DEPSCoR program is adequately funded, at a level that ensures 
our Nation maintains a nationwide infrastructure of DOD 
research capabilities.
    Allowing the DEPSCoR program to go unfunded in fiscal year 
2010 will not only create a critical shortfall in our national 
research infrastructure, but it will, likewise, have dire 
consequences for DEPSCoR States that otherwise may not receive 
an investment of DOD research funding. Therefore, we 
respectfully request that the DEPSCoR program at a minimum of 
$20 million.
    Mr. Chairman, every State has important contributions to 
make to our Nation's research competitiveness, and every State 
has scientists and engineers that can contribute significantly 
to supporting the research needs of DOD.
    Thank you for the opportunity to testify before the 
subcommittee.
    Chairman Inouye. I thank you very much, sir.
    [The statement follows:]

                 Prepared Statement of Philip Boudjouk

    Chairman Inouye, Ranking Member Cochran, Members of the 
Subcommittee: Thank you for the opportunity to testify today on the 
importance of maintaining and adequately funding the Department of 
Defense Experimental Program to Stimulate Competitive Research 
(DEPSCoR) \1\.
---------------------------------------------------------------------------
    \1\ Alabama, Alaska, Arkansas, Delaware, Hawaii, Idaho, Kansas, 
Kentucky, Louisiana, Maine, Mississippi, Montana, Nebraska, Nevada, New 
Hampshire, New Mexico, North Dakota, Oklahoma, Puerto Rico, Rhode 
Island, South Carolina, South Dakota, Vermont, Virgin Islands, West 
Virginia, and Wyoming.
    States in bold letters are eligible for the DEPSCoR program. All of 
the States listed above are also eligible for the EPSCoR program.
---------------------------------------------------------------------------
    My name is Philip Boudjouk and I serve as the Vice President of 
Research, Creative Activities and Technology Transfer at North Dakota 
State University. I also currently serve as Chair of the Coalition of 
EPSCoR/IDeA States, a non-profit organization representing the 21 
States and 2 territories currently eligible to receive Department of 
Defense DEPSCoR research awards.
    EPSCoR States have a vast reservoir of talent and capacity. They 
represent 20 percent of the U.S. population, 25 percent of the research 
and doctoral universities, and 18 percent of the Nation's scientists 
and engineers. The EPSCoR program is critical to ensuring that we 
maintain a national infrastructure of research and engineering by 
providing much needed funding to these leading universities and 
scientists.
    As you know, DEPSCoR was initially authorized by Section 257 of the 
National Defense Authorization Act of 1995 (Public Law 103-337) to 
ensure a nationwide, multi-State infrastructure to support the 6.1 
basic research needs of the Department of Defense. Today, 21 States and 
two territories participate in DEPSCoR, receiving grants from the 
Department to perform research that directly responds to specific 
priorities identified by the Department and announced under competitive 
solicitations to the eligible DEPSCoR States.
    At the program's peak funding level, DEPSCoR received nearly $25 
million to fund Department of Defense basic research in eligible 
States. In recent years, Congress has generously provided funding for 
DEPSCoR between $15 million and $17 million, and has affirmatively 
rejected efforts by the previous administration to reduce the size of 
the DEPSCoR program.
    Additionally, in the fiscal year 2009 National Defense 
Authorization Act, the Senate directed a federally funded research and 
development center assessment of the DEPSCoR program to determine its 
value to the Department and to the American taxpayer. The Institute for 
Defense Analayses (IDA) was entrusted with the assessment and concluded 
in its study that DEPSCoR has strengthened the nationwide basic 
research capacity in the following areas:
  --DEPSCoR awards have funded first-time investigators in defense-
        related basic research;
  --DEPSCoR awards have contributed to publications and patents;
  --DEPSCoR awards have supported graduate student and postdoctoral 
        training;
  --DEPSCoR awards have supported purchase and maintenance of cutting 
        edge research equipment; and
  --DEPSCoR awards have supported collaborations among researchers in 
        all States.
    Perhaps most importantly, the IDA assessment determined that the 
DEPSCoR States' share of non-DEPSCoR Department of Defense science and 
engineering funding increased steadily from inception of the program to 
today. This finding provides firm evidence that DEPSCoR is a valuable 
use of taxpayer dollars because it demonstrates that DEPSCoR provides a 
return on investment to the Department of Defense that far exceeds the 
funding amount provided for the program each year.
    Mr. Chairman, DEPSCoR is also a valuable use of taxpayer dollars 
because it represents Federal research money well spent. Past DEPSCoR 
research has included:
  --designing helicopter rotors;
  --modeling sea ice predictions to aid ship and submarine navigation;
  --prediction of river currents for Navy operations;
  --securing critical software systems;
  --developing chem.-biodefense agents;
  --enhancing stored energy density for weapons;
  --improving wireless communication for warfighter systems;
  --determining the effect of exposure of military personnel to extreme 
        physical and climatic conditions;
  --preventing laser damage to aircraft optical guidance systems;
  --increasing durability of lightweight composite materials; and
  --developing small plastic air-vehicles for the Air Force.
    Despite this important work, and despite the positive assessment 
provided to the Senate by the Institute for Defense Analyses, the 
administration's proposed fiscal year 2010 Department of Defense budget 
recommends no funding for DEPSCoR. The 23 DEPSCoR eligible 
jurisdictions must therefore rely on Congress once again to ensure the 
DEPSCoR program is adequately funded at a level that ensures our Nation 
maintains a nationwide infrastructure of Department of Defense research 
capabilities.
    Mr. Chairman, every State has important contributions to make to 
our Nation's research competitiveness and every State has scientists 
and engineers that can contribute significantly to supporting the 
research needs of the Department of Defense. Accordingly, it is vital 
that we build a Department of Defense research infrastructure that 
leaves no State behind. Allowing the DEPSCoR program to go unfunded in 
fiscal year 2010 will not only create a critical shortfall in our 
national research infrastructure, but it will likewise have dire 
consequences for DEPSCoR States that otherwise may not receive an 
investment of Department of Defense research funding.
    As the Committee considers the President's fiscal year 2010 budget 
proposal for the Department of Defense, the Coalition of EPSCoR/IDeA 
States, representing major research universities and institutions 
across 23 participating jurisdictions, respectfully requests that the 
DEPSCoR program be funded at a minimum of $20 million. Participating 
DEPSCoR institutions continue to advance the basic research priorities 
of the Department of Defense and it is the sincere hope of our 
Coalition that this Subcommittee will consider robustly funding the 
DEPSCoR program in fiscal year 2010.
    The Coalition of EPSCoR/IDeA States is grateful for this 
opportunity to testify before the Subcommittee. We look forward to 
continuing to work with the Senate to ensure the DEPSCoR program fully 
supports our Nation's critical research infrastructure requirements.
    Thank you Mr. Chairman.

    Chairman Inouye. And our next witness is the president and 
chief executive officer of the Lupus Foundation of America, Ms. 
Sandra Raymond.
    Ms. Raymond?

STATEMENT OF SANDRA C. RAYMOND, PRESIDENT AND CHIEF 
            EXECUTIVE OFFICER, LUPUS FOUNDATION OF 
            AMERICA, INC.
    Ms. Raymond. Thank you, Chairman Inouye, Ranking Member 
Cochran, and all of the subcommittee members. We thank you for 
the work that you are doing to serve and protect our country 
and the health of our servicemen and women. I'm here today to 
talk with you about a largely undiagnosed health issue of 
concern in the military and in the population at large, and 
that is lupus.
    In April 2003, a 22-year-old female soldier was about to be 
deployed to Iraq. As is the practice, she was given the 
standard battery of vaccines, and soon after she received the 
shots, she died. This soldier had undiagnosed lupus, and the 
live viruses in the vaccine were said, by a panel of medical 
experts, to have caused a fatal reaction.
    In people with compromised immune systems, live viruses and 
other triggers can cause the body to attack its own tissues and 
organs, and this can lead to morbidity and death.
    Lupus is a chronic, life-threatening disease of the immune 
system. It's the prototypical autoimmune disease, and learning 
more about it will provide clues to understanding autoimmune 
diseases that affect 23 million Americans.
    The disease principally affects young women in their 
childbearing years, but men and children also develop lupus. It 
is two to three times more common among African-Americans, 
Hispanics, Asian Americans and Pacific Islanders, and American 
Indians. This health disparity remains unexplained.
    Three issues make lupus directly relevant to the DOD's 
medical research program.
    First, vaccinations given routinely to American servicemen 
and women may trigger fatal reactions, especially since 
military doctors have no way to screen for lupus or underlying 
autoimmune diseases.
    Second, lupus disproportionately affects minority 
populations and young people, those most likely to be in the 
military. Minorities comprise over one-third of the active duty 
military members; and among enlisted women the percentage in 
2004 was almost 40 percent.
    Third, environmental stresses are known to cause lupus. We 
know that genes linked to lupus are triggered by environmental, 
hormonal, and stress factors. These may be exacerbated by 
intense training, foreign deployment, exposure to chemical 
agents, battle, and more.
    But, there is a way to insure that military personnel are 
protected, and that is through identification of biological 
markers that can detect lupus. We all know that measurement of 
blood pressure or cholesterol are biological markers that can 
tell us if we're at risk for cardiovascular disease or stroke. 
In lupus, scientists have now identified a number of biomarkers 
that are prime candidates for validation. And, once validated, 
an early detection test can be developed to screen for lupus. 
With the leadership of military lupus scientists, and academic 
centers across the United States, this research can get off to 
a running start.
    While it's important that lupus remain in the peer-review 
program, we respectfully ask you to consider initiating what we 
call the Lupus Biomarker and Test Development Research Project. 
As part of the defense program, or the clinical investigation 
program of force health protection and readiness, establishing 
this program has the potential to save lives. Start-up costs 
are estimated to be $6 million.
    We thank you for the opportunity to speak today, and we 
look forward to working with you to address this public health 
issue.
    Thank you.
    Chairman Inouye. Thank you very much, Ms. Raymond.
    [The statement follows:]

                Prepared Statement of Sandra C. Raymond

    Chairman Inouye, Ranking Member Cochran, and Distinguished 
Subcommittee Members, my name is Sandra Claire Raymond and I am the 
President and CEO of the Lupus Foundation of America. I want to take 
this opportunity to thank you for all you are doing to serve and 
protect our country and the health of our servicemen and women.
    In April of 2003, a 22-year-old female soldier about to be deployed 
to Iraq was given the standard battery of vaccines and soon after these 
were administered she died. This soldier had undiagnosed lupus and live 
viruses in the vaccines triggered a fatal reaction. Lupus is a chronic 
and life-threatening disease that causes the immune system to become 
unbalanced, causing inflammation and tissue damage to virtually every 
organ system. It is the prototypical autoimmune disease and learning 
more about lupus will have broad-ranging implications for the estimated 
23 million Americans suffering from autoimmune diseases. Lupus affects 
women, men and children, but, women in their child-bearing years are 
most at risk. The disease is two to three times more common among 
African Americans, Hispanics, Asian Americans and Pacific Islanders and 
American Indians. This health disparity remains unexplained. A recent 
study indicates that lupus annually costs the Nation an estimated $31.4 
billion in direct and indirect expenditures.
    Here are the issues that are directly relevant to the DOD's medical 
research programs:
  --Vaccinations given routinely to American Service men and women may 
        trigger fatal reactions. Military physicians have no way to 
        screen personnel for lupus or other autoimmune diseases prior 
        to administering necessary vaccinations.
  --Lupus disproportionately affects minorities and young people--those 
        most likely to be in the military. Minorities comprise over one 
        third of the active duty military members. 2004 statistics 
        indicate that among active duty enlisted women, the minority 
        percentage is even higher: 38.7 percent are minorities. And, 
        again the 2004 statistics indicate that African Americans make 
        up 18.3 percent of the military but less than 13 percent of the 
        general population. African Americans are among those most at 
        risk for lupus. Their disease begins earlier in life and is 
        generally more severe. More than 90 percent of active duty 
        military personnel are age 40 or younger and lupus strikes 
        people between the ages of 15 and 44. In 2004, 11,000 
        individuals with lupus, active duty personnel and dependents, 
        receive care through the DOD healthcare system and that number 
        has been increasing in these last 5 years.
  --Environmental stresses are known to cause lupus flares. Genes 
        linked to lupus may be triggered by environmental, hormonal and 
        stress factors exacerbated by intense training, foreign 
        deployment, exposure to unaccustomed environment, chemical 
        agents, battle and trauma.
    Chairman Inouye, I want to thank you and the Congress for naming 
lupus as one of the diseases that can be researched under the Peer 
Reviewed Medical Research Program. The research projects that have been 
funded since 2005 have provided valuable insights into this devastating 
disease. However, in order to ensure that military personnel and their 
families are protected, there is an urgent and unmet need to validate 
biomarkers to detect lupus. Scientists have identified a number of 
biomarkers that are now ready for validation and this work will lead to 
an early detection test to screen for lupus. In fact, there is a 
network of academic medical centers across the country interested in 
this project and with leadership and coordination from the military 
lupus scientists, this project can get off to a running start. We ask 
that lupus remain in the congressionally directed Peer Reviewed Medical 
Research Program; however, in addition, we believe that lupus biomarker 
and test development research should originate in the DOD's Defense 
Health Program. With respect, we ask for $6 million to establish this 
program. Thank you for providing me with this opportunity to speak 
today and I look forward to working with all of you to help improve the 
lives of our soldiers living with lupus.

    Chairman Inouye. Our next witness is Dr. Zitnay, co-founder 
of the Defense and Veterans Brain Injury Center.

STATEMENT OF GEORGE A. ZITNAY, Ph.D., CO-FOUNDER, 
            DEFENSE AND VETERANS BRAIN INJURY CENTER
    Dr. Zitnay. Good morning, Mr. Chairman, Vice Chairman 
Cochran. It's a pleasure to be with you today.
    As the chairman stated, I'm the co-founder of the Defense 
and Veterans Brain Injury Center, and I recently retired, so 
I'm here today as a volunteer on behalf of the participants in 
the 2008 International Conference on Behavioral Health and 
Traumatic Brain Injury, convened at the request of the 
Congressional Brain Injury Task Force, chaired by Mr. Bill 
Pascrell and Todd Platts.
    I come before you today to request $370 million in funding 
for brain injury care, research, treatment, and training, 
through the Defense and Veterans Brain Injury Center, an 
affiliate of the Defense Center of Excellence in Psychological 
Health and TBI. As you know, TBI is the signature injury in the 
wars in Iraq and Afghanistan, affecting over 360,000 of our 
troops. Some 300,000 have also been identified as experiencing 
post traumatic stress disorder.
    Blast-related injuries, extended deployments, all 
contribute to the unprecedented number of warriors suffering 
from TBI and psychological conditions such as anxiety, 
depression, PTSD, and, unfortunately, suicide.
    The long-term effects and consequences of TBI and PTSD will 
cost millions unless we start treating now, with available 
technology that is now currently available in the private 
sector.
    In a report to Congress issued earlier this year, the 
experts at the international conference noted that the private 
sector--mostly academic centers of excellence across the 
country, and major clinics--have available the advanced 
technology and treatments that should be made available now to 
our men and women, and our wounded warriors, especially in the 
rural areas. They will benefit from this advanced care through 
the use of telemedicine and rehabilitation.
    For example, new technology, and new advances in brain 
imaging, reveals that even the most severe--the most severe TBI 
patient improves, with brain stimulation. It's electrical 
stimulation applied to the inner brain. This helps the 
individual wake up. And once they wake up we can then provide 
rehabilitation until they gain function. We also know that 
neutraceuticals can also help repair brain tissue.
    Our request includes $50 million for a--DVBIC demonstration 
project, to utilize these advanced techniques to improve the 
standard of care for severe TBI patients. While many with 
severe TBI will never return to active duty, some may, if they 
get this advanced technology. But, most importantly, they will 
be able to live a life worth living.
    DVBIC is a partnership between the DOD and the VA with 
the--trauma centers, and it was created by Congress to ensure 
the optimum care is given.
    Finally, we request $20 million for education and training 
of brain injury specialists. There is confusion between mild 
TBI and PTSD, but they are distinct conditions. TBI can be 
mild, as in concussion, or severe, as in unresponsive states of 
consciousness. Training is particularly needed in our rural 
areas of the country, as some of our young men and women who 
return home never get the chance to seek treatment, because it 
is too far away.
    Thank you for your leadership; thank you for your support 
of the Defense and Veterans Brain Injury; but most of all for 
your care for our wounded warriors.
    Chairman Inouye. Thank you very much, Dr. Zitnay.
    [The statement follows:]

                 Prepared Statement of George A. Zitnay

    Dear Chairman Inouye, Vice Chairman Cochran and Members of the 
Senate Appropriations Subcommittee on Defense: Thank you for this 
opportunity to submit testimony in support of funding brain injury 
programs and initiatives in the Department of Defense. I am George A. 
Zitnay, PhD, a neuropsychologist and co-founder of the Defense and 
Veterans Brain Injury Center (DVBIC).
    I have over 40 years of experience in the fields of brain injury, 
psychology and disability, including serving as the Executive Director 
of the Kennedy Foundation, Assistant Commissioner of Mental Retardation 
in Massachusetts, Commissioner of Mental Health, Mental Retardation and 
Corrections for the State of Maine, and a founder and Chair of the 
International Brain Injury Association and the National Brain Injury 
Research, Treatment and Training Foundation. I have served on the 
Advisory Committees to the Centers for Disease Control and Prevention 
(CDC) and the National Institutes of Health (NIH), was an Expert 
Advisor on Trauma to the Director General of the World Health 
Organization (WHO) and served as Chair of the WHO Neurotrauma 
Committee.
    In 1992, as President of the national Brain Injury Association, I 
worked with Congress and the Administration to establish what was then 
called the Defense and Veterans Head Injury Program (DVHIP) after the 
Gulf War as there was no brain injury program at the time. I have since 
worn many hats, and helped build the civilian partners to DVBIC: 
Virginia NeuroCare, Laurel Highlands and DVBIC-Johnstown. I recently 
retired as an advisor to the Department of Defense (DOD) regarding 
policies to improve the care and rehabilitation of wounded warriors 
sustaining brain injury.
    I am pleased to report that DVBIC continues to be the primary 
leader in DOD for all brain injury issues. DVBIC has come to define 
optimal care for military personnel and veterans with brain injuries. 
Their motto is ``to learn as we treat.''
    The DVBIC has been proactive since its inception, and what began as 
a small research program, the DVBIC now has 19 sites.\1\ In 2007 your 
committee helped move DVBIC funding from under the auspices of the 
Uniformed Services University of the Health Sciences (USUHS) over to 
the Army's Medical and Materiel Command at Fort Detrick. DVBIC is now 
the key operational component for brain injury of Defense Centers of 
Excellence for Psychological Health and Traumatic Brain Injury (DCoE) 
under DOD Health Affairs.
---------------------------------------------------------------------------
    \1\ Walter Reed Army Medical Center, Washington, DC; Landstuhl 
Regional Medical Center, Germany; National Naval Medical Center, 
Bethesda, MD; James A. Haley Veterans Hospital, Tampa, FL; Naval 
Medical Center San Diego, San Diego, CA; Camp Pendleton, San Diego, CA; 
Minneapolis Veterans Affairs Medical Center, Minneapolis, MN; Veterans 
Affairs Palo Alto Health Care System, Palo Alto, CA; Fort Bragg, NC; 
Fort Carson, CO; Fort Hood, TX; Camp Lejeune, NC; Fort Campbell, 
Kentucky; Boston VA, Massachusetts; Virginia Neurocare, Inc., 
Charlottesville, VA; Hunter McGuire Veterans Affairs Medical Center, 
Richmond, VA; Wilford Hall Medical Center, Lackland Air Force Base, TX; 
Brooks Army Medical Center, San Antonio, TX; Laurel Highlands, 
Johnstown, PA; DVBIC-Johnstown, PA.
---------------------------------------------------------------------------
    I am here today to ask for your support for $370 million in the 
Defense Appropriations bill for fiscal year 2010 for the DCoE which 
includes $50 million specifically for a consortium of private sector 
entities to partner with DCoE and DVBIC to move the standard of care 
for brain injury forward, as well as $20 million for education and 
training of brain injury specialists.
    As you know, traumatic brain injury (TBI) is the ``signature 
injury'' of the conflicts in Iraq and Afghanistan, affecting some 
360,000 service personnel and some 300,000 have experienced post 
traumatic stress disorder (PTSD). Blast-related injuries and extended 
deployments are contributing to an unprecedented number of warriors 
suffering from traumatic brain injury (ranging from mild, as in 
concussion, to severe, as in unresponsive states of consciousness) and 
psychological conditions such as anxiety, depression, PTSD and suicide.
    The Rand Corporation, DOD, and CDC report that the long term 
effects and consequences of TBI, PTSD, and other psychological health 
issues will cost billions of dollars in care, treatment, and 
rehabilitation unless action is taken. The Rand Report estimates that 
PTSD-related and major depression-related costs could range from a 1-
year cost of $25,000 in mild cases to $408,000 for severe cases. The 
total cost for TBI-related health issues is in the billions of dollars 
and does not include the lost productivity or the deleterious effects 
to quality of life. In reality, it has been well-established that the 
health care needs of our young service members returning from OIF/OEF 
are not being met and are overwhelming the current veterans' health 
care system that has been primarily designed to care for elderly 
veterans.
    In 2005, the Conemaugh International Symposium, brought together 60 
of the world's finest neuroscientists and physicians from across the 
United States and from 12 other nations, including representatives from 
the National Institutes of Health (NIH), CDC, DOD, Veterans 
Administration (VA), and the National Institute for Disability and 
Rehabilitation Research, resulting in a strong recommendation for 
United States Congressional action to significantly improve outcomes in 
wounded warriors with traumatic brain injury. In addition, the 
Symposium report called for the creation of Seven Centers of Excellence 
in TBI treatment, research and training to be located across the 
Nation.
    A second international meeting on Disorders of Consciousness 
produced the Mohonk Report, in which scientists, ethicists, physicians, 
and family members from across the United States, as well as leading 
neuroscientists from Israel, Europe, and South America, collaborated to 
prepare an action report to Congress that focused on Improving Outcomes 
for Individuals with Disorders of Consciousness. The report called on 
Congress to fund a network of highly specialized centers, utilizing the 
latest technology available, to significantly improve outcomes for 
wounded warriors living in the minimally conscious state.
    A third follow-up meeting of experts, the Symposium on Severe and 
Minimally Conscious Wounded Warriors, occurred in the spring of 2008, 
in Johnstown, Pennsylvania. This meeting rendered a Feasibility Study 
on treating wounded warriors with disorders of consciousness which was 
subsequently delivered to the DVBIC for consideration.
    Based upon the history and results of these international meetings, 
the International Conference on Behavioral Health and Traumatic Brain 
Injury was convened in October 2008, hosted by Congressmen Bill 
Pascrell and Todd Platts, co-chairs of the Congressional Brain Injury 
Task Force, and sponsored by the DOD, DVBIC, and numerous other groups 
to prepare recommendations for action and funding by the United States 
Congress.
    The Executive Report from this meeting of over 100 international 
experts generated critical recommendations in the areas of Research, 
Education, Assessment, Family, and Treatment. The authors of the report 
concluded: ``The over-arching goal is to provide our wounded warriors 
and their families with what they deserve: the best health care and 
support services that our state-of-the-art science and medicine have to 
offer. In doing so, we will create a standard of excellence in military 
health care, research, and training that will serve as an exemplary 
model for the rest of the world.'' The report requested from Congress a 
total of $350 million in funding to achieve that goal.
    On March 12, 2009 representatives of the International Conference 
unveiled a Report to Congress (the Paterson Report) calling for action 
now to improve the care of wounded warriors.
    The Paterson Report noted:
  --new advances in brain imaging are revealing that even those with 
        the most severe levels of TBI have preserved brain tissue which 
        can be used through deep brain electrical stimulation to help 
        the individual wake up and regain function;
  --new advanced technologies can help those wounded warriors with loss 
        of sight regain some vision;
  --new cognitive protheses can help those wounded warriors with severe 
        memory loss regain the ability to plan and remember;
  --neutraceuticals can help restore parts of damaged brains; and
  --new screening and early automated psychological tools and tests can 
        help detect those at risk for PTSD and other psychological 
        disorders.
    What we need to do now is to make these advanced technologies and 
treatments that are available in the private sector available to our 
wounded warriors, and we need to offer services and clinics in our 
rural areas through telemedicine and tele-rehabilitation.

                          TREAT NOW CONSORTIUM

    Our funding request includes $50 million specifically for the work 
of a consortium of private sector providers (called TREAT NOW: 
Treatment and Research Excellence Achieved Today: Neuroscientists for 
Our Warriors) who have come together to improve the standard of care of 
wounded warriors as soon as possible.
    For those warriors who have sustained the most severe TBIs, the 
recommendations from the Reports of the Aspen and Mohonk Meetings are 
not being followed. Thus, the current standard of care for these 
warriors is inconsistent, clinically unreliable, and not maximally 
effective. The exact number of these wounded warriors from Operation 
Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) who suffer 
from severe disorders of consciousness (SDOC) is unknown. The DVBIC 
reports that 4 percent of the 15,000 TBI patients examined and/or 
treated by their Center suffer from SDOC. This is an underestimation of 
the true number of warriors because it does not include those seen or 
treated at other military hospitals and programs and the dependents of 
wounded warriors and veterans.
    Serving under the auspices of the DCoE, the Consortium will 
complement, and partner with the DVBIC and the National Intrepid Center 
of Excellence (NICoE) in their vision and commitment to improve the 
current system of medical care and support for troops sustaining severe 
TBIs. The partners include some of the best scientists, researchers and 
rehabilitation specialists from around the United States. While 
geographically diverse, participating members are heavily invested in 
improving tele-health technologies. There is no project like it and DOD 
Health Affairs is interested in moving it forward.

                              TBI VS. PTSD

    Much has been accomplished by the DCoE in its efforts to improve 
public awareness of TBI and psychological disorders, address the stigma 
associated with such conditions, and help connect family, caregivers 
and wounded warriors with appropriate information, treatment and 
services.
    There are concerns however about an overemphasis on psychological 
disorders that affects the public perception of TBI. Many in the brain 
injury medical and family support community do not want to see TBI 
becoming considered a ``psychological disorder.'' This concern comes 
from the fact that in no other health care system are psychological 
issues and brain injury combined--not in the DVA, NIH, or any 
university medical program. Brain injury specialists and family 
advocates want to be assured that as much focus and funding is being 
put into the science of brain injury rehabilitation and treatment as is 
being put into the psychological effects of combat. Of the 25 programs 
funded under the Congressionally Directed Medical Research Program with 
2007 supplemental funding, only 8 were for brain injury.
    We must not lose sight of the actual cause of subsequent 
psychological problems. TBI can lead to depression and suicide but TBI 
is not itself a psychological disorder. Treatments for TBI and PTSD are 
not only different, but can be contraindicated and make the patient 
worse. In working with the Wounded Warrior Project, I have heard many 
stories of warriors with brain injury not getting the right treatment 
because they were sent to a psychologist instead of a neuropsychologist 
and given drugs for PTSD that exacerbated the effects of TBI.
    There are harmful reports like the USA Today article on April 15, 
2009 \2\, in which Cols. Charles Hoge and Carl Castro argue that the 
DOD and DVA are overemphasizing mild TBI among troops and that the 
focus should be more on the symptoms rather than the cause. Citing the 
Hoge-Castro article in The New England Journal of Medicine, USA Today 
reports that ``symptoms blamed on TBI after troops return home likely 
are due to depression, PTSD or substance abuse . . . and overemphasis 
on mild TBI keeps troops with those conditions from being properly 
treated . . . most troops who suffered a concussion in battle recovered 
within days of the injury.'' This is very damaging to the efforts to 
improve public awareness of TBI.
---------------------------------------------------------------------------
    \2\ Zoroya, Gregg, ``Officials: Troops Hurt by Brain Injury 
Focus,'' USA Today, April 15, 2009.
---------------------------------------------------------------------------
    A plethora of leading brain injury specialists dispute Hoge and 
Castro's claims and urge caution in making changes to screening 
procedures. David Hovda, PhD, Director of the Brain Injury Research 
Center at UCLA, strongly recommended continuing screening, saying that 
without it, troops may develop long-term neurological problems after 
numerous concussions, similar to former professional football players. 
Research conducted at the Defense Advanced Research Projects Agency 
(DARPA) shows that the most common cause of TBI in combat, blast 
injury, causes a range of injury from mild (concussion) to severe.
    I urge your Committee to recommend that DOD continue its practice 
of screening which is based on the best science available and offers 
troops the best chance at recovery.
    In addition the Paterson Report recommended that the National 
Institutes of Health and the DOD convene a ``Consensus Conference'' to 
clearly define mild TBI and PTSD and establish specific standards for 
treatment. The Report recommended that definitions and treatment 
standards be evidence based and incorporate a thorough review of 
available treatment programs and outcome measures. The Report urged the 
Consensus Conference to strive to equitably involve all stakeholders.
    The confusion has devastating effects when it results in wounded 
warriors not seeking treatment. DVBIC officials have reported that 
troops are now less likely to seek help for mild brain injury if it is 
considered to be a ``psychological disorder.''
    President Obama made a speech last week regarding health care 
reform and urged that we ``fix what's broken and move forward with what 
works.'' The same should be said about improving DOD's health system. 
While the increase in suicides has brought public attention to the 
stresses of combat, the complex issues of TBI should not get lost or 
overlooked. The research and treatment for TBI must remain distinct and 
the focus of the DVBIC must be preserved. DVBIC needs to continue to be 
recognized as the center of excellence in providing brain injury care 
and research.
    $20 million for education and training brain injury specialists
    We recommend an additional $20 million be appropriated specifically 
for training medical students in brain injury diagnosis, treatment and 
rehabilitation. We need more brain injury specialists in the medical 
field. More neurologists, neuropsychologists and physiatrists and 
rehabilitation specialists should be educated by the Uniformed Services 
University for the Health Sciences.
    In summary, we respectfully request $370 million for fiscal year 
2010 to enhance ongoing projects of the DCoE and to develop new 
initiatives to improve the care of wounded warriors and support for 
their families. We need to assure that our brave men and women who are 
injured in the course of duty are given every possible opportunity for 
the best medical care, rehabilitation and community reentry assistance 
that we as a Nation can provide.
    Thank you for your consideration of this request to help improve 
the care of our wounded warriors.

    Chairman Inouye. Our next witness is the director of 
legislation, Association of the United States Navy, Captain Ike 
Puzon.

STATEMENT OF CAPTAIN IKE PUZON, UNITED STATES NAVY 
            (RET.), DIRECTOR OF LEGISLATION, 
            ASSOCIATION OF THE UNITED STATES NAVY
    Captain Puzon. Mr. Chairman, Mr. Vice Chairman, and the 
Association of the United States Navy is grateful to have the 
opportunity to testify today.
    Our newly transitioned association is now focused on 
equipment, force structure, policy issues, manpower issues, for 
a total force.
    Your unwavering support for our deployed servicemembers in 
Iraq and Afghanistan and the worldwide fight against terrorism 
is of crucial importance. AUSN would like to highlight three 
areas of importance.
    The C-40--first, the C-40 aircraft originally listed in the 
unfunded list, to replace critically overused C-20G aircraft, 
and to replace overaged and overused C-9 transport, both are 
playing a vital role in Iraq and Afghanistan and worldwide 
contingency operations.
    Second, the EF-18 Growler aircraft for U.S. Navy and U.S. 
Navy Reserves, specifically in the Navy Reserve, to replace 
aged aircraft in a Maryland-based squadron that is currently 
deployed to Iraq and Afghanistan.
    And finally, number three, stabilization of authorized end-
strength for active Navy and Navy Reserve.
    In recent years, the Pentagon has recommended the repeal of 
separate budget requests for procurement Reserve equipment. A 
combined appropriations for each service does not guarantee 
needed equipment for National Guard and Reserve components. We 
do not agree with the Pentagon's position on this issue, and 
ask that the subcommittee continue to provide separate 
appropriations against National Guard and Reserve equipment.
    For the foreseeable future, we must be realistic about what 
the unintended consequences are for a very high rate of usage 
for active and Reserve components. Our active duty Navy and the 
current Reserve members are pleased to making it--a significant 
contribution to the Navy's defense as operational forces. 
However, the reality of it all is that the added stress on the 
total force could pose long-term consequences for our country 
in terms of recruiting, retention, and family support. The Navy 
has a total of over 10,000 people--personnel deployed in 
Operation Iraqi Freedom (OIF). The Navy Reserve continues to 
mobilize 4,500 sailors for the support of the ongoing global 
war on terror (GWOT). Your Navy is engaged throughout.
    We recognize that there are many issues that need address 
by the subcommittee. We are perplexed by the short Navy 
unfunded program list. History points to a larger list. 
Overwhelmingly, we hear that--discussions and requirements for 
more and better equipment for training total force is 
necessary.
    In summary, we believe the subcommittee needs to address 
the following issues for total force, in the best interest of 
our national security: fund the C-40A for Navy Reserve and 
Navy, per previous supplementals, and we replace the C-9 
transport and the C-20G; fund the E/F-18 Growler; increase 
funding for the National Guard and Reserve equipment; and 
establish end-strength stabilization for the Navy and Navy 
Reserve.
    Thank you for your--opportunity.
    Chairman Inouye. Thank you very much, Captain Puzon.
    [The statement follows:]

                    Prepared Statement of Ike Puzon

    Mister Chairman and distinguished members of the Committee, the 
Association of the United States Navy is very grateful to have the 
opportunity to testify.
    Our newly transitioned association looks at equipment, force 
structure, policy issues, and manpower issues.
    We would like to thank this Committee for the on-going stewardship 
on the important issues of national defense and, especially, the 
reconstitution and transformation of the Navy. At a time of war, non-
partisan leadership sets the example.
    Your unwavering support for our deployed Service Members in Iraq 
and Afghanistan and the world-wide fight against terrorism and piracy 
is of crucial importance. AUSN would like to highlight some areas of 
emphasis.
  --C-40A Aircraft to replace critically overused C-20G in Hawaii and 
        Maryland; and, to replace over aged C-9 transports--both are 
        playing a vital role in Iraq and Afghanistan. They are not VIP 
        aircraft--but, can be used for such missions.
  --EF/A 18 Growler aircraft for U.S. Navy and U.S. Navy Reserve--
        specifically to replace aged aircraft in a Maryland based 
        squadron that is currently deployed to Iraq and Afghanistan.
  --C-130J aircraft--to meet the intra-theater needs of the Geographic 
        Commanders and Navy component commanders.
    These issues are in line with all previous years Navy and Navy 
Reserve unfunded list.
    As a Nation, we need to supply our service members (active duty and 
reserve) with the critical equipment and support needed for individual 
training, unit training, and combat.
    In recent years, the Pentagon has recommended the repeal of 
separate budget requests for procuring Reserve Equipment. A combined 
equipment appropriation for each service does not guarantee needed 
equipment for the National Guard and Reserve Components. For the Navy 
Reserve, this is especially true. We do not agree with the Pentagon's 
position on this issue and history has proven the requirements for 
NGREA, and we ask this committee to continue to provide separate 
appropriations against NG and RE requirements.
    In addition to equipment to accomplish assigned missions, AUSN 
believes that the Administration and Congress must make it a high 
priority to maintain, if not increase, the end strengths of already 
overworked, and perhaps even overstretched, military forces. This 
includes the Active Duty Navy & Navy Reserve. The Navy Reserve has 
always proven to be a highly cost-effective and superbly capable 
operational and surge force in times of both peace and war. At a 
minimum, the Navy Reserve should be stabilized since they are deployed 
with active forces in Iraq and Afghanistan.
    For the foreseeable future, we must be realistic about what the 
unintended consequences are from a high rate of usage. History shows 
that a Reserve force is needed for any country to adequately meet its 
defense requirements, and to enable success in offensive operations. 
Our Active Duty Navy and the current Reserve members are pleased to be 
making a significant contribution to the Nation's defense as 
operational forces; however, the reality of it all is that the added 
stress on the Reserve could pose long term consequences for our country 
in recruiting, retention, family and employer support. This issue 
deserves your attention in Family Support Programs, Transition 
Assistance Programs and for the Employer Support for the Guard and 
Reserve programs.
    At the same time, the Navy has a total of over 10,000 personnel 
deployed in OIF/OEF theaters; Navy Reserve continues to mobilize over 
4,500 Sailors in support for the on-going GWOT. Your Navy is engaged 
throughout the world in operations.
    Care must be taken that that tremendous reservoir of operational 
capability be maintained and not capriciously dissipated. Officers, 
Chief Petty Officers, and Petty Officers need to exercise leadership 
and professional competence to maintain their capabilities. There is a 
risk that they will not be able to do so in the present model of 
utilization of Navy Reserve and Active Duty IA utilizations.
    AUSN is perplexed by this year's Navy Unfunded Programs list 
provided by the Chief of Naval Operations. We fully support CNO's 
unfunded list. However, history points at a much larger unfunded list 
and the needs are there.
    Specific Equipment and Funding needs of the Navy Reserve include:
  --C-40 funding to replace dangerously aged C-9s. These are war 
        fighting logistic weapons systems. 2 Aircraft were programmed 
        for fiscal year 2009 supplemental, and 4 were programmed for 
        fiscal year 2009 funding. The Navy did not get these funded. We 
        have to replace aging C-9s to maintain Navy and Marine Corps 
        engagement in the GWOT.
    First:
  --It is the Navy's only world-wide intra-theater organic airlift, 
        operated by the U.S. Navy.
  --Navy currently operates 9 C-40As, in three locations: Fort Worth, 
        Jacksonville, San Diego.
  --These aircraft are needed for Hawaii, Maryland, Texas and 
        Washington units.
  --A pending CNA study--substantiates the requirements for 31-35 C-
        40As to replace aging C-9s.
    Second:
  --CNO, SECNAV, & DOD have supported the requirement for C-40As.
  --Commander, Naval Air Force 2007 Top Priority List stated the 
        requirement for at least 32 aircraft.
    Third:
  --Current average age of remaining C-9s that the C-40 replaces is: 38 
        years.
  --There will be no commercial operation of the C-9s or derivates by 
        2011.
  --C-9s can not meet the GWOT requirement, due to MC rates, and 
        availability of only 171 days in 2006.
  --Modifications required to make C-9s compliant with stage III Noise 
        compliance, and worldwide Communications/Navigation/
        Surveillance/Air Traffic Management compliance--are cost 
        prohibitive.
  --There are growing concerns about the availability and Mission 
        Capability rates of the C-20Gs at Hawaii and Maryland units.
    Fourth:
  --737 Commercial Availability is slipping away, if we do not act now; 
        loss of production line positions in fiscal year 2008-09--due 
        to commercial demand would slip to 2013, and increase in DOD, 
        Service expenditures.
  --C-130J procurement funding for 6 C-130s for the Navy Reserve.
  --E/F-18 Growler procurement to replace aged and retiring EA-6B 
        aircraft at Maryland units, and for Active Duty Navy usage. 
        Currently the NR EA-6B unit provides 90 continuous detachments 
        in support of OIF/OEF.
  --A full range of Navy Expeditionary Command equipment.
    People join the Reserve Components to serve their country and 
operate equipment. Recruiting and retention issues have moved to center 
stage for all services and their reserve components. In all likelihood 
the Navy will not meet its target for new Navy Reservists and the Navy 
Reserve will be challenged to appreciably slow the departure of 
experienced personnel this fiscal year. We've heard that Reserve Chiefs 
are in agreement, expressing concern that senior personnel could leave 
when equipment is not available for training. Besides reenlistment 
bonuses which are needed, we feel that dedicated Navy Reserve equipment 
and Navy Reserve units are a major factor in recruiting and retaining 
qualified personnel in the Navy Reserve.
    Overwhelmingly, we have heard Reserve Chiefs and Senior Enlisted 
Advisors discuss the need and requirement for more and better equipment 
for Reserve Component training. The Navy Reserve is in dire need of 
equipment to keep personnel in the Navy Reserve and to keep them 
trained. We must have equipment and unit cohesion to keep personnel 
trained. This means--Navy Reserve equipment and Navy Reserve specific 
units with equipment.
                 the reserve component as a worker pool
    Issue: The view of the Reserve Component that has been suggested 
within the Pentagon is to consider the Reserve as of a labor pool, 
where Reservists could be brought onto Active Duty at the needs of a 
Service and returned, when the requirement is no longer needed. It has 
also been suggested that an Active Duty member should be able to rotate 
off active duty for a period, spending that tenure as a Reservist, 
returning to active duty when family, or education matters are 
corrected.
    Position: The Guard and Reserve should not be viewed as a 
temporary-hiring agency. Too often the Active Component views the 
recall of a Reservist as a means to fill a gap in existing active duty 
manning.

                          EQUIPMENT OWNERSHIP

    Issue: An internal study by the Navy has suggested that Naval 
Reserve equipment should be transferred to the Navy. At first glance, 
the recommendation of transferring Reserve Component hardware back to 
the Active component appears not to be a personnel issue. However, 
nothing could be more of a personnel readiness issue and is ill 
advised. Besides being attempted several times before, this issue needs 
to be addressed if the current National Security Strategy is to 
succeed.
    Position: The overwhelming majority of Reserve members join the RC 
to have hands-on experience on equipment. The training and personnel 
readiness of Reserve members depends on constant hands-on equipment 
exposure. History shows, this can only be accomplished through Reserve 
equipment, since the training cycles of Active Components are rarely if 
ever--synchronized with the training or exercise times of Reserve 
units. Additionally, historical records show that Reserve units with 
hardware maintain equipment at or higher than average material and 
often better training readiness. Current and future war fighting 
requirements will need these highly qualified units when the Combatant 
Commanders require fully ready units.
    Reserve and Guard units have proven their readiness. The personnel 
readiness, retention, and training of Reserve and Guard members will 
depend on them having Reserve equipment that they can utilize, 
maintain, train on, and deploy with when called upon. Depending on 
hardware from the Active Component, has never been successful for many 
functional reasons. The AUSN recommends the Committee strengthen the 
Reserve and Guard equipment appropriation in order to maintain 
optimally qualified and trained Reserve and Guard personnel.
    In summary, we believe the Committee needs to address the following 
issues for Navy and Navy Reservists in the best interest of our 
National Security:
  --Fund C-40A for the Navy Reserve, per the fiscal year 2009 
        Supplemental; we must replace the C-9s and replace the C-20Gs 
        in Hawaii and Maryland.
  --Fund 6 C-130Js for the Navy Reserve, per the CNO unfunded list.
  --Moratorium on Active Duty end-strength cuts.
  --Establish an End-strength cap of 68,000 as a floor for end strength 
        to Navy Reserve manpower--providing for surge-ability and 
        operational force.
  --Increase funding for Naval Reserve equipment in NGREA
    --E/F-18 Growler aircraft for Navy and Navy Reserve units, 
            especially the NR unit stationed in Maryland.
    --Explosive Ordnance Disposal Equipment
    We thank the committee for consideration of these tools to assist 
the Navy and Navy Reserve in an age of increased sacrifice and 
utilization of these forces.
    Thank you for your ongoing support of the Nation, the Armed 
Services, The United States Navy, The United States Navy Reserve, and 
the fine men and women who defend our country.

    Chairman Inouye. Our next witness represents the 
Mesothelioma Applied Research Foundation, Ms. Mary Hesdorffer.

STATEMENT OF MARY HESDORFFER, NURSE PRACTITIONER, 
            MEDICAL LIAISON, MESOTHELIOMA APPLIED 
            RESEARCH FOUNDATION (MARF)
    Ms. Hesdorffer. Good morning, distinguished members of the 
U.S. Senate Defense Appropriations Subcommittee. Thank you for 
the opportunity to address you on a cruel cancer that kills our 
veterans.
    My name is Mary Hesdorffer, I'm a nurse practitioner, and 
I'm the medical liaison to the Mesothelioma Applied Research 
Foundation.
    Your subcommittee has recognized the strong connection 
between mesothelioma and military service. Because asbestos was 
heavily used all over Navy ships, millions of servicemen and 
shipyard workers were exposed. One study found that one-third 
of today's meso victims were exposed on U.S. Navy ships, or 
shipyards, like Pearl Harbor, Puget Sound, and Groton.
    A renowned meso researcher from Lake Forest just shared 
with me, the other night, that the rate of veterans who have 
been exposed to asbestos have a sevenfold increase in 
mesothelioma over the normal population. Dangerous exposures 
continue today, and have been reported among the troops in Iraq 
and Afghanistan, and there's also grave concern for our first 
responders to 9/11. My son just returned from Iraq, and he was 
a responder at 9/11, so I have a deep concern over these 
exposures.
    Asbestos is common in buildings, including the utility 
tunnels right below us. For all those who develop mesothelioma 
as a result, the only hope is that we will develop an effective 
treatment, yet mesothelioma has virtually received no Federal 
funding. Therefore, treatments have not advanced. We only have 
one approved treatment for this disease; it takes a life 
expectancy of between 6 to 9 months to, now, 12.2 months.
    Your subcommittee has recognized the need and has taken the 
lead. For the past 2 years, you have directed DOD to spur 
research for meso by including it in the PR and RP. However, 
your leadership was thwarted this year. Thirty-eight 
mesothelioma research grants were submitted to the--for the 
review year for 2008, which demonstrates a huge interest in 
mesothelioma. But, while other diseases got six grants each, 
DOD is funding only one mesothelioma grant.
    It's critically needed, our research funding. The research 
with--Dr. Courtney Broaddus is one of the world's top meso 
experts, and she told us that, without this grant, she was 
going to have to close her lab. This really has salvaged her 
career.
    Going forward on an award rate of 2.6 percent is still not 
enough to encourage top researchers to apply, or new 
researchers to establish their careers in mesothelioma. The 
research will not advance, effective treatments will not be 
found. We believe that the subcommittee must make clear to DOD 
its intent to spur mesothelioma research by directing DOD to 
establish funding of $67 million to DOD for seven new programs, 
including a peer-reviewed cancer research program that does not 
currently include mesothelioma.
    It's a rapidly fatal, excruciatingly painful cancer, 
directly related to military service. We ask the subcommittee 
to appropriate DOD $5 million for a peer-reviewed cancer 
research program that will boost the long-neglected field of 
mesothelioma research, translating directly to saving lives and 
reducing suffering in veterans.
    Thank you.
    Chairman Inouye. I thank you very much, Ms. Hesdorffer.
    [The statement follows:]

                 Prepared Statement of Mary Hesdorffer

    Distinguished members of the U.S. Senate Defense Appropriations 
Subcommittee: Thank you for this opportunity to address a tragic 
disease that kills our veterans. My name is Mary Hesdorffer. I am a 
nurse practitioner with over a decade's experience in mesothelioma 
treatment and research, and am the Medical Liaison for the Mesothelioma 
Applied Research Foundation.

                         MALIGNANT MESOTHELIOMA

    Mesothelioma is an aggressive cancer caused by asbestos. It is 
among the most painful and fatal of cancers, as it invades the chest, 
destroys vital organs, and crushes the lungs.

            THE ``MAGIC MINERAL''--EXPOSURES WERE WIDESPREAD

    From the 1930s through the 1970s asbestos was used all over Navy 
ships. Millions of servicemen and shipyard workers were exposed. Many 
of them are now developing mesothelioma, following the disease's long 
latency period.

                     MESOTHELIOMA TAKES OUR HEROES

    These are the people who served our country's defense. Heroes like 
Admiral Elmo Zumwalt, Jr., Chief Naval Officer during Vietnam, 
Commander Harrison Starn, who served from World War II through Vietnam, 
and thousands of servicemen like USS Kitty Hawk Boilerman Lewis Deets, 
who volunteered for Vietnam at barely 18, all struck down by 
mesothelioma. Last year I testified about mesothelioma patient Bob 
Tregget, who was exposed to asbestos aboard a nuclear submarine from 
1965 to 1972. Following grueling best-available treatment, Bob was 
recurrent and in extreme untreatable pain. But he was hanging on, 
hoping the next treatment advance would come soon enough to help him. 
It didn't and Bob passed away a few months ago.
    Almost 3,000 more Americans like Bob die each year of mesothelioma, 
and one study found that one-third were exposed on U.S. Navy ships or 
shipyards, lost through service to country just as if they had been on 
a battlefield.
    Many more are being exposed now. Asbestos exposures have been 
reported among the troops in Iraq and Afghanistan. There is grave 
concern for the heroic first responders from 9/11, including my son, 
who just returned from service in Iraq. Asbestos is common in 
buildings. The utility tunnels in this very building have dangerous 
levels. Even low-dose, incidental exposures cause mesothelioma. 
Minnesota Congressman Bruce Vento worked near an asbestos-insulated 
boiler in a summer college job. He died of mesothelioma in 2000. His 
wife Sue Vento testified before you in 2007. For all those who will 
develop mesothelioma as a result of these past or ongoing exposures, 
the only hope is that we will develop effective treatment.

                 MESOTHELIOMA FUNDING HAS NOT KEPT PACE

    Yet mesothelioma research has been overlooked. With the huge 
Federal investment in cancer research through the NCI, and $4.8 billion 
spent in biomedical research through the DOD Congressionally Directed 
Research Program since 1992, we are winning the war on cancer and many 
other diseases. But for mesothelioma, the National Cancer Institute has 
provided virtually no funding, in the range of only $1.7 to $3 million 
annually over the course of the last 6 years, and the DOD has not 
invested in any mesothelioma research despite the military-service 
connection. As a result, advancements in the treatment of mesothelioma 
have lagged far behind other cancers. In fact, for decades, there was 
no approved treatment better than doing nothing at all. Our veterans 
who develop mesothelioma have an average survival of only 4-14 months.

                           NEW OPPORTUNITIES

    But there is good news. Brilliant researchers are dedicated to 
mesothelioma. The FDA has now approved one drug which has some 
effectiveness, proving that the tumor is not invincible. Biomarkers are 
being identified. Two of the most exciting areas in cancer research--
gene therapy and anti-angiogenesis--look particularly promising in 
mesothelioma. The Meso Foundation has funded $6 million to support 
research in these and other areas. Now we need the Federal Government's 
partnership, to develop the promising findings into effective 
treatments.

                    COMMITTEE'S LEADERSHIP THWARTED

    Your committee has recognized the need and taken the lead. For the 
past 2 years (fiscal years 2008 and 2009), you have directed DOD to 
spur research for this service-related cancer by including it as an 
area of emphasis in the Peer Reviewed Medical Research Program.
    However, I have to report to you that unfortunately your leadership 
in acting to spur mesothelioma research has been thwarted. DOD just 
announced the results of the PRMRP program for fiscal year 2008. 
Thirty-eight mesothelioma research projects were submitted. This 
demonstrates the huge demand for mesothelioma research funding that we 
testified about and that you directed DOD to address. But while other 
diseases got six grants each, DOD (tentatively) funded only one 
researcher (Courtney Broaddus) for a mesothelioma project. This is a 
successful application rate of just 2.6 percent.
    This is critically-needed funding. Dr. Broaddus is one of the 
world's top mesothelioma researchers. Indeed she was president of the 
International Mesothelioma Interest Group from 1999 through 2002. She 
and her team were surviving on three now concluded grants from the Meso 
Foundation. This DOD grant salvaged career in mesothelioma research. 
(See attached 5/24/09 email from Dr. Broaddus to Meso Foundation 
Executive Director Chris Hahn.) We are extremely grateful that thanks 
to your leadership and the DOD's awarding this one grant this renowned 
researcher will not have to abandon her investment and expertise in 
mesothelioma. But 37 other researchers put in the time, effort and 
expense to gather preliminary data and apply, and then were rejected. 
What happens to them? Going forward, a success rate of just 2.6 percent 
will discourage top researchers from applying in mesothelioma; they 
will direct their effort and expertise into other, better funded 
cancers. Similarly, new researchers will not establish their careers in 
mesothelioma either. Mesothelioma research will not advance, effective 
treatments will not be found, and veterans and current members exposed 
to asbestos through their military service will be left without hope.

                         A DEDICATED INVESTMENT

    Since the Committee's intent to spur mesothelioma research is not 
being executed through the PRMRP, we believe the Committee must respond 
by directing DOD to establish a dedicated mesothelioma program. For 
2009, Congress added dedicated funding for all of the following as new 
programs, in addition to the DOD's existing programs for Breast Cancer, 
Prostate Cancer, Ovarian Cancer, Neurofibromatosis, Tuberous Sclerosis 
Complex, and the Peer Reviewed Medical Research Program:
  --Autism Research Program, $8 million;
  --Gulf War Illness Research Program, $8 million;
  --Amyotrophic Lateral Sclerosis Research Program, $5 million;
  --Bone Marrow Failure Research Program, $5 million;
  --Multiple Sclerosis Research Program, $5 million;
  --Peer Reviewed Lung Cancer Research Program, $20 million;
  --Peer Reviewed Cancer Research Program, $16 million, restricted as 
        follows: $4 million for research of melanoma and other skin 
        cancers as related to deployments of service members to areas 
        of high exposure; $2 million for research of pediatric brain 
        tumors within the field of childhood cancer research; $8 
        million for genetic cancer research and its relation to 
        exposure to the various environments that are unique to a 
        military lifestyle; and $2 million for non-invasive cancer 
        ablation research into non-invasive cancer treatment including 
        selective targeting with nano-particles.
    All of these research areas warrant attention, but mesothelioma is 
a rapidly fatal, excruciatingly painful cancer directly related to 
military service. We ask the Committee to appropriate to DOD for fiscal 
year 2010 $5 million for a dedicated Mesothelioma Research Program or 
as a specific restriction within the Peer Reviewed Cancer Research 
Program. This will boost the long-neglected field of mesothelioma 
research, enabling mesothelioma researchers to build a better 
understanding of the disease and develop effective treatments. This 
will translate directly to saving lives and reducing suffering of 
veterans battling mesothelioma.
    We look to the Senate Defense Appropriations Subcommittee to 
provide continued leadership and hope to the servicemen and women and 
veterans who develop this cancer after serving our Nation. Thank you 
for the opportunity to provide testimony before the Subcommittee and we 
hope that we can work together to develop life-saving treatments for 
mesothelioma.

    Chairman Inouye. And now may I call upon the secretary 
treasurer of the American Society of Tropical Medicine and 
Hygiene, Dr. Jonathan Berman.

STATEMENT OF JONATHAN D. BERMAN, MD, Ph.D., COLONEL, 
            UNITED STATES ARMY (RET.), SECRETARY-
            TREASURER, AMERICAN SOCIETY OF TROPICAL 
            MEDICINE AND HYGIENE
    Dr. Berman. Mr. Chairman, ranking member, I welcome the 
opportunity to testify before you today on behalf of the 
American Society of Tropical Medicine and Hygiene, ASTMH.
    I commend this subcommittee for its focus on the vital 
issue of military infectious disease research, and the 
important role of that research in protecting troops deployed 
abroad.
    I am Dr. Jonathan Berman, secretary/treasurer of ASTMH, and 
a retired U.S. Army colonel.
    With nearly 3,500 members, ASTMH is the world's largest 
professional membership organization dedicated to the 
prevention and control of tropical diseases. We represent, 
educate, and support tropical medicine's scientists and 
clinicians. I want to talk to you today about the importance of 
funding for the DOD's infectious disease research and 
particularly malaria research.
    Malaria is one of the most serious health threats facing 
U.S. troops serving abroad. The U.S. military has, for decades, 
been on the forefront of global efforts to develop new 
antimalarial drugs and the world's first malaria vaccine. These 
research efforts are appropriately aimed at protecting and 
treating the warfighter, but they have important civilian 
applications, as well. Malaria is one of the greatest 
infectious-disease killers, and countless lives worldwide have 
been saved by antimalarial medicines developed in part or 
primarily by the DOD.
    Unfortunately, the parasite that causes malaria, like all 
microorganisms, is adaptive and develops resistance to drugs 
quickly. Until very recently, the military's first-line malaria 
therapeutic and prophylactic agent was mefloquine, a drug 
developed by military researchers to create a replacement for 
chloroquine, used soon after World War II.
    Mefloquine came into use in the 1980s, but parasites in 
Southeast Asia have already developed resistance to it, and 
resistance is now being identified in West Africa and South 
America, as well. Consequently, the military no longer 
considers mefloquine to be a first-line treatment, and at this 
time the military does not have an ideal malarial prophylactic 
agent. Ensuring that we can protect troops from malaria in 
future deployments means that we must continue to develop new 
drugs and an effective vaccine.
    Military malaria research funding represented approximately 
$23 million in fiscal year 2008, the most recent fiscal year 
for which figures are available. This level is not commensurate 
with the health threat malaria poses to military operations, 
therefore ASTMH respectively requests that the subcommittee 
increase funding for malaria research in fiscal year 2010 to 
$30 million, and provide subsequent annual increases, ending up 
at $77 million in funding in fiscal year 2015.
    Mr. Chairman and ranking member, thank you for providing me 
with the opportunity to speak today on behalf of ASTMH 
regarding this important but often overlooked defense issue.
    Chairman Inouye. Thank you very much, Dr. Berman.
    [The statement follows:]

                Prepared Statement of Jonathan D. Berman

    Overview: The American Society of Tropical Medicine and Hygiene 
(ASTMH) appreciates the opportunity to submit written testimony to the 
Senate Defense Appropriations Subcommittee. With nearly 3,300 members, 
ASTMH is the world's largest professional membership organization 
dedicated to the prevention and control of tropical diseases. We 
represent, educate, and support tropical medicine scientists, 
physicians, clinicians, researchers, epidemiologists, and other health 
professionals in this field.
    Because the military operates in and deploys to so many tropical 
regions, reducing the risk that tropical diseases present to servicemen 
and women is often critical to mission success. Malaria is a 
particularly important disease in this respect, because it is both one 
of the world's most common and deadly infectious diseases, and the U.S. 
military has a long history of deploying to regions endemic to malaria 
and suffering malaria casualties as a result.
    For this reason, we respectfully request that the Subcommittee 
expand funding for the Department of Defense's longstanding and 
successful efforts to develop new drugs, vaccines, and diagnostics 
designed to protect servicemen and women from malaria while deployed 
abroad. Specifically, we request that in fiscal year 2010, the 
Subcommittee ensure that the Department of Defense spends $30 million 
on malaria research and development. Furthermore, we request that the 
Subcommittee provide annual increases such that total military spending 
on malaria research is $76.5 million in fiscal year 2015. This funding 
will support ongoing efforts by military researchers to develop a 
vaccine against malaria and to develop new anti-malaria drugs to 
replace older drugs that are losing their effectiveness as a result of 
parasite resistance. Increased malaria research will help ensure that 
our soldiers, sailors, airmen, and marines are protected from this 
deadly disease when deployed to tropical regions.
    We very much appreciate the Subcommittee's consideration of our 
views, and we stand ready to work with Subcommittee members and staff 
on these and other important tropical disease matters.

                                 ASTMH

    ASTMH plays an integral and unique role in the advancement of the 
field of tropical medicine. Its mission is to promote global health by 
preventing and controlling tropical diseases through research and 
education. As such, the Society is the principal membership 
organization representing, educating, and supporting tropical medicine 
scientists, physicians, researchers, and other health professionals 
dedicated to the prevention and control of tropical diseases. Our 
members reside in 46 States and the District of Columbia and work in a 
myriad of public, private, and nonprofit environments, including 
academia, the U.S. military, public institutions, Federal agencies, 
private practice, and industry.
    The Society's long and distinguished history goes back to the early 
20th century. The current organization was formed in 1951 with the 
amalgamation of the National Malaria Society and the American Society 
of Tropical Medicine. Over the years, the Society has counted many 
distinguished scientists among its members, including Nobel laureates. 
ASTMH and its members continue to have a major impact on the tropical 
diseases and parasitology research carried out around the world.
    The central public policy priority of ASTMH is reducing the burden 
of infectious disease in the developing world. To that end, we advocate 
implementation and funding of Federal programs that address the 
prevention and control of infectious diseases that are leading causes 
of death and disability in the developing world, and which pose threat 
to U.S. citizens. Priority diseases include malaria, Dengue fever, 
Leishmaniasis, Ebola, cholera, and tuberculosis.

                    MALARIA AND MILITARY OPERATIONS

    Servicemen and women deployed from the U.S. military comprise a 
majority of the healthy adults traveling each year to malarial regions 
on behalf of the U.S. Government. For this reason, the U.S. military 
has long taken a primary role in the development of anti-malarial 
drugs, and nearly all of the most effective and widely used anti-
malarials were developed in part by U.S. military researchers. Drugs 
that have saved countless lives throughout the world were originally 
developed by the U.S. military to protect troops serving in tropical 
regions during WWII, the Korean War, and the Vietnam War.
    Fortunately, in recent years the broader international community 
has stepped up its efforts to reduce the impact of malaria in the 
developing world, particularly by reducing childhood malaria mortality, 
and the U.S. military is playing an important role in this broad 
partnership. But military malaria researchers are working practically 
alone in the area most directly related to U.S. national security: 
drugs and vaccines designed to protect or treat healthy adults with no 
developed resistance to malaria who travel to regions endemic to the 
disease. These drugs and vaccines would benefit everyone living or 
traveling in the tropics, but are particularly essential to the United 
States for the protection of forces from disease during deployments.
    Unfortunately, the prophylaxis and therapeutics currently given to 
U.S. servicemen and women are losing their effectiveness. During World 
War II, the Korean War, and Vietnam, the quinine-based anti-malaria 
drug chloroquine was the chemoprophylaxis and therapy of choice for the 
U.S. military. Over time, however, the malaria parasite developed 
widespread resistance to choloroquine, making the drug less effective 
at protecting deployed troops from malaria. Fortunately, military 
researchers at the Walter Reed Army Institute of Research (WRAIR) 
achieved the scientific breakthroughs that led to the development of 
mefloquine, which quickly replaced chloroquine as the military's front-
line drug against malaria.
    The malaria parasite has consistently demonstrated a notorious 
ability to quickly become resistant to new drugs, and the latest 
generation of medicines is no exception. Malaria parasites in Southeast 
Asia have already developed significant resistance to mefloquine, and 
resistant strains of the parasite have also been identified in West 
Africa and South America. In addition, there are early indications that 
parasite populations in southeast Asia may already be developing 
limited resistance to arteminisin, currently the most powerful anti-
malarial available. Indeed, the most deadly variant of malaria--
Plasmodium falciparum--is believed by the World Health Organization to 
have become resistant to ``nearly all antimalarials in current use.'' 
This resistance is not yet universal among the global Plasmodium 
falciparum population, with parasites in a given geographic area having 
developed resistance to some drugs and not others. But the sheer speed 
with which the parasite is developing resistance to mefloquine and 
arteminisin--drugs developed in the 1970s and 1980s--reminds us that 
military malaria researchers cannot afford to rest on their laurels. 
Developing new anti-malarials as quickly as the parasite becomes 
resistant to existing ones is an extraordinary challenge, and one that 
requires significant resources. Without new anti-malarials to replace 
existing drugs as they become obsolete, U.S. military operations in 
regions endemic to malaria may be compromised.
    Unfortunately, our limited ability to protect forces from malaria 
infection is not hypothetical: overseas operations are already being 
impacted. A 2007 study by Army researchers found that from 2000 through 
2005, at least 423 U.S. service members contracted malaria while 
deployed overseas, with the vast majority of these cases the result of 
deployments to South Korea (where malaria has recently remerged along 
the demilitarized zone with North Korea), Afghanistan and, to a lesser 
extent, Iraq. Notably, none of these countries are thought of by 
experts as being especially dangerous in terms of malaria, as opposed 
to the many countries in Sub-Saharan Africa and Southeast Asia where 
malaria is much more prevalent, and where more deadly strains of the 
parasite thrive. For example, a 2003 peacekeeping operation in Liberia 
resulted in a 44 percent malaria infection rate among Marines who spent 
at least one night ashore.
    Clearly, U.S. service members are insufficiently protected from 
malaria. The reasons for this are many, and include drug resistance as 
well as ongoing issues with compliance by soldiers who have difficulty 
maintaining a malaria prophylaxis regimen under combat conditions, or 
who have contraindications to the use of mefloquine or other drugs.\1\ 
Regardless of the cause for continuing vulnerability to malaria, 
however, the outlook is the same: until a malaria vaccine is finally 
developed, ensuring the safety and health of U.S. troops deploying to 1 
of the more than 100 countries where malaria is endemic will require 
the constant development of new malaria drugs, in a race against the 
parasite's ability to develop drug resistances.
---------------------------------------------------------------------------
    \1\ The aforementioned 2007 Army study found that of 11,725 active 
duty Army personnel deployed to Afghanistan during the study period, 
9.6 percent had contraindications to the use of mefloquine, the Army's 
first-line malaria treatment.
---------------------------------------------------------------------------
    To ensure that as many American soldiers as possible are protected 
from tropical and other diseases, Congress provides funding each year 
to support Department of Defense programs focused on the development of 
vaccines and drugs for priority infectious diseases. To that end, the 
Walter Reed Army Institute of Research and the Naval Medical Research 
Center coordinate one of the world's premier tropical disease research 
programs. These entities contributed to the development of the gold 
standard for experimental malaria immunization of humans, and the most 
advanced and successful drugs current being deployed around the world.
    The need to develop new and improved malaria prophylaxis and 
treatment for U.S. service members is not yet a crisis, but it could 
quickly become one if the United States were to become involved in a 
large deployment to a country or region where malaria is endemic, 
especially sub-Saharan Africa. Fortunately, a comparatively tiny amount 
of increased support for this program would restore the levels of 
research and development investment required to produce the drugs that 
will safeguard U.S. troops from malaria. In terms of the overall DOD 
budget, that malaria research program's funding is small--approximately 
$23.1 million in fiscal year 2008--but very important. Cutting funding 
for this program would deal a major blow to the military's work to 
reduce the impact of malaria on soldiers and civilians alike, thereby 
undercutting both the safety of troops deployed to tropical climates, 
and the health of civilians in those regions.

                  FISCAL YEAR 2010 DOD APPROPRIATIONS

    To protect U.S. military personnel, research must continue to 
develop new anti-malarial drugs and better diagnostics, and to identify 
an effective malaria vaccine appropriate for adults with no developed 
resistance to malaria. Much of this important research currently is 
underway at the Department of Defense. Additional funds and a greater 
commitment from the Federal Government are necessary to make progress 
in malaria prevention, treatment, and control.
    In fiscal year 2008, the Department of Defense spent only $23.1 
million on malaria research, despite the fact that malaria historically 
has been a leading cause of troop impairment and continues to be a 
leading cause of death worldwide. As the 2006 Institute of Medicine 
report Battling Malaria: Strengthening the U.S. Military Malaria 
Vaccine Program noted, ``Malaria has affected almost all military 
deployments since the American Civil War and remains a severe and 
ongoing threat.'' ASTMH agrees that malaria remains a severe and 
ongoing threat to U.S. military deployments to countries and regions 
endemic to malaria, and we believe that increased support for efforts 
to reduce this threat is warranted. A more substantial investment will 
help to protect American soldiers and potentially save the lives of 
millions of individuals around the world.
    Therefore, we request that the Subcommittee take support a fiscal 
year 2010 Department of Defense malaria research funding level of $30 
million. Furthermore, we request that the Subcommittee provide annual 
increases to this account such that total military spending on malaria 
research is $76.5 million in fiscal year 2015.
    By way of comparison with this request, in March of 2007 the 
Department of Defense estimated that it would spend $23.1 million on 
malaria research in fiscal year 2008. Unfortunately, neither an 
estimated level of fiscal year 2009 spending nor a fiscal year 2010 
request is available, because the Department of Defense does not 
typically report these numbers. However, recent funding trends suggest 
that military spending on research in this vital area is falling 
steadily.
    The role of infectious disease in the success or failure of 
military operations is often overlooked, but even a cursory review of 
U.S. and world military history underscores the fact that keeping 
military personnel safe from infectious disease is critical to mission 
success. The drugs and prophylaxis used to keep our men and women safe 
from malaria during previous conflicts in tropical regions are no 
longer reliable. Ensuring the safety of those men and women in future 
conflicts and deployments will require research on new anti-malaria 
tools. Thank you for your attention to this matter. We appreciate the 
opportunity to share our views, and please be assured that ASTMH stands 
ready to serve as a resource on this and any other tropical disease 
policy matters.

    Our next witness is the senior vice president for public 
policy of The Leukemia & Lymphoma Society, Mr. George Dahlman.

STATEMENT OF GEORGE DAHLMAN, SENIOR VICE PRESIDENT FOR 
            PUBLIC POLICY, THE LEUKEMIA & LYMPHOMA 
            SOCIETY
    Mr. Dahlman. Thank you very much, Mr. Chairman and Senator 
Cochran.
    I am George Dahlman, I'm pleased to appear today on behalf 
of The Leukemia & Lymphoma Society, and all the thousands of 
blood cancer patients we represent.
    As you know, there have been impressive strides in blood 
cancers--that's leukemia, lymphoma, myeloma, and some others--
but, there is a lot of work to be done, and we believe that the 
public/private partnership that's part of the DOD's 
congressionally directed medical research program is an 
important part of that effort, and should be strengthened.
    The Leukemia & Lymphoma Society, along with its partners, 
believe that this is especially important for the Department of 
Defense to address. First, research in blood-related cancers 
has significant relevance to the Armed Forces because the 
incidence of these cancers is substantially higher among 
individuals with chemical and nuclear exposure. Higher 
incidences of leukemia have been substantiated in extreme 
nuclear incidents in both military and civilian populations, 
and individual exposures to chemical agents, such as Agent 
Orange in the Vietnam war, caused an increased risk of 
contracting lymphoid malignancies.
    And now we're seeing the applicability of blood cancer 
research played out once again in Iraq and Afghanistan as U.S. 
service personnel face consequences of burn pits and the blood 
cancers that have been reported.
    DOD research on blood cancers addresses the importance of 
preparing civilian and military exposure to the weapons being 
developed by several hostile nations, and aid in the research 
of all cancers.
    Mr. Chairman, and members of the subcommittee, with all due 
respect to our colleagues fighting a broad range of 
malignancies that are represented in this program, and 
certainly not to diminish their significance, a cancer research 
program designed for application of military and national 
security needs would invariably begin with a strong blood-
cancer research foundation. And recognizing that fact and the 
opportunity this research represents, a bipartisan group of 48 
Members of Congress recently requested that the program be 
instated for $25 million, and be expanded to all blood cancers.
    Furthermore, we respectfully request that funding be 
dedicated to a collaborative, public/private effort between the 
United States Military Cancer Institute, The Leukemia & 
Lymphoma Society, and a blue-ribbon panel of scientific 
academicians.
    Chairman Inouye, as the cosponsor of Senate Bill 51, which 
authorizes the U.S. Military Cancer Institute, surely you 
recognize that the USMCI has over 9 million electronic medical 
records detailing the health histories of servicemen and women 
and their families. The military also has serum and tissue 
specimens from these individuals stored, as a routine step in 
their healthcare. These records and samples together provide a 
unique base that can power blood cancer research relevant to 
the military environment and lifestyle in a way that is not 
possible for any other population. A joint effort, tapping the 
expertise of both the USMCI and The Leukemia & Lymphoma Society 
represents a unique opportunity to identify valuable research 
opportunities and state-of-the-art technology that can address 
significant questions on the origins and diagnosis of blood 
cancers.
    And I would just add, Senator Inouye, it seems odd that 
there is this disconnect between the USMCI, on the one hand, 
that studies cancer, and the cancer programs that are done 
through the CDMRP, as part--at Fort Dietrich--these two groups 
do not communicate with one another.
    The Leukemia & Lymphoma Society strongly endorses and 
enthusiastically supports an effort to pursue this project, and 
respectfully urges the subcommittee to include this funding in 
the fiscal year 2010 defense appropriations bill.
    Thank you.
    Chairman Inouye. Thank you very much, Mr. Dahlman.
    [The statement follows:]

                  Prepared Statement of George Dahlman

                              INTRODUCTION

    Mr. Chairman and members of the committee, my name is George 
Dahlman, Senior Vice President, Public Policy for The Leukemia & 
Lymphoma Society. I am pleased to appear today and testify on behalf of 
the Society and the more than 900,000 Americans currently living with 
blood cancers and the 135,000 who will be diagnosed with one this 
year--recently some of whom have been right here in the Senate 
Furthermore, every 10 minutes, someone dies from one of these cancers--
leukemia, lymphoma, Hodgkin's disease and myeloma.
    During its 60-year history, the Society has been dedicated to 
finding a cure for the blood cancers, and improving the quality of life 
of patients and their families. The Society has the distinction of 
being both the nation's second largest private cancer organization and 
the largest private organization dedicated to biomedical research, 
education, patient services and advocacy as they pertain to blood 
cancers.
    Our central contribution to the search for cures for the blood 
cancers is providing a significant amount of the funding for basic, 
translational and clinical research. In 2009, we will provide 
approximately $70 million in research grants. In addition to our 
research funding role, we help educate health care and school 
professionals as needed and provide a wide range of services to 
individuals with a blood cancer, their caregivers, families, and 
friends through our 64 chapters across the country. Finally, we 
advocate responsible public policies that will advance our mission of 
finding cures for the blood cancers and improving the quality of life 
of patients and their families.
    We are pleased to report that impressive progress is being made in 
the effective treatment of many blood cancers, with 5-year survival 
rates doubling and even tripling over the last two decades. More than 
90 percent of children with Hodgkin's disease now survive, and survival 
for children with acute lymphocytic leukemia and non-Hodgkin's lymphoma 
has risen as high as 86 percent.
    Just 7 years ago, in fact, a new therapy was approved for chronic 
myelogenous leukemia, a form of leukemia for which there were 
previously limited treatment options, all with serious side-effects--5-
year survival rates were just over 50 percent. Let me say that more 
clearly, if 8 years ago your doctor told you that you had CML, you 
would have been informed that there were limited treatment options and 
that you should get your affairs in order. Today, those same patients 
have access to this new therapy, called Gleevec, which is a so-called 
targeted therapy that corrects the molecular defect that causes the 
disease, and does so with few side effects. Now, 5-year survival rates 
are as high as 96 percent for patients newly diagnosed with chronic 
phase CML.
    The Society funded the early research that led to Gleevec's 
approval, as it has contributed to research on a number of new 
therapies. We are pleased that we played a role in the development of 
this life-saving therapy, but we realize that our mission is far from 
realized. Many forms of leukemia, lymphoma and myeloma still present 
daunting treatment challenges. There is much work still to be done, and 
we believe that the research partnership between the public and private 
sectors--as represented in the Department of Defense's Congressionally 
Directed Medical Research Program--is an integral part of that 
important effort and should be further strengthened.

         THE GRANT PROGRAMS OF THE LEUKEMIA & LYMPHOMA SOCIETY

    The grant programs of the Society have traditionally been in three 
broad categories: Career Development Program grants, Translational 
Research Program grants, and Specialized Centers of Research Program 
grants. In our Career Development Program, we fund Scholars, Special 
Fellows, and Fellows who are pursuing careers in basic or clinical 
research. In our Translational Research Program, we focus on supporting 
investigators whose objective is to translate basic research 
discoveries into new therapies.
    The work of Dr. Brian Druker, an oncologist at Oregon Health 
Sciences University and the chief investigator responsible for 
Gleevec's development, was supported by a Translational Research 
Program grant from the Society.
    Our Specialized Centers of Research grant program is intended to 
bring investigators together to form new research teams focused on the 
discovery of innovative approaches to treating and/or preventing 
leukemia, lymphoma, and myeloma. The awards go to those groups that can 
demonstrate that their close interaction will create research synergy 
and accelerate our search for new and better treatments.
    Dr. Druker is certainly a star among those supported by the 
Society, but our support in the biomedical field is broad and deep. 
Through the Society's research grant programs, we are currently 
supporting more than 380 investigators at 134 institutions in 34 States 
and 12 other countries.
    Not content with these extensive efforts, the Society has launched 
a new Therapy Acceleration Program intended to proactively invest in 
promising blood cancer therapies that are in early stages of 
development by industry, but which may not have sufficient financial 
support or market potential to justify private sector investment. In 
addition, the Society will use this program to further facilitate the 
advancement of therapies in development by academic researchers who may 
not have the spectrum of resources or expertise to fulfill the 
potential of their discoveries. Directed early phase clinical trial 
support in this funding program will further advance new and better 
treatments for blood cancer treatments.

                    IMPACT OF HEMATOLOGICAL CANCERS

    Despite enhancements in treating blood cancers, there are still 
significant research challenges and opportunities. Hematological, or 
blood cancers pose a serious health risk to all Americans. These 
cancers are actually a large number of diseases of varied causes and 
molecular make-up, and with different treatments, that strike men and 
women of all ages. In 2009, more than 130,000 Americans will be 
diagnosed with a form of blood-related cancer and almost 65,000 will 
die from these cancers. For some, treatment may lead to long-term 
remission and cure; for others these are chronic diseases that will 
require treatments across a lifetime; and for others treatment options 
are still extremely limited. For many, recurring disease will be a 
continual threat to a productive and secure life.
    A few focused points to put this in perspective:
  --Taken together, the hematological cancers are fifth among cancers 
        in incidence and fourth in mortality.
  --Over 900,000 Americans are living with a hematological malignancy 
        in 2009.
  --Almost 65,000 people will die from hematological cancers in 2009, 
        compared to 160,000 from lung cancer, 41,000 from breast 
        cancer, 27,000 from prostate cancer, and 52,000 from colorectal 
        cancer.
  --Blood-related cancers still represent serious treatment challenges. 
        The improved survival for those diagnosed with all types of 
        hematological cancers has been uneven. The 5-year survival 
        rates are:
    --Hodgkin's disease, 87 percent;
    --Non-Hodgkin's lymphoma, 64 percent;
    --Leukemias (total), 50 percent;
    --Multiple Myeloma, 33 percent;
    --Acute Myelogenous Leukemia, 21 percent.
  --Individuals who have been treated for leukemia, lymphoma, and 
        myeloma may suffer serious adverse consequences of treatment, 
        including second malignancies, organ dysfunction (cardiac, 
        pulmonary, and endocrine), neuropsychological and psychosocial 
        aspects, and poor quality of life.
  --For the period from 1975 to 2005, the incidence rate for non-
        Hodgkin's lymphoma increased by 79 percent (increasing 2.6 
        percent/year).
  --Non-Hodgkin's lymphoma and multiple myeloma rank second and fifth, 
        respectively, in terms of increased cancer mortality since 
        1973.
  --Lymphoma is the third most common childhood cancer and the fifth 
        most common cancer among Hispanics of all races. Recent 
        statistics indicate both increasing incidence and earlier age 
        of onset for multiple myeloma.
  --Multiple myeloma is one of the top 10 leading causes of cancer 
        death among African Americans.
  --Hispanic children of all races under the age of 20 have the highest 
        rates of childhood leukemias.
  --Despite the significant decline in the leukemia and lymphoma death 
        rates for children in the United States, leukemia is still the 
        leading cause of death in the United States among children less 
        than 20 years of age, in females between the ages of 20 and 39 
        and males between the ages of 60-79.
  --Lymphoma is the fourth leading cause of death among males between 
        the ages of 20 and 39 and the fifth leading cause of death for 
        females older than 80. Overall, cancer is now the leading cause 
        of death for U.S. citizens younger than 85 years of age, 
        overtaking heart disease as the primary killer.

         POSSIBLE ENVIRONMENTAL CAUSES OF HEMATOLOGICAL CANCERS

    The causes of hematological cancers are varied, and our 
understanding of the etiology of leukemia, lymphoma, and myeloma is 
limited. Extreme radiation exposures are clearly associated with an 
increased incidence of leukemias. Benzene exposures are associated with 
increased incidence of a particular form of leukemia. Chemicals in 
pesticides and herbicides, as well as viruses such as HIV and EBV, 
apparently play a role in some hematological cancers, but for most 
cases, no environmental cause is identified. Researchers have recently 
published a study reporting that the viral footprint for simian virus 
40 (SV40) was found in the tumors of 43 percent of NHL patients. These 
research findings may open avenues for investigation of the detection, 
prevention, and treatment of NHL. There is a pressing need for more 
investigation of the role of infectious agents or environmental toxins 
in the initiation or progression of these diseases.

                IMPORTANCE TO THE DEPARTMENT OF DEFENSE

    The Leukemia & Lymphoma Society, along with its partners in the 
American Society of Hematology, Aplastic Anemia & MDS International 
Foundation, International Myeloma Foundation, Lymphoma Research 
Foundation, and Multiple Myeloma Research Foundation, believe 
biomedical research focused on the hematological cancers is 
particularly important to the Department of Defense for a number of 
reasons.
    First, research on blood-related cancers has significant relevance 
to the armed forces, as the incidence of these cancers is substantially 
higher among individuals with chemical and nuclear exposure. Blood 
cancers are linked to members of the military who were exposed to 
ionizing radiation, such as those who occupied Japan after World War II 
and those who participated in atmospheric nuclear tests between 1945-
1962. Service members who contract multiple myeloma, non-Hodgkin's 
lymphoma, and leukemias other than chronic lymphocytic leukemia are 
presumed to have contracted these diseases as a result of their 
military service; hence, they are eligible to receive benefits from the 
Department of Veterans Affairs (VA).
    Secondly, in-country Vietnam veterans who contract Hodgkin's 
disease, chronic lymphocytic leukemia, multiple myeloma, or non-
Hodgkin's lymphoma are presumed to have contracted these diseases as a 
result of their military service and the veterans are eligible to 
receive benefits from the VA.
    Thirdly, the Institute of Medicine (IOM) has found that Gulf War 
veterans are at risk for contracting a number of blood cancers. For 
instance, the IOM has found sufficient evidence of a causal 
relationship between exposure to benzene and acute leukemias. 
Additionally, the IOM has found there is sufficient evidence of an 
association between benzene and adult leukemias, and solvents and acute 
leukemias. Finally, the IOM has also found there is also limited or 
suggestive evidence of an association between exposure to 
organophosphorous insecticides to non-Hodgkin's lymphoma and adult 
leukemias; carbamates and Benzene to non-Hodgkin's lymphoma; and 
solvents to multiple myeloma, adult leukemias, and myelodysplastic 
syndromes--a precursor to leukemia.
    Furthermore, research in the blood cancers has traditionally 
pioneered treatments in other malignancies. Cancer treatments that have 
been developed to treat a blood-related cancer are now used or being 
tested as treatments for other forms of cancer. Combination 
chemotherapy and bone marrow transplants are two striking examples of 
treatments first developed for treating blood cancer patients. More 
recently, specific targeted therapies have proven useful for treating 
patients with solid tumors as well as blood cancers.
    From a medical research perspective, it is a particularly promising 
time to build a DOD research effort focused on blood-related cancers. 
That relevance and opportunity were recognized for a 6-year period when 
Congress appropriated $4.5 million annually--for a total of $28 
million--to begin initial research into chronic myelogenous leukemia 
(CML) through the Congressionally Directed Medical Research Program 
(CDMRP). As members of the Subcommittee know, a noteworthy and 
admirable distinction of the CDMRP is its cooperative and collaborative 
process that incorporates the experience and expertise of a broad range 
of patients, researchers and physicians in the field. Since the Chronic 
Myelogenous Leukemia Research Program (CMLRP) was announced, members of 
the Society, individual patient advocates and leading researchers have 
enthusiastically welcomed the opportunity to become a part of this 
program and contribute to the promise of a successful, collaborative 
quest for a cure.
    In spite of the utility and application to individuals who serve in 
the military, the CML program was not included in January's 2007 
Continuing Resolution funding other fiscal year 2007 CDMRP programs. 
This omission, and the program's continued absence seriously 
jeopardizes established and promising research projects that have clear 
and compelling application to our armed forces as well as pioneering 
research for all cancers.
    Recognizing that fact and the opportunity this research represents, 
a bipartisan group of 45 Members of Congress have requested that the 
program be reconstituted at a $25 million level and be expanded to 
include all the blood cancers--the leukemias, lymphomas and myeloma. 
This would provide the research community with the flexibility to build 
on the pioneering tradition that has characterized this field.
    With all due respect to our colleagues fighting a broad range of 
malignancies that are represented in this program--and certainly not to 
diminish their significance--a cancer research program designed for 
application to military and national security needs would invariably 
include a strong blood cancer research foundation. DOD research on 
blood cancers addresses the importance of preparing for civilian and 
military exposure to the weapons being developed by several hostile 
nations and to aid in the march to more effective treatment for all who 
suffer from these diseases. This request clearly has merit for 
inclusion in the fiscal year 2010 legislation.
    Furthermore, we respectfully request that funding be dedicated to a 
collaborative public-private effort between the U.S. Military Cancer 
Institute, The Leukemia & Lyphoma Society and a blue ribbon panel of 
scientific academicians.
    The USMCI has over 9 million electronic medical records detailing 
the health histories of service men and women and their families. The 
military also has serum and tissue specimens from these individuals 
stored as a routine step in their health care. These records and 
samples, together, provide a unique base that can power blood cancer 
research relevant to the military environment and lifestyle in a way 
that is not possible for any other population.
    A joint effort, tapping the expertise of both USMCI and LLS, 
represents a unique opportunity to identify valuable research 
opportunities and state-of-the-art technology that can address 
significant questions on the origins and diagnosis of blood cancers. 
For example:
  --meta-analysis of the existing data may be used to gain insight into 
        the exposure risks inherent in the military environment that 
        may predispose the war fighter or their dependents to develop 
        blood cancer.
  --Gene profiling might be used to gauge the existing genetic risk for 
        blood cancer in a given individual and may guide the delivery 
        of healthcare and/or deployment decisions.
  --Proteomic analysis of historically preserved serial blood samples 
        from a military member diagnosed with blood cancer may reveal 
        exposures related to development of the disease and drive 
        decisions about safety precautions and protective gear.
    The Leukemia & Lymphoma Society strongly endorses and 
enthusiastically supports this effort and respectfully urges the 
Committee to include this funding in the fiscal year 2010 Defense 
Appropriations bill.
    We believe that building on the foundation Congress initiated over 
a 6-year period should not be abandoned and would both significantly 
strengthen the military's cancer program and accelerate the development 
of all cancer treatments. As history has demonstrated, expanding its 
focus into areas that demonstrate great promise; namely the blood-
related cancers of leukemia, lymphoma and myeloma, would substantially 
aid the overall cancer research effort and yield great dividends.

    Chairman Inouye. And now may I call upon the president of 
the Air Force Association, Lieutenant General Michael M. Dunn.

STATEMENT OF LIEUTENANT GENERAL MICHAEL M. DUNN (RET.), 
            PRESIDENT/CHIEF EXECUTIVE OFFICER, AIR 
            FORCE ASSOCIATION
    General Dunn. Thank you, Mr. Chairman.
    Last but not least. Mr. Chairman, Mr. Vice Chairman, I'm 
honored to be with you today to talk about the fiscal year 2010 
defense budget.
    I represent 120,000 members of the Air Force Association, 
and I need to point out to this subcommittee that we are 
independent of the Air Force, that the Air Force has not made 
any inputs, nor seen my statement or my remarks.
    At this time I request my written statement be included in 
the record.
    Chairman Inouye. Without objection.
    General Dunn. Mr. Chairman, I have to tell this 
subcommittee I'm worried, at this point in history, about the 
future. The average age of Air Force aircraft is the oldest in 
its very short history--25 years old, one-quarter of a century. 
Some types of aircraft are over 50 years old, and, when they 
are eventually replaced, some are going to be over 90 years 
old.
    To begin to replace the fleet, the Air Force has to buy 
about 165 aircraft per year, of all types. The 2010 budget 
request purchases only 81 aircraft, and 29 of them are unmanned 
aerial vehicles, and 13 are for the Air Force Academy.
    This puts the Air Force on a replacement rate of about 100 
years. Obviously, this is not a sustainable path. Costs to keep 
the fleet are rising--fleet ready--are rising, many aircraft 
have been grounded over the past few years, planes are breaking 
in unpredictable ways, and readiness rates are falling. Our men 
and women who serve deserve the very best we, as a Nation, can 
provide to them. We have to turn this around.
    DOD has stated they need to rebalance the force to focus on 
irregular warfare (IW). The sad fact is, they have to do both--
modernize and recapitalize, as well as focusing on IW.
    I hope DOD is right about the future, that they won't face 
a strong opponent. But, the one thing certain about the future 
is we have been wrong over the type of opponent we will face. 
We did not anticipate the Japanese attacking the Hawaiian 
Islands in World War--to begin World War II for the United 
States; we did not anticipate the Korean War, Vietnam, the fall 
of the Soviet Union, Iraq's attack on Kuwait, 9/11, nor 
Operation Iraqi Freedom. To maintain that all wars in the 
future will be irregular wars is--well--not supported by the 
lessons of the past.
    The decisions made by DOD and this Congress are ones we 
will live with for a long time. They are 30-year decisions. 
When the Nation terminates or delays seven aircraft production 
lines, the impact on our aerospace industry is devastating. And 
this is an industry that adds almost $40 billion per year in 
positive trade balance. Engineers, design teams, and innovation 
will be lost, or hard or expensive to replace; tens of 
thousands of jobs will be lost. And these are high paying 
manufacturing jobs that benefit, not just local communities, 
but the Nation as a whole.
    Mr. Chairman, I think you can see why I'm worried. This is 
not just about one system or another, this is about air power, 
our asymmetric advantage and the reason our past conflicts have 
so spectacular, with some of the lowest friendly casualty rates 
in the history of warfare. We have to nurture this capability 
for the future.
    And thank you for your time, sir.
    Chairman Inouye. Well, thank you very much, General Dunn.
    [The statement follows:]

                 Prepared Statement of Michael M. Dunn

    Ladies and gentleman of the Committee, I am honored to come before 
you today, representing the Air Force Association, to discuss your 
United States Air Force. I would like to begin my remarks by saluting 
our Airmen who strive every day to ensure that America's Air Force is 
second to none. These men and women are true heroes and we salute their 
dedication and determination, while also recognizing the sacrifices 
they make for our Nation.
    To borrow a phrase from General Schwartz, the United States Air 
Force is truly ``all in.'' Whether deterring potential adversaries, 
striking strategic targets, gathering critical intelligence, delivering 
humanitarian relief supplies, evacuating wounded, airlifting cargo 
around the globe, enabling command and control, rescuing personnel 
behind enemy lines, or providing close air support, the Air Force is an 
invaluable national asset. Just looking at operations in Iraq and 
Afghanistan, the Air Force has flown nearly 60,000 sorties this year 
alone. In the real world, this translates into Airmen doing their very 
best 24/7 to fight and win on the front lines along with their joint 
team partners.
    While we are certainly proud of the Air Force's current record, 
this success cannot be taken for granted. The Air Force has spent the 
past two decades engaged in continuous combat operations and is 
utilizing an aircraft fleet that averages nearly a quarter of a century 
in age--with some planes in the inventory dating back to the Eisenhower 
Administration.
    The most obvious problem associated with this aging fleet is that 
old airplanes break more often and eventually are no longer airworthy. 
In the time since Desert Storm the average age of the Air Force fleet 
has increased by nearly a decade and the availability rate has dropped 
in a corresponding fashion. This means that since 1991 the percentage 
of time an aircraft is not broken and can fly a mission has fallen from 
77 percent to 65 percent. Aside from these costly maintenance 
challenges, a number of dramatic airworthiness issues have also 
afflicted the Air Force fleet. In 2000 the service grounded one third 
of its KC-135 air refueling aircraft because of a faulty flight control 
component. In 2004 the Air Force discovered that many of its C-130s had 
major cracks in their wings. In 2007 an F-15 broke in two while on a 
training flight due to structural fatigue, grounding the entire fleet 
for months. In 2008 the entire T-38 fleet was grounded for an extended 
period because of an aging control surface fixture. Most recently, half 
of the A-10 fleet was grounded due to wing cracks and the C-130 fleet 
was also grounded due to a faulty bolt found in the wings of many of 
the aircraft. More problems are certain to arise as the age of the 
fleet continues to increase.
    It is also important to consider that most next generation aircraft 
yield tremendous operational efficiencies that dramatically offset 
their higher per-unit acquisition cost and yield long-term savings. 
This performance increase was clearly demonstrated on the first night 
of Desert Storm when 20 new F-117 stealth fighters took the 
unprecedented step of attacking 28 separate targets. On the same night 
it took a combined force of 41 legacy non-stealth aircraft to strike 
one target--4 F/A-18s to defend against enemy aircraft, 3 drones to 
serve as decoys, 5 EA-6B aircraft to jam enemy radar, along with 4 F-4s 
and 17 F/A-18s to suppress enemy surface-to-air missiles so that 4 A-6s 
and 4 Tornadoes could strike one target. The full spectrum cost imposed 
by these legacy aircraft was tremendous--aircraft development and 
acquisition funding, operations and maintenance expenses, personnel 
bills, base access issues, etc. Viewed from this perspective, the 
encompassing price of new aircraft like the F-22 and F-35 is not so 
high.
    The global threat environment is rapidly evolving and proliferation 
of modern weaponry is negating the survivability of the Air Force's 
legacy fleet. Over 30 nations operate fighter aircraft that equal or 
exceed the capabilities of the F-15 and F-16, whose designs 
respectively date back to the 1960s and 1970s. Nations such as Russia 
and China are also developing 5th generation fighters that will have F-
22-like capabilities and will be bought in F-35-like quantities . . . 
and sold to other countries. Additionally, dozens of nations operate 
surface-to-air missiles that can easily shoot down aircraft such as the 
B-1, B-52, F-15, F-16, F-18, Predator, Global Hawk, and more. It is 
important to remember that in the final days of Vietnam the Air Force 
lost 15 B-52s in 12 days during Operation Linebacker II. Air defenses 
have advanced markedly since then but 47 percent of the long range 
strike fleet is comprised of these same B-52s. Had the U.S. Air Force 
been called upon to engage in the recent Georgian conflict, the B-2 and 
F-22 were the only aircraft in the U.S. inventory that would have 
survived in the threat environment. U.S. national security demands a 
broader array of effective capabilities than just 20 B-2s and 186 F-
22s.
    The fiscal year 2010 budget proposal currently under consideration 
by Congress fails to make necessary recapitalization investments and 
actually exacerbates the challenges facing several key mission sets. 
For example, the fiscal year 2010 budget proposal ends production of 
the F-22 at 187 aircraft even though the stated military requirement is 
for 243 airframes. A fleet comprised of 187 airframes yields a force of 
about 100 combat-ready aircraft, no attrition/reserve inventory, and 
too few aircraft to engage/deter in more than one operation at a time. 
All known analysis undertaken to this point has concluded such a 
limited fleet size entails high risk. Air dominance is the precondition 
for all successful U.S. military combat operations--this isn't just 
about the U.S. Air Force--it is essential for the entire joint team.
    This year's budget also discontinues C-17 acquisition at 205 
aircraft even though demand for airlift is so high that the Air Force 
is currently flying its C-17 airframes over 1,000 hours past what was 
originally programmed per year. Additional developments have seen the 
ground component grow by 92,000 Soldiers and Marines, increased 
reliance on airlift, to include leased Russian aircraft, to get 
equipment to Afghanistan and Iraq, and a decision to relocate many 
units back to CONUS. Each one of these developments suggests that the 
need for military airlift will increase. Closing the C-17 production 
line at 205 aircraft risks creating a high-demand low-density mission 
set.
    Even though existing Combat Search and Rescue (CSAR) helicopters 
are rapidly nearing the end of their service lives, the budget cancels 
their replacement program. CSAR is a moral imperative. Our current 
enemies do not take prisoners of war. They welcome the opportunity to 
torture and kill their captives, making CSAR even more critical than 
before. In fact, the Air Force CSAR capabilities are in such high 
demand in Iraq and Afghanistan that the Weapons School has been closed 
so that a maximum number of assets can be surged forward.
    The Next Generation Bomber program was also cancelled even though 
the current long range strike fleet averages over 40 years in age. 
While elements of the force are still capable in certain threat 
environments, the proliferation of advanced anti-access weaponry is 
curtailing when and where many of the legacy assets can successfully 
operate. Twenty B-2s are the only long range strike assets in the Air 
Force inventory that can penetrate high threat environments and 
survive. These aircraft are approaching 20 years in age, have not been 
in production since 1997, and have no viable replacements to backfill 
losses. During the Cold War, bombers were primarily viewed as nuclear 
deterrence assets. However, actual combat operations have demonstrated 
that long range conventional strike is an incredibly important tool. 
Modern long range bombers can penetrate air defense systems, respond 
rapidly to strike fleeting targets, and operate over long distances 
without excessive logistical support. The tactical strike fleet, while 
capable, simply does not have the range and payload capabilities to 
fulfill many of these missions.
    The Airborne Laser (ABL) program was also curtailed even though 
nuclear weapons proliferation, combined with advances in delivery 
system technology, is yielding an increasingly dangerous world. 
Sufficient investment in robust missile defense capabilities is 
essential for the security of United States and its allies.
    Cumulatively, these decisions will also have a tremendous impact on 
the defense industrial base. This sector is an invaluable strategic 
partner for the United States. Whether addressing problems through 
innovation, delivering high-quality products that enable our forces to 
attain victory, or developing solutions for future challenges, the 
industrial base is a critical national security asset. The United 
States is rapidly approaching the point where it will be limited to one 
major heavy aircraft production line (Boeing in Seattle, WA) and one 
advanced fighter production facility (Lockheed Martin in Fort Worth, 
TX). The proposed fiscal year 2010 budget cuts rapidly accelerate the 
decline of this sector. The barriers to entry are extraordinarily high 
within the military aerospace industrial base and once the Nation loses 
certain core competencies, they will be exceedingly difficult and 
costly to regenerate. For example, low observable (stealth) design 
teams are incredibly skilled in a highly nuanced field that does not 
lend itself to dual-use applications within the civilian aerospace 
sector. If projects are not forthcoming to maintain this skill set, 
then the country will face major challenges trying to regenerate such 
capabilities in the future. Additionally, the military aerospace sector 
will have an increasingly difficult time recruiting and retaining 
talent amidst these challenging times. Failing to build a viable and 
competent workforce for the next generation will have a dramatic impact 
on the national security options available to the Nation for the 
foreseeable future.
    Clearly the United States Air Force is at a strategic crossroads. 
The Nation cannot realistically expect Airmen to successfully engage 
and survive in future campaigns if it does not equip them with modern 
and effective equipment. One of the key lessons from history is the 
importance of preparing for the full spectrum of operations. This 
country has failed to anticipate numerous critical events--Pearl 
Harbor, Berlin Blockade, Cuban Missile Crisis, Soviet Invasion of 
Afghanistan, fall of the Shah in Iran, end of the Cold War, Iraq's 
invasion of Kuwait, 9/11, etc. Events in the modern world develop 
rapidly and the country has to respond quickly with the forces on hand. 
The days of WWII-like rapid wartime industrialization are gone. Aside 
from rudimentary supplies, effective weapons systems can no longer be 
developed in a matter of months and events are often decided by the 
time new items are fielded. This demands that the Nation prepare for a 
wide variety of contingencies. Otherwise, the lives of the men and 
women in uniform will be placed at undue risk as they struggle to 
achieve their respective objectives with inadequate tools. While 
airpower can operate with relative impunity in current operations, such 
access must not be taken for granted in the future. Current legacy 
systems will last a few more years, but eventually they will be 
retired. Most of the cuts involved in this budget kill the platforms 
that were intended to replace these legacy systems. The Chief of Staff 
of the Air Force has stated he needs to buy 165 aircraft per year in 
order to keep the average age of the fleet the same as it is now--a 
quarter of a century old. This budget only buys 81 aircraft--13 of 
which are for the Air Force Academy and 29 of which are UAVs. That puts 
the Air Force on a replacement rate of over 100 years. It is important 
that Congress and the American people fully appreciate the full 
ramifications of these decisions. We risk imposing drastic limitations 
on the strategic options available to the country for decades into the 
future.

                     ADDITIONAL SUBMITTED STATEMENT

    Chairman Inouye. The subcommittee has received testimony 
from the National Military and Veterans Alliance and their 
testimony will be made part of the record.
    [The statement follows:]

   Prepared Statement of the National Military and Veterans Alliance

    The Alliance was founded in 1996 as an umbrella organization to be 
utilized by the various military and veteran associations as a means to 
work together towards their common goals. The Alliance member 
organizations are: American Logistics Association; American Military 
Retirees Association; American Military Society; American Retirees 
Association; American World War II Orphans Network; AMVETS (American 
Veterans); Armed Forces Marketing Council; Army and Navy Union; 
Catholic War Veterans; Gold Star Wives of America, Inc.; Japanese 
American Veterans Association; Korean War Veterans Foundation; Legion 
of Valor; Military Order of the Purple Heart; Military Order of the 
World Wars; Military Order of Foreign Wars; National Assoc. for 
Uniformed Services; National Gulf War Resource Center; Naval Enlisted 
Reserve Association; Naval Reserve Association; Paralyzed Veterans of 
America; Reserve Enlisted Association; Reserve Officers Association; 
Society of Military Widows; The Retired Enlisted Association; TREA 
Senior Citizens League; Tragedy Assist. Program for Survivors; 
Uniformed Services Disabled Retirees; Veterans of Foreign Wars; Vietnam 
Veterans of America; Women in Search of Equity.
    These organizations have over three and a half million members who 
are serving our Nation or who have done so in the past, and their 
families.

                              INTRODUCTION

    Mister Chairman and distinguished members of the Committee, the 
National Military and Veterans Alliance (NMVA) is very grateful for the 
invitation to testify before you about our views and suggestions 
concerning defense funding issues. The overall goal of the National 
Military and Veterans Alliance is a strong National Defense. In light 
of this overall objective, we would request that the committee examine 
the following proposals.
    While the NMVA highlights the funding of benefits, we do this 
because it supports National Defense. A phrase often quoted ``The 
willingness with which our young people are likely to serve in any war, 
no matter how justified, shall be directly proportional as to how they 
perceive the Veterans of earlier wars were treated and appreciated by 
their country,'' has been frequently attributed to General George 
Washington. Yet today, many of the programs that have been viewed as 
being veteran or retiree are viable programs for the young serving 
members of this war. This phrase can now read ``The willingness with 
which our young people, today, are willing to serve in this war is how 
they perceive the veterans of this war are being treated.''
    This has been brought to the forefront by how quickly an issue such 
as the treatment of wounded warriors suffering from Traumatic Brain 
Injury or Post Traumatic stress Disorder has been brought to the 
national attention.
    In a long war, recruiting and retention becomes paramount. The 
National Military and Veterans Alliance, through this testimony, hopes 
to address funding issues that apply to the veterans of various 
generations.

                        FUNDING NATIONAL DEFENSE

    NMVA is pleased to observe that the Congress continues to discuss 
how much should be spent on National Defense. The Alliance urges the 
President and Congress to increase defense spending to 5 percent of 
Gross Domestic Product during times of war to cover procurement and 
prevent unnecessary personnel end strength cuts.

                          PAY AND COMPENSATION

    Our serving members are patriots willing to accept peril and 
sacrifice to defend the values of this country. All they ask for is 
fair recompense for their actions. At a time of war, compensation 
rarely offsets the risks.
    The NMVA requests funding so that the annual enlisted military pay 
raise exceeds the Employment Cost Index (ECI) by at least half of a 
percent.
    Further, we hope that this committee continues to support targeted 
pay raises for those mid-grade members who have increased 
responsibility in relation to the overall service mission. Pay raises 
need to be sufficient to close the civilian-military pay gap.
    NMVA would apply the same allowance standards to both Active and 
Reserve when it comes to Aviation Career Incentive Pay, Career Enlisted 
Flyers Incentive Pay, Diving Special Duty Pay, Hazardous Duty Incentive 
Pay and other special pays.
    The Service chiefs have admitted one of the biggest retention 
challenges is to recruit and retain medical professionals. NMVA urges 
the inclusion of bonus/cash payments (Incentive Specialty pay IPS) into 
the calculations of Retirement Pay for military health care providers. 
NMVA has received feedback that this would be incentive to many medical 
professionals to stay in longer.
    G-R Bonuses.--Guard and Reserve component members may be eligible 
for one of three bonuses, Prior Enlistment Bonus, Reenlistment Bonus 
and Reserve Affiliation Bonuses for Prior Service Personnel. These 
bonuses are used to keep men and woman in mission critical military 
occupational specialties (MOS) that are experiencing falling numbers or 
are difficult to fill. During their testimony before this committee the 
Reserve Chiefs addressed the positive impact that bonuses have upon 
retention. This point cannot be understated. The operation tempo, 
financial stress and civilian competition for jobs make bonuses a 
necessary tool for the DOD to fill essential positions. The NMVA 
supports expanding and funding bonuses to the Federal Reserve 
Components.
    Reserve/Guard Funding.--NMVA is concerned about ongoing DOD 
initiatives to end ``two days pay for one days work,'' and replace it 
with a plan to provide 1/30 of a Month's pay model, which would include 
both pay and allowances. Even with allowances, pay would be less than 
the current system. When concerns were addressed about this proposal, a 
retention bonus was the suggested solution to keep pay at the current 
levels. Allowances differ between individuals and can be affected by 
commute distances and even zip codes. Certain allowances that are 
unlikely to be paid uniformly include geographic differences, housing 
variables, tuition assistance, travel, and adjustments to compensate 
for missing health care. The NMVA strongly recommends that the reserve 
pay system ``two days pay for one days work,'' be funded and retained, 
as is.

                           EDUCATIONAL ISSUES

MGIB-SR Enhancements
    Practically all active duty and Selected Reserve enlisted 
accessions have a high school diploma or equivalent. A college degree 
is the basic prerequisite for service as a commissioned officer, and is 
now expected of most enlisted as they advance beyond E-6. Officers to 
promote above O-4 are expected to have a post graduate degree. The 
ever-growing complexity of weapons systems and support equipment 
requires a force with far higher education and aptitude than in 
previous years.
    Both political parties are looking at ways of enhancing the GI 
bill. There are suggested features in legislation be suggested by both 
sides. At a minimum, the GI bill needs to be viewed as more than a 
recruiting and retention incentive. Education is a means to help 
reintegrate our returning veterans into society. A recent survey by 
military.com, of returning military veterans, found that 81 percent 
didn't feel fully prepared to enter the work force, and 76 percent of 
these veterans said they were unable translate their military skills 
into civilian proficiencies.
    Transferability of educational benefits to spouses and children are 
another key aspect that should be included in a GI Bill enhancement. In 
addition, for those with existing degrees and outstanding debts, the GI 
Bill stipend, should be allowed to pay-off outstanding student loans.
    No enhancement can be accomplished without funding. This should be 
viewed as an investment rather than an expense. The original GI bill 
provided years of economic stimulus, returning seven dollars for every 
dollar invested in veterans.
    The National Military and Veterans Alliance asks this subcommittee 
to support funding for suggested GI Bill funding.
    The Montgomery G.I. Bill for Selective Reserves (MGIB-SR) will 
continue to be an important recruiting and retention tool. With massive 
troop rotations the Reserve forces can expect to have retention 
shortfalls, unless the government provides enhances these incentives as 
well.
    The problem with the current MGIB-SR is that the Selected Reserve 
MGIB has failed to maintain a creditable rate of benefits with those 
authorized in Title 38, Chapter 30. MGIB-SR has not even been increased 
by cost-of-living increases since 1985. In that year MGIB rates were 
established at 47 percent of active duty benefits. The MGIB-SR rate is 
28 percent of the Chapter 30 benefits. Overall the allowance has inched 
up by only 7 percent since its inception, as the cost of education has 
climbed significantly.
    The NMVA requests appropriations funding to raise the MGIB-SR and 
lock the rate at 50 percent of the active duty benefit. Cost: 
$25,000,000/first year, $1,400,000,000 over 10.

                       FORCE POLICY AND STRUCTURE

War Funding
    The Alliance thanks the committee for the war funding amended to 
the Supplemental Appropriations Act 2008, H.R. 2642. While the debate 
on Iraqi policy is important, the Alliance would like to stress that 
resulting legislation should be independent and not included as 
language in any Defense Appropriation bill. Supporting the troops 
includes providing funding for their missions.
    NMVA supports the actions by this subcommittee to put dollars for 
the War back into the Emergency Supplemental.

End Strength
    The NMVA concurs with funding increases in support of the end 
strength boosts of the Active Duty Component of the Army and Marine 
Corps that have been recommended by Defense Authorizers. New recruits 
need to be found and trained now to start the process so that American 
taxpayer can get a return on this investment. Such growth is not 
instantaneously productive. Yet, the Alliance is concerned with 
continued end strength cuts to the other services: the Air Force and 
the Navy. Trying to pay the bills by premature manpower reductions may 
have consequences.

Manning Cut Moratorium
    The NMVA would also like to put a freeze on reductions to the Guard 
and Reserve manning levels. A moratorium on reductions to End Strength 
is needed until the impact of an operational reserve structure is 
understood. Many force planners call for continuation of a strategic 
reserve as well. NMVA urges this subcommittee to at least fund to last 
year's levels.

         SURVIVOR BENEFIT PLAN (SBP) AND SURVIVOR IMPROVEMENTS

    The Alliance wishes to deeply thank this Subcommittee for your 
funding of improvements in the myriad of survivor programs.
    However, there is still an issue remaining to deal with: Providing 
funds to end the SBP/DIC offset.
    SBP/DIC Offset affects several groups. The first is the family of a 
retired member of the uniformed services. At this time the SBP annuity 
the servicemember has paid for is offset dollar for dollar for the DIC 
survivor benefits paid through the VA. This puts a disabled retiree in 
a very unfortunate position. If the servicemember is leaving the 
service disabled it is only wise to enroll in the Survivor Benefit Plan 
(perhaps being uninsurable in the private sector). If death is service 
connected then the survivor loses dollar for dollar the compensation 
received under DIC.
    SBP is a purchased annuity, available as an elected earned employee 
benefit. The program provides a guaranteed income payable to survivors 
of retired military upon the member's death. Dependency and Indemnity 
Compensation (DIC) is an indemnity program to compensate a family for 
the loss of a loved one due to a service connected death. They are 
different programs created to fulfill different purposes and needs.
    A second group affected by this dollar for dollar offset is made up 
of families whose service member died on active duty. Recently Congress 
created active duty SBP. These service members never had the chance to 
pay into the SBP program. But clearly Congress intended to give these 
families a benefit. With the present offset in place the vast majority 
of families receive no benefit from this new program, because the vast 
numbers of our losses are young men or women in the lower paying ranks. 
SBP is completely offset by DIC payments.
    Other affected families are service members who have already served 
a substantial time in the military. Their surviving spouse is left in a 
worse financial position that a younger widow. The older widows will 
normally not be receiving benefits for her children from either Social 
Security or the VA and will normally have more substantial financial 
obligations (mortgages, etc). This spouse is very dependent on the SBP 
and DIC payments and should be able to receive both.
    The NMVA respectfully requests this Subcommittee fund the SBP/DIC 
offset.
    current and future issues facing uniformed services health care
    The National Military and Veterans Alliance must once again thank 
this Committee for the great strides that have been made over the last 
few years to improve the health care provided to the active duty 
members, their families, survivors and Medicare eligible retirees of 
all the Uniformed Services. The improvements have been historic. 
TRICARE for Life and the Senior Pharmacy Program have enormously 
improved the life and health of Medicare Eligible Military Retirees 
their families and survivors. It has been a very successful few years. 
Yet there are still many serious problems to be addressed:

Wounded Warrior Programs
    As the committee is aware, Congress has held a number of hearings 
about the controversy at Walter Reed Army Medical Center. The NMVA will 
not revisit the specifics. With the Independent Review Group and the 
Dole/Shalala Commission recommending the closure of Walter Reed, an 
emphasis needs to be placed on the urgency of upgrades at Bethesda, and 
the new military treatment hospital at Fort Belvoir. NMVA hopes that 
this committee will financially support the studies that measure the 
adequacy of this plan.
    The Alliance supports continued funding for the wounded warriors, 
including monies for research and treatment on Traumatic Brain Injuries 
(TBI), Post Traumatic Stress Disorder, the blinded, and our amputees. 
The Nation owes these heroes an everlasting gratitude and recompense 
that extends beyond their time in the military. These casualties only 
bring a heightened need for a DOD/VA electronic health record accord to 
permit a seamless transition from being in the military to being a 
civilian.

Full Funding for the Defense Health Program
    The Alliance applauds the Subcommittee's role in providing adequate 
funding for the Defense Health Program (DHP) in the past several budget 
cycles. As the cost of health care has risen throughout the country, 
you have provided adequate increases to the DHP to keep pace with these 
increases.
    Full funding for the defense health program is a top priority for 
the NMVA. With the additional costs that have come with the deployments 
to Southwest Asia, Afghanistan and Iraq, we must all stay vigilant 
against future budgetary shortfalls that would damage the quality and 
availability of health care.
    With the authorizers having postponed the Department of Defenses 
suggested fee increases, the Alliance is concerned that the budget 
saving have already been adjusted out of the President's proposed 
budget. NMVA is confident that this subcommittee will continue to fund 
the DHP so that there will be no budget shortfalls.
    The National Military and Veterans Alliance urges the Subcommittee 
to continue to ensure full funding for the Defense Health Program 
including the full costs of all new programs.

TRICARE Pharmacy Programs
    NMVA supports the continued expansion of use of the TRICARE Mail 

Order pharmacy.
    To truly motivate beneficiaries to a shift from retail to mail 
order adjustments need to be made to both generic and brand name drugs 
co-payments. NMVA recommends that both generic and brand name mail 
order prescriptions be reduced to zero $$ co-payments to align with 
military clinics.
    Ideally, the NMVA would like to see the reduction in mail order co-
payments without an increase in co-payments for Retail Pharmacy.
    The National Military and Veterans Alliance urges the Subcommittee 
to adequately fund adjustments to co-payments in support of 
recommendations from Defense Authorizers.

TRICARE Standard Improvements
    TRICARE Standard grows in importance with every year that the 
Global War on Terrorism continues. A growing population of mobilized 
and demobilized Reservists depends upon TRICARE Standard. A growing 
number of younger retirees are more mobile than those of the past, and 
likely to live outside the TRICARE Prime network.
    An ongoing challenge for TRICARE Standard involves creating 
initiatives to convince health care providers to accept TRICARE 
Standard patients. Health care providers are dissatisfied with TRICARE 
reimbursement rates that are tied to Medicare reimbursement levels. The 
Alliance is pleased by Congress' plan to prevent near-term reductions 
in Medicare reimbursement rates, which will help the TRICARE Program.
    Yet this is not enough. TRICARE Standard is hobbled with a 
reputation and history of low and slow payments as well as what still 
seems like complicated procedures and administrative forms that make it 
harder and harder for beneficiaries to find health care providers that 
will accept TRICARE. Any improvements in the rates paid for Medicare/
TRICARE should be a great help in this area. Additionally, any further 
steps to simplify the administrative burdens and complications for 
health care providers for TRICARE beneficiaries hopefully will increase 
the number of available providers.
    The Alliance asks the Defense Subcommittee to include language 
encouraging continued increases in TRICARE/Medicare reimbursement 
rates.

TRICARE Retiree Dental Plan (TRDP)
    The focus of the TRICARE Retiree Dental Plan (TRDP) is to maintain 
the dental health of Uniformed Services retirees and their family 
members. Several years ago we saw the need to modify the TRDP 
legislation to allow the Department of Defense to include some dental 
procedures that had previously not been covered by the program to 
achieve equity with the active duty plan.
    With ever increasing premium costs, NMVA feels that the Department 
should assist retirees in maintaining their dental health by providing 
a government cost-share for the retiree dental plan. With many retirees 
and their families on a fixed income, an effort should be made to help 
ease the financial burden on this population and promote a seamless 
transition from the active duty dental plan to the retiree dental plan 
in cost structure. Additionally, we hope the Congress will enlarge the 
retiree dental plan to include retired beneficiaries who live overseas.
    The NMVA would appreciate this Committee's consideration of both 
proposals.

                 NATIONAL GUARD AND RESERVE HEALTH CARE

Funding Improved TRICARE Reserve Select
    It is being suggested that the TRICARE Reserve Select healthcare 
plan be changed to allow the majority of Selected Reserve participate 
at a 28 percent co-payment level with the balance of the premium being 
paid by the Department of Defense.
    NMVA asks the committee to continue to support funding of the 
TRICARE Reserve Select program.

Mobilized Health Care--Dental Readiness of Reservists
    The number one problem faced by Reservists being recalled has been 
dental readiness. A model for healthcare would be the TRICARE Dental 
Program, which offers subsidized dental coverage for Selected 
Reservists and self-insurance for SELRES families.
    In an ideal world this would be universal dental coverage. Reality 
is that the services are facing challenges. Premium increases to the 
individual Reservist have caused some junior members to forgo coverage. 
Dental readiness has dropped. The Military services are trying to 
determine how best to motivate their Reserve Component members but feel 
compromised by mandating a premium program if Reservists must pay a 
portion of it.
    Services have been authorized to provide dental treatment as well 
as examination, but without funding to support this service. By the 
time many Guard and Reserve are mobilized, their schedule is so short 
fused that the processing dentists don't have time for extensive 
repair.
    The National Military Veterans Alliance supports funding for 
utilization of Guard and Reserve Dentists to examine and treat 
Guardsmen and Reservists who have substandard dental hygiene. The 
TRICARE Dental Program should be continued, because the Alliance 
believes it has pulled up overall Dental Readiness.
Demobilized Dental Care
    Under the revised transitional healthcare benefit plan, Guard and 
Reserve who were ordered to active duty for more than 30 days in 
support of a contingency and have 180 days of transition health care 
following their period of active service.
    Similar coverage is not provided for dental restoration. Dental 
hygiene is not a priority on the battlefield, and many Reserve and 
Guard are being discharged with dental readiness levels much lower than 
when they were first recalled. At a minimum, DOD must restore the 
dental state to an acceptable level that would be ready for 
mobilization, or provide some subsidize for 180 days to permit 
restoration from a civilian source.
    Current policy is a 30-day window with dental care being space 
available at a priority less than active duty families.
    NMVA asks the committee for funding to support a DOD's 
demobilization dental care program. Additional funds should be 
appropriated to cover the cost of TRICARE Dental premiums and co-
payment for the 6 months following demobilization if DOD is unable to 
do the restoration.

                     OTHER GUARD AND RESERVE ISSUES

    Ensure adequate funding to equip Guard and Reserve at a level that 
allows them to carry out their mission. Do not turn these crucial 
assets over to the active duty force. In the same vein we ask that the 
Congress ensure adequate funding that allows a Guardsman/Reservist to 
complete 48 drills, and 15 annual training days per member, per year. 
DOD has been tempted to expend some of these funds on active duty 
support rather than personnel readiness.
    The NMVA strongly recommends that Reserve Program funding remain at 
sufficient levels to adequately train, equip and support the robust 
reserve force that has been so critical and successful during our 
Nation's recent major conflicts.
    While Defense Authorizers provided an early retirement benefit in 
fiscal year 2008, only those who have served in support of a 
contingency operation since 28 January 2008 are eligible, nearly 6 
years and 4 months after Guard and Reserve members first were mobilized 
to support the active duty force in this conflict. Over 600,000 
Reservists have served during this period and were excluded from 
eligibility. The explanation given was lack of mandatory funding 
offset. To exclude a portion of our warriors is akin to offering the 
original GI Bill to those who served after 1944.
    NMVA hopes that this subcommittee can help identify excess funding 
that would permit an expanded early retirement benefit for those who 
have served.

                     ARMED FORCES RETIREMENT HOMES

    Following Hurricane Katrina, Navy/Marine Corps residents from AFRJ-
Gulfport were evacuated from the hurricane-devastated campus and were 
moved to the AFRH-Washington, D.C. campus. Dormitories were reopened 
that are in need of refurbishing.
    NMVA urges this subcommittee to continue funding upgrades at the 
Washington, D.C. facility, and to continue funding to rebuild the 
Gulfport facility.

                               CONCLUSION

    Mr. Chairman and distinguished members of the Subcommittee the 
Alliance again wishes to emphasize that we are grateful for and 
delighted with the large steps forward that the Congress has affected 
the last few years. We are aware of the continuing concern all of the 
subcommittee's members have shown for the health and welfare of our 
service personnel and their families. Therefore, we hope that this 
subcommittee can further advance these suggestions in this committee or 
in other positions that the members hold. We are very grateful for the 
opportunity to submit these issues of crucial concern to our collective 
memberships. Thank you.

                         CONCLUSION OF HEARINGS

    Chairman Inouye. I'd like to thank all of you for your 
testimony this morning. The subcommittee will take all issues 
seriously, I can assure you. And if you do have documents to 
support your testimony, please submit them.
    With that, the meeting will stand in recess, subject to the 
call of the Chair.
    Thank you.
    [Whereupon, at 11:40 a.m., Thursday, June 18, the hearings 
were concluded, and the subcommittee was recessed, to reconvene 
subject to the call of the Chair.]