[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


                                  

                         [H.A.S.C. No. 116-52]

                    MILITARY HEALTH SYSTEM REFORM: 
                  A CURE FOR EFFICIENCY AND READINESS?

                               __________

                                HEARING

                               BEFORE THE

                   SUBCOMMITTEE ON MILITARY PERSONNEL

                                 OF THE

                      COMMITTEE ON ARMED SERVICES

                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              HEARING HELD

                            DECEMBER 5, 2019


                                     
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]


                                __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
41-441                      WASHINGTON : 2020                     
          
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                   SUBCOMMITTEE ON MILITARY PERSONNEL

                 JACKIE SPEIER, California, Chairwoman

SUSAN A. DAVIS, California           TRENT KELLY, Mississippi
RUBEN GALLEGO, Arizona               RALPH LEE ABRAHAM, Louisiana
GILBERT RAY CISNEROS, Jr.,           LIZ CHENEY, Wyoming
    California, Vice Chair           PAUL MITCHELL, Michigan
VERONICA ESCOBAR, Texas              JACK BERGMAN, Michigan
DEBRA A. HAALAND, New Mexico         MATT GAETZ, Florida
LORI TRAHAN, Massachusetts
ELAINE G. LURIA, Virginia
                 Glen Diehl, Professional Staff Member
                          Dan Sennott, Counsel
                         Danielle Steitz, Clerk
                            
                            
                            C O N T E N T S

                              ----------                              
                                                                   Page

              STATEMENTS PRESENTED BY MEMBERS OF CONGRESS

Kelly, Hon. Trent, a Representative from Mississippi, Ranking 
  Member, Subcommittee on Military Personnel.....................     3
Speier, Hon. Jackie, a Representative from California, 
  Chairwoman, Subcommittee on Military Personnel.................     1

                               WITNESSES

Dingle, LTG Scott, USA, Surgeon General of the Army, United 
  States Army....................................................     9
Friedrichs, Brig Gen Paul, USAF, Joint Staff Surgeon, Joint 
  Chiefs of Staff................................................    11
Gillingham, RADM Bruce, USN, Surgeon General of the Navy, United 
  States Navy....................................................    10
Hogg, Lt Gen Dorothy, USAF, Surgeon General of the Air Force, 
  United States Air Force........................................     7
McCaffery, Thomas, Assistant Secretary of Defense for Health 
  Affairs, Department of Defense.................................     5
Place, LTG Ronald, USA, Director, Defense Health Agency..........     6

                                APPENDIX

Prepared Statements:

    Dingle, LTG Scott............................................    65
    Friedrichs, Brig Gen Paul....................................    84
    Gillingham, RADM Bruce.......................................    74
    Hogg, Lt Gen Dorothy.........................................    52
    McCaffery, Thomas, joint with LTG Ronald Place...............    40
    Speier, Hon. Jackie..........................................    37

Documents Submitted for the Record:

    Article from Military Times..................................    97

Witness Responses to Questions Asked During the Hearing:

    Mr. Kelly....................................................   103
    Ms. Speier...................................................   103
    Ms. Trahan...................................................   103

Questions Submitted by Members Post Hearing:

    Mr. Gaetz....................................................   107
    Mr. Gallego..................................................   107
    Mrs. Luria...................................................   108
    Mr. Mitchell.................................................   108
    
.    
  MILITARY HEALTH SYSTEM REFORM: A CURE FOR EFFICIENCY AND READINESS?

                              ----------                              

                  House of Representatives,
                       Committee on Armed Services,
                        Subcommittee on Military Personnel,
                        Washington, DC, Thursday, December 5, 2019.
    The subcommittee met, pursuant to call, at 3:15 p.m., in 
room 2212, Rayburn House Office Building, Hon. Jackie Speier 
(chairwoman of the subcommittee) presiding.

OPENING STATEMENT OF HON. JACKIE SPEIER, A REPRESENTATIVE FROM 
   CALIFORNIA, CHAIRWOMAN, SUBCOMMITTEE ON MILITARY PERSONNEL

    Ms. Speier. Good afternoon, everyone. We will call this 
hearing of the Military Personnel Subcommittee on Military 
Health System reform to order.
    Today, this hearing is focused on the status of military 
health reforms Congress enacted in the 2017 NDAA [National 
Defense Authorization Act] and whether the Department and the 
military services are working towards achieving congressional 
intent.
    The reform that most impacts service members and their 
families is the transition of management of the military 
treatment facilities from services to the Defense Health 
Agency, which is the focal point of this hearing.
    The last time we had a briefing on this issue was in 
December of 2017. I recall there was some disagreement among 
the military departments and DOD [Department of Defense] on how 
to implement these changes. I understand this transition began 
at least in part as of October 1 this year, but it was painful 
getting to that point, and it was a very small step towards 
accomplishing the overall goal of a single military health 
system instead of three separate service health systems.
    There also are many important reforms critical to making 
the MTF [military treatment facility] transition successful 
that are lagging behind, such as implementation of the new 
electronic health records GENESIS, the proper analysis of what 
medical skills and the number of medical providers are needed 
to support the warfighters and beneficiaries, the appropriate 
number and sizes of medical facilities, and reforms that could 
create economies of scale and effective efficiencies within the 
MHS [Military Health System].
    To be clear, budget cuts are not the same thing as 
efficiencies in MHS. And many rumored cuts to the military 
medical workforce, whether primary care physicians or 
ophthalmologists, lack rationale or evidence that they would 
actually save taxpayers money.
    One of the top concerns many of my colleagues have heard 
over the past 8 months was about the military medical manpower 
cuts in the President's fiscal year 2020 budget. This was done 
to repurpose 17,944 military department officer and enlisted 
health specialty medical billets and transition them to other 
manning needs in the military departments.
    I was baffled as to why this request was submitted when the 
services and the Joint Staff had not completed the analysis of 
the operational requirements for supporting combatant 
commanders in time of conflict of war. It appeared to me that 
this proposal prioritized cost cutting over operational needs 
and common sense.
    In February 2019, the GAO [Government Accountability 
Office] confirmed our concerns when they reported that the DOD 
has not determined the required size and composition of its 
operational, medical, and dental personnel who support the 
wartime mission or submitted a complete report to Congress as 
required under the NDAA for fiscal year 2017.
    We have also heard that there is a defense-wide review 
underway that is considering a wide variety of cost-cutting 
proposals, including shuttering major military medical centers, 
a restructured TRICARE benefit that could significantly 
increase copays, closure of the Uniformed Services University 
of the Health Sciences, and the potential destruction of some 
reforms that we have made into law over the past 3 years.
    The goal of military health reform is not to reduce the 
military's ability to deliver healthcare in times of peace or 
war. The goal is to find ways to be more efficient so that we 
can save taxpayers money while providing better quality 
healthcare for our service members and their families. Private 
insurance and private providers may serve these goals for some 
types of services in some communities, but privatization can 
also threaten worse outcomes and higher costs if done without 
care and consideration.
    The ranking member and I recently visited Madigan Army 
Medical Center, Naval Hospital Bremerton, and the David Grant 
Air Force Medical Center, where we spoke with military spouses 
about quality of life issues. Access to military healthcare 
came up at every discussion.
    At each installation, we heard about challenges with the 
lack of mental health resources in the local community. We 
heard about civilian healthcare networks that either lacked the 
capacity or are unwilling to admit TRICARE beneficiaries. And 
we have heard about challenges accessing appointments at 
military treatment facilities.
    The larger problem we heard is not that local providers 
think TRICARE reimbursement rates are low. It is that the 
healthcare market is already oversaturated, even in large 
metropolitan areas like Seattle and San Francisco.
    It is not all bad news. At Travis Air Force Base we saw a 
busy military treatment facility working hand in hand with the 
VA [Department of Veterans Affairs] in collaboration that 
could, along with civilian providers, create an integrated 
delivery system. The 2017 NDAA encouraged these types of 
relationships with local healthcare facilities. We need to see 
more of this kind of cooperation and hear more from these 
programs in order to replicate their successes.
    Instead, DOD seems intent on gutting our Military Health 
System and calling it an efficiency. The system is costing 
less. It has saved billions of dollars, at least $1 billion in 
just the last year, but there remain urgent coverage needs that 
should be addressed by reinvesting any savings in the military 
healthcare system, not continuing to squeeze every last penny 
out of the system in order to fund other priorities.
    Healthcare is a need and right. We must continue to provide 
for our military families. Weakening the delivery system will 
only cost us and our service members more down the road. The 
Department must do better.
    Today we will hear from a panel of senior leaders from 
across the Department of Defense that are responsible for 
implementing the Military Health System reform. We are seeking 
to better understand how DOD is implementing major Military 
Health System reforms, how they are determining TRICARE success 
and meeting the needs of its beneficiaries, and how DOD plans 
to repurpose roughly 18,000 medical positions and how that will 
affect health services.
    We will also hear how DOD is balancing readiness with 
efficiency and how the Joint Staff and the service surgeons 
general are approaching readiness to ensure that we have the 
right personnel and the right capabilities at the right time.
    I now would like to have Ranking Member Mr. Kelly offer us 
any opening remarks.
    [The prepared statement of Ms. Speier can be found in the 
Appendix on page 37.]

     STATEMENT OF HON. TRENT KELLY, A REPRESENTATIVE FROM 
MISSISSIPPI, RANKING MEMBER, SUBCOMMITTEE ON MILITARY PERSONNEL

    Mr. Kelly. Thank you, Chairwoman Speier.
    And that is as long as I have heard our chairwoman talk on 
any subject, and mine is going to be lengthier than usual too, 
and that is because we are very passionate about it in getting 
this right. This is one of the most important things I think we 
do on this subcommittee.
    I want to welcome our witnesses to today's hearing, and 
thank you for your service to our service members and their 
families. The Military Health System is one of the largest 
healthcare systems in the world, and you all have the critical 
mission of providing care to one of the most venerated segments 
of the United States population, our service members, veterans, 
and their families.
    We hold the Military Health System to a higher standard 
than civilian healthcare, given your important mission, and I 
know that you share that commitment. That is why this committee 
has worked continuously with the Department of Defense to 
ensure that our Military Health System has the resources and 
systems in place to provide exceptional healthcare.
    The 2017 Military Health System reforms are an integral 
part of improving healthcare delivery. The primary goal of that 
reform effort was to improve medical readiness, standardize 
patient experience in military medical treatment facilities, 
and where possible, improve efficiency.
    I am encouraged by the progress that DOD and the services 
have made in implementing these reforms, but there remain 
several areas of concern.
    In particular, I am very concerned with the Department's 
current efforts to restructure and realign military treatment 
facilities, commonly known as section 703 implementation. I 
believe the Department may be viewing this as a cost-saving 
exercise when the actual purpose is to improve efficiency and 
healthcare quality.
    It is crucial that prior to any reductions in MTF services 
that DOD fully understand the civilian network capability to 
absorb those patients.
    In our visits to military installations around the country, 
I can tell you that many civilian healthcare networks are 
oversaturated and will not be able to absorb more patients. I 
look forward to hearing what analysis has been done regarding 
network adequacy in preparation for any MTF realignment.
    I am also very concerned about the planned reduction in 
military healthcare billets. The services identified over 
17,000 healthcare billets for elimination. While some of these 
positions are purely administrative in nature, many of them are 
medical professional billets.
    At nearly every military installation I have visited, one 
of the chief complaints regarding healthcare is that patients 
must wait weeks in order to get an appointment. That is 
unacceptable, and I am concerned that further personnel 
reductions will make the problem worse. I would like to hear 
more about what analysis was done to support these reductions.
    Finally, I am concerned about the state of behavioral 
healthcare in the military. I have repeatedly heard from 
medical providers, service members, and their families about 
chronic staffing shortages and long wait times for 
appointments. Meanwhile, the rates of suicide in our military 
continue to increase.
    I understand that this is national problem, but I want to 
know what the services and the Defense Health Agency are doing 
to fix this problem in the military.
    In a recent report, each of the services said that the 
number one recruiting challenge for behavioral health providers 
is low pay and the lengthy hiring process. So now that you have 
identified the problem, what specific authorities do you need 
in order to fix it?
    I want to thank our witnesses for their considerable 
efforts to improve healthcare and institute the Military Health 
System reforms. I look forward to a robust discussion that is 
focused on readiness and quality care.
    Thank you, and I yield back, Chairwoman.
    Ms. Speier. Thank you, Ranking Member. And as you can see 
from both of our statements, they are fairly consistent, which 
is a recognition, I think, that we here in Congress are very 
concerned about what is happening.
    We now welcome our distinguished panelists. Mr. Thomas 
McCaffery is the Assistant Secretary of Defense for Health 
Affairs. Lieutenant General Ronald Place, Director of the 
Defense Health Agency. Lieutenant General Dorothy Hogg, Surgeon 
General of the Air Force. Lieutenant General Scott Dingle, 
Surgeon General of the Army. Rear Admiral Bruce Gillingham, 
Surgeon General of the Navy. Brigadier General Paul Friedrichs, 
Joint Staff Surgeon.
    I will ask unanimous consent to allow any Members not on 
the subcommittee to participate in today's hearing and be 
allowed to ask questions after all subcommittee members have 
been recognized.
    Without objection?
    Mr. Kelly. Without objection.
    Ms. Speier. That is granted.
    Let us then ask each of you to summarize your testimony in 
5 minutes or less. Your written comments and statements will be 
made part of the hearing record, and each member has the 
opportunity to question the witnesses for 5 minutes.
    We will start with Mr. McCaffery, and you may offer your 
opening statement.

 STATEMENT OF THOMAS McCAFFERY, ASSISTANT SECRETARY OF DEFENSE 
           FOR HEALTH AFFAIRS, DEPARTMENT OF DEFENSE

    Secretary McCaffery. Thank you, Chairwoman Speier and 
Ranking Member Kelly, members of the committee. Thank you for 
the opportunity today to discuss our combined efforts to 
maintain and strengthen our Military Health System.
    The men and women of the MHS are justifiably proud of what 
they do. They provide a platform to train our uniformed medical 
force, and they ensure our Active Duty service members have 
access to the healthcare they need in order to do their jobs 
anywhere, anytime.
    They support one of the largest and most successful medical 
research enterprises in the country. They operate a global 
health surveillance network that monitors for infectious 
threats to our forces and our homeland. They manage one of the 
country's largest networks of hospitals and clinics.
    They do all that with unfailing professionalism and, I 
might add, with incredible passion. They and we are grateful 
for the committee's support of this work.
    Our primary mission, as you had indicated, is readiness, 
the readiness of the medical personnel to support our forces in 
battle and the medical readiness of combat forces to complete 
their missions.
    And that readiness mission also entails caring for the 
families of our troops and our retirees. After all, while 
service members who deploy must be medically ready to do their 
jobs, they also need to know that their families back home are 
cared for, and that in retirement they will receive a health 
benefit that recognizes the value of their service.
    Meeting this obligation to our beneficiaries is vital to 
recruiting and retaining a high-quality force.
    In order to advance these goals, we believe the MHS, like 
the rest of the Department of Defense, must adapt and change in 
order to carry out our mission in an ever-evolving security 
environment, and very importantly for us, a consistently 
dynamic medical landscape.
    And we know that Congress shares this belief. In the past 
three National Defense Authorization Acts, Congress has given 
the Department very clear direction on the fundamental reforms 
it expects us to implement. Building off that direction, we are 
changing to ensure that the system can most effectively meet 
our mission.
    Some of the things that the reforms that we are partnering 
with Congress on are aimed at: ensuring that the uniformed 
medical force is properly sized and has the skills to respond 
to operational requirements; ensuring that our system of 
hospitals and clinics is optimally sized and shaped to support 
the readiness of our medical forces, the medical readiness of 
combat forces, and our obligations to our beneficiaries; better 
organizing and integrating our direct care system to form a 
true unified medical enterprise that can improve our 
effectiveness and efficiency and provide a more standardized, 
dependable, high-quality experience for our Active Duty, their 
families and our retirees; and finally, most effectively 
managing private sector care through TRICARE's managed care 
networks.
    General Place and I outline in more detail in our written 
testimony each of these reform efforts, but the point we would 
like to emphasize is that all of these efforts are aimed at 
ensuring that the Military Health System provides maximum 
support to the Department as it executes the National Defense 
Strategy.
    It is our privilege to testify before you today on this 
critical mission of the health system and to provide you 
information on the status of the numerous reforms Congress has 
directed us to pursue. Thank you to the members of this 
committee for their support of that mission and the men and 
women who carry it out, and we look forward to answering your 
questions.
    [The joint prepared statement of Secretary McCaffery and 
General Place can be found in the Appendix on page 40.]
    Ms. Speier. Thank you.
    Lieutenant General Place.

 STATEMENT OF LTG RONALD PLACE, USA, DIRECTOR, DEFENSE HEALTH 
                             AGENCY

    General Place. Chairman Speier, Ranking Member Kelly, 
members of the committee, I will add a few comments to Mr. 
McCaffery's opening comments.
    As he made clear, our principal mission is enabling 
readiness, and within that mission are two distinct 
responsibilities. First, to ensure every person in uniform is, 
in fact, medically ready to perform their job anywhere in the 
world. And then secondarily, to ensure our military medical 
personnel are individually and collectively prepared to support 
the full range of military medical operations.
    The Defense Health Agency [DHA] serves as the supporting 
agency in this readiness mission to the combatant commands and 
to the military departments. The Military Health System's 
performance on the battlefield is exemplified by historically 
high survival rates from combat wounds and historically low 
rates of disease and non-battle injuries. These successes 
reflect processes in which joint solutions contributed to these 
outcomes.
    Now, the DHA was established to strengthen our health 
system in both the deployed settings and in the fixed 
healthcare facilities around the world. Our combat support 
responsibilities include a broad range of military health 
support. They include management of the Armed Services Blood 
Program, the Joint Trauma System, public health, Armed Forces 
medical examiners, medical logistics in the operational 
environment, health information technology in the operational 
environment, and really a whole lot more.
    But as the DHA assumes responsibility for managing all the 
military's hospitals and clinics, we continue to view these 
medical facilities as readiness platforms where medical 
professionals from the Army, from the Navy, and from the Air 
Force obtain and sustain their knowledge and skills and for 
which these professionals deploy in support of our military 
missions.
    The DHA approach better enables the MHS to optimize the 
care we can deliver along with clinical skill sustainment 
experiences for our medical staff within and across geographic 
markets.
    As DOD leadership evaluates the size of the medical force 
and makes determinations about the configurations of hospitals 
and clinics, the DHA is also prepared to ensure our 
beneficiaries have access to care they need through the 
management of the TRICARE program.
    Now, the Department has long relied on civilian healthcare 
to provide and deliver care to our beneficiaries in locations 
where we don't operate medical facilities or when the needs of 
our patients exceed the capabilities that we have locally.
    Over the past three decades, with changes in military 
basing, reductions in the military force strength, we have 
successfully increased specific civilian healthcare networks. 
We are performing those assessments again today and will do so 
continuously. And we are working with the military departments 
to ensure military families and retirees continue to enjoy 
access to high-quality care if military medical capabilities 
are exceeded.
    I am grateful for the opportunity to share our detailed 
plans to further improve military medical support to combatant 
commands and to the military departments. Thank you again to 
the members of this committee for your time and your continuing 
service to the men and women of our Armed Forces and the 
families who support them.
    Ms. Speier. Thank you.
    Lieutenant General Hogg.

STATEMENT OF LT GEN DOROTHY HOGG, USAF, SURGEON GENERAL OF THE 
               AIR FORCE, UNITED STATES AIR FORCE

    General Hogg. Chairwoman Speier, Ranking Member Kelly, and 
distinguished members of the subcommittee, thank you for the 
opportunity to provide an update on Air Force Medical Service 
reform.
    This committee is well aware of the reemergence of great 
power competition, such as China and Russia, and the Air 
Force's need to increase lethality, strengthen alliances, and 
realign resources in preparation of these potential threats. 
The Air Force Medical Service is evolving in support of these 
overarching national defense objectives.
    Air Force medics continue to answer the call across a broad 
spectrum of operational, humanitarian, and disaster response 
missions. We specialize in aerospace and operational medicine, 
most notably aeromedical evacuation, while ensuring the 
readiness and deployability of our warfighters.
    Our charge is crystal clear, and I am confident that these 
reforms will maximize our ability to meet combatant commander 
requirements and support line of the Air Force operations 
across the enterprise.
    With this renewed focus in operational readiness, we 
restructured our headquarters by deactivating the Air Force 
Medical Support Agency and redesignating the Air Force Medical 
Operations Agency as the Air Force Medical Readiness Agency. 
This new organization directly supports readiness, aerospace 
and operational medicine activities, and provides oversight of 
strategic medical readiness initiatives at Air Force 
installations.
    We are also realigning medical resources at our base 
installations in order to improve airman deployability and 
overall wellness. This initiative reorganizes medical groups 
into two squadrons, an Operational Medical Readiness Squadron, 
which serves Active Duty, Guard, and Reserves, and a Healthcare 
Operations Squadron, which serves non-uniformed members and 
dependents. While these squadrons are interconnected, they have 
a singular focus which allows each of the squadrons to optimize 
care for its designated population.
    We continue to enhance our ability to save lives both on 
and off the battlefield by investing in our most vital pacing 
units, our Critical Care Air Transport Teams and our Ground 
Surgical Teams. Complementing these efforts is one of my 
strategic initiatives, called MedicX. This goal is to develop 
multifunctional medics who can perform duties beyond their 
primary specialty, which will have exponentially expanded 
clinical capabilities.
    Our partnerships with military, educational, and civilian 
medical institutions will remain a critical component to 
maintaining medical airmen's clinical skills and currency. 
Collectively, these efforts increase our ability and agility to 
support homeland defense, deployed requirements, and operate in 
tomorrow's highly contested environment.
    I would like to highlight the progress and the 
collaboration with the Defense Health Agency in transitioning 
authority, direction, and control of military treatment 
facilities to the Defense Health Agency.
    The Air Force Medical Service will continue to provide 
direct support to the Defense Health Agency until it can 
establish its headquarters, markets, and functional 
capabilities. We are committed to a successful transition that 
will continue delivering high-quality readiness and beneficiary 
care.
    My testimony gives the committee a clear picture of the Air 
Force Medical Service and how we are aligning our efforts with 
Defense Department and Air Force priorities.
    As our Nation faces new challenges, preparing for an 
uncertain future requires bold and innovative thinking. I have 
no doubt we are moving in the right direction, and our medics 
throughout the Military Health System will rise to the 
occasion.
    Thank you again for your time, and I look forward to your 
questions.
    [The prepared statement of General Hogg can be found in the 
Appendix on page 52.]
    Ms. Speier. Thank you.
    Lieutenant General Dingle.

  STATEMENT OF LTG SCOTT DINGLE, USA, SURGEON GENERAL OF THE 
                    ARMY, UNITED STATES ARMY

    General Dingle. Chairwoman Speier, Ranking Member Kelly, 
distinguished members of the subcommittee, it is an honor to 
speak before you today as the 45th Army Surgeon General, 
representing over 130,000 soldiers and civilians in Army 
Medicine.
    I also would like to thank my Military Health System and my 
sister service colleagues here today. We all share a common 
commitment to ensuring our Military Health System is manned, 
organized, trained, and equipped to meet the needs of our 
services and the joint force.
    The Chief of Staff of the Army states, ``Winning matters,'' 
and, ``People are our number one priority.'' As the Army 
modernizes and prepares for large-scale combat operations, it 
is imperative that our medical force remains ready, responsive, 
and relevant in order to conserve the fighting strength in the 
multi-domain battlespace because in combat, winning not only 
matters but there is no second place.
    As required by law, the Army transitioned authority, 
direction, and control of our medical treatment facilities to 
the Defense Health Agency. The transfer has been transparent to 
our soldiers, civilians, and our beneficiaries. Partnering with 
the Defense Health Agency, we will continue to deliver high-
quality and safe care.
    The Army is continually assessing the risks with changes to 
medical end strength. Personnel changes currently under review 
are a necessary part of our modernization and our force 
shaping. We will ensure that adjustments are informed and 
support the operational force as well as the healthcare 
delivery mission.
    As we reform and reorganize, we are committed to providing 
ready and responsive health services and force health 
protection. I have established my priorities to ensure that we 
remain ready, reformed, reorganized, responsive, and relevant. 
Ready to deploy, fight, and win when called upon. Reformed in 
accordance with the law. Reorganized to support Army 
modernization. Responsive to the demands of the multi-domain 
operations. And relevant to the rapid changes in modern 
warfare.
    Finally, Army Medicine must change at the speed of 
relevance. This includes modernization of key capabilities, 
innovation of organizational concepts, advancement of 
technology, and integration with the joint and interagency 
community.
    In closing, I am committed to meeting the congressional 
intent and sustaining the readiness of Army Medicine. Further, 
I am committed to my statutory responsibilities in support of 
the Secretary of the Army and as the chief adviser to the 
Defense Health Agency for the Army. I will inform the committee 
as we make strides in Military Health System reform and Army 
Medicine.
    I want to thank the committee for your longstanding support 
to Army and military medicine. For the service and sacrifice of 
our soldiers and their families, we must get this right. This 
is our solemn obligation to our Nation.
    Thank you for the opportunity to come before this 
committee, and I look forward to answering your questions. 
Thank you.
    [The prepared statement of General Dingle can be found in 
the Appendix on page 65.]
    Ms. Speier. Thank you.
    Rear Admiral Gillingham.

STATEMENT OF RADM BRUCE GILLINGHAM, USN, SURGEON GENERAL OF THE 
                    NAVY, UNITED STATES NAVY

    Admiral Gillingham. Chairwoman Speier, Ranking Member 
Kelly, distinguished members of the subcommittee, on behalf of 
the mission-ready Navy Medicine team, I am pleased to be here 
today with my colleagues to provide you an update on an 
important issue for us all, Military Health System reform.
    As we move forward with systemic changes in the MHS, I want 
to assure you that the foundation of Navy Medicine is 
readiness. Our highest priority is keeping sailors and Marines 
healthy and ready to deploy and ensuring they get the best care 
possible from trained and confident providers when they are 
wounded or injured.
    The Nation depends upon Navy Medicine's unique 
expeditionary medical expertise to prepare and support our 
naval forces.
    To this end, our priorities of people, platforms, 
performance, and power are aligned to meet this commitment: 
well-trained people, working as cohesive teams on optimized 
platforms, demonstrating high-velocity performance that will 
project medical power in support of maritime superiority.
    On any given day, Navy Medicine personnel are deployed and 
operating forward in a full range of diverse missions, 
including austere damage control resuscitation and surgery 
teams in U.S. Central Command and U.S. Africa Command; trauma 
care at NATO [North Atlantic Treaty Organization] Role 3 
Multinational Medical Unit in Kandahar; humanitarian assistance 
aboard hospital ship USNS [United States Naval Ship] Comfort; 
and expeditionary health services support with Joint, Fleet, 
and Fleet Marine Forces around the world.
    A week ago, I had the honor of celebrating Thanksgiving 
with our Navy Medicine personnel forward deployed at Camp 
Lemonnier, Djibouti, as part of the Combined Joint Task Force 
Horn of Africa. I saw firsthand the important work they 
continue to do to ensure the health and readiness of our 
service members and multinational partners. All of us can be 
justifiably proud of the great work that they do.
    Collectively, the substantive reform legislation contained 
in the fiscal years 2017 and 2019 National Defense 
Authorization Acts represents an important inflection point for 
military medicine and catalyzed our efforts to strengthen our 
integrated system of readiness and health. Navy and Marine 
Corps leadership recognize the tremendous opportunity we have 
to refocus our efforts on medical readiness while transitioning 
healthcare benefit administration to the Defense Health Agency.
    I want to emphasize that while significant organizational 
change in healthcare is inherently complex, all of us 
testifying before you today know we have a shared 
responsibility to ensure that both the services and the Defense 
Health Agency are successful. Our efforts will continue to 
reflect this imperative moving forward.
    Integral to the MHS-wide transformation is the transition 
of our military treatment facilities to the DHA. In October, as 
you know, the DHA assumed authority, direction, and control of 
all MTFs in the continental United States, including Alaska and 
Hawaii. As a component of this significant transition, we are 
continuing to provide defined support to the DHA as it 
progresses to full operating capability.
    In addition, Navy Medicine is making important changes at 
all levels to support our refocus on readiness. We are 
streamlining activities that directly impact our capabilities 
to support operational requirements and ensure we have a 
trained and ready medical force. We must have the agility to 
rapidly deploy anytime, anywhere to support Fleet and Fleet 
Marine Force missions and platforms, including expeditionary 
medical facilities and units, hospital ships, as well as 
casualty receiving and treatment ships.
    The success of Navy Medicine is inextricably linked to a 
dedicated and well-trained workforce. We continue to emphasize 
recruiting and retaining personnel with the proper skill sets 
to care for sailors and Marines, particularly those with 
critical wartime specialties.
    Thank you for your support both in resources and 
authorities to help us maintain our most important asset, the 
Navy Medicine team.
    In summary, we continue to make progress in our 
transformation efforts. However, all of us recognize there is 
much hard work ahead as we continue to build an efficient and 
sustainable integrated system of readiness and health.
    Once again, thank you, and I look forward to your 
questions.
    [The prepared statement of Admiral Gillingham can be found 
in the Appendix on page 74.]
    Ms. Speier. Thank you.
    Brigadier General Friedrichs.

   STATEMENT OF BRIG GEN PAUL FRIEDRICHS, USAF, JOINT STAFF 
                 SURGEON, JOINT CHIEFS OF STAFF

    General Friedrichs. Thank you, Chairwoman Speier, Ranking 
Member Kelly, and distinguished members of the Military 
Personnel Subcommittee. On behalf of Chairman Milley, it is 
truly an honor and a privilege to be here this afternoon to 
provide the Joint Staff perspective on health system 
transformation and its impacts on the operational readiness of 
the joint force.
    As the 15th Joint Staff Surgeon, I also want to thank you 
for the strong support you have continuously provided to 
military personnel, including to me. This support has impacted 
more personnel than we can acknowledge this afternoon.
    But I would like to tell you a little bit about my father, 
who grew up in southern Louisiana on a farm during the 
Depression, served at the end of World War II, and through the 
GI Bill received his college education, went on to help design 
aircraft carriers at the Brooklyn Navy Shipyard. He inspired 
me.
    Later he met my mother, who was born in Hungary, fought in 
the 1956 revolution, was tortured by the KGB [Committee for 
State Security], eventually came to this country to teach, 
married, and the two of them taught me the value of freedom and 
the price that must be paid to preserve it. They have inspired 
me to become a military physician, and I am honored to be here 
in that role.
    I also want to thank you for your continued support of the 
Reserve Officer Training Program, which allowed me to attend 
the Louisiana State University and then Tulane, and your 
support for the Uniformed Services University, which provided a 
phenomenal medical education and allowed me to be a competent 
and more than competent surgeon in Iraq when people relied on 
me to care for them, and they relied on many of us to care for 
them, whether it was in Iraq or Afghanistan, the North Pole, 
the South Pole, and all the other places where military service 
members receive care from military medics.
    I am grateful for your commitment to joint medical 
operations. I met my wife, an Army physician, in the back 
stairs of the old Beach Pavilion at Brooke Army Medical Center. 
We have a much better facility today, thanks to you, but we 
have always had great facilities in which we provided great 
care for our service members.
    As the son of a Navy service member, the husband of a 
former Army service member, the father of two young men who 
hope to serve in the Navy, I am fiercely committed to 
continuing to ensure we provide great care. My wife now works 
for the Veterans Health Administration and is a constant 
reminder to me of the importance not only of getting it right 
while people are serving, but also, as Americans transition 
from the Department of Defense to the VA, we must continue to 
improve that interagency collaboration.
    As Chairman Milley recently noted, we are in a period of 
great power competition within a complex and dynamic security 
environment. The fundamental character of war is changing 
rapidly, the threats are worsening, and we must evolve to meet 
them, and thanks to your continued help, we are doing so.
    You asked us in section 732 of the 2019 National Defense 
Authorization Act to develop a Joint Medical Estimate [JME], 
and our office is leading that effort. We will put the initial 
draft in coordination next month and plan to publish it in May. 
That will be an annual report in which, as other functional 
communities have done, we will describe requirements, gaps, and 
the risks that those gaps create to the mission and to the 
force based on the National Defense Strategy, COCOM [combatant 
command] inputs, the inputs from the services, our interagency 
partners, and our allies. After the JME is published, if 
helpful, it would be a privilege to return and brief you on its 
contents.
    The National Defense Strategy describes significant 
challenges, and the 2019 Capstone Concept for Joint Operations 
begins to describe how the Department integrates those 
requirements across the force in order to reshape the force.
    In addition, we know our Nation continues to face natural 
disasters and other events which require a whole-of-government 
response, and we continue to partner with the Department of 
Health and Human Services, Department of Veterans Affairs, 
other Federal, State, regional, tribal, and local stakeholders 
to ensure we are ready when our Nation requires us to respond.
    But regardless of the technology employed by our 
warfighters, there is always a human being in that process, and 
our job as military medics is to maintain that human weapon 
system. Our job is to ensure that human is ready to deploy and 
that we are there and ready to care for them when they need us.
    I am grateful for your support for our mission and for our 
service members, grateful for the opportunity to serve as a 
military medic, and grateful for the opportunity to answer your 
questions this afternoon. Thank you.
    [The prepared statement of General Friedrichs can be found 
in the Appendix on page 84.]
    Ms. Speier. Thank you all for your testimony.
    Let me begin by asking the question that probably is on the 
minds of a lot of people. Are there going to be 18,000 billets 
that are going to be reduced as part of this defense-wide 
review?
    Is that a question for you, Mr. McCaffery?
    Secretary McCaffery. Yes. I will start an initial response.
    The proposal that you are referring to in terms of the 
proposed reduction of around 18,000 medical billets is 
something that was put forward in the President's 2020 budget, 
so last year. That is distinct and separate from your reference 
to the defense-wide review, which is something that just 
started within the last 3 months by Secretary Esper, so the two 
are separate.
    To get to your question about the plans for the 18,000, I 
will let each of the military departments kind of weigh in in 
more specifics. But the bottom line, last year each of the 
military departments determined that their current medical 
force exceeded the operational requirements they needed, and 
each military department made a decision to look at a subset of 
their medical billets and repurpose them for other high 
priorities tied to the military department's needs in meeting 
national defense goals.
    That is the basis for the proposed reductions. I will defer 
to the military departments in terms of giving them a little 
more detail in terms of the numbers and the timing.
    The initial planning here is in, I think with some 
exceptions, in 2020 the plan would be to only make changes to 
vacant billets, so billets that don't have somebody currently 
occupying, doing a job.
    And right now, our focus, working with the military 
departments, the Defense Health Agency, is really around what 
would be the scheduled reductions coming in fiscal year 2021 
and what would our plans be to implement that in a way that we 
maintain the capability in our system, be it through 
contractors, the TRICARE network, hiring civilians, to restore 
that capability that could be removed based upon the medical 
billet reduction.
    Ms. Speier. All right. Do you have numbers for each of the 
services?
    Secretary McCaffery. I think I will let each of the 
services get into their particular numbers.
    General Hogg. Yes, ma'am.
    So every year in the Air Force Medical Service, we go 
through a process to identify what our operational medical 
requirement is, and that process is called the Critical 
Operational Readiness Requirement. And in that process, it 
identifies what I need in uniform to do my operational mission. 
And the last year's review of that indicated that I had a 
little over 4,000 medics that were over my uniformed 
requirement.
    Ms. Speier. Okay. I am going to have to--we are going to 
have to move quickly because I have a number of other questions 
I want to ask.
    Lieutenant General Dingle. So 4,000 in the Air Force, is 
that right?
    General Hogg. Yes, ma'am.
    General Dingle. Ma'am, in the Army, we have 6,935 billets 
that we have identified for conversion. In our analysis, these 
do not impact any services or any risk to mission, and we 
continue to do analysis with the DHA and the other service to 
ensure that it is not impacting multi-service markets.
    Ms. Speier. All right.
    Admiral.
    Admiral Gillingham. Chairwoman Speier, the number for the 
Navy is 5,386. This was based on a careful analysis of the 
National Defense Strategy. But as General Dingle stated, we 
continue to assess this against the DHA requirement.
    Ms. Speier. All right. I think we are going to need to have 
you provide us something a little more detailed. So if you 
would, make a point of providing us the specific specialties 
that you are extracting these positions, these billets from, 
and then we will go from there. We may have to do a deeper dive 
than that.
    Ranking Member Kelly, do you have any other thoughts about 
that?
    Mr. Kelly. Just any adds that they have got, because the 
OB/GYN [obstetrics and gynecology] shortage that we talked 
about with our female combat surgeons. So I see the 
subtractions, but if you have any adds, we would like to know 
those, too.
    Ms. Speier. Okay. Very good.
    Now, my time has expired, but I am going to take the 
privilege of asking just one more question.
    Mental health was an issue we heard about over and over 
again when we visited the various bases. That initial 
assessment may be made within 72 hours, but then they wait 
upwards of 3 months. Now, that is an unacceptable length of 
time to wait for mental health services.
    So I don't know that you can speak to that today, but I 
think I would like for you to be on notice that I am not 
confident that we are providing the level of mental health 
services we need. And I would like for you to each go back and 
look at the length of time between initial assessment and the 
ability to actually get the regular services.
    And then the oversaturation, I think it is a--we heard it 
loud and clear in Seattle in particular when we were there. 
People are--families are not able to access the services in 
TRICARE, and there is some speculation that TRICARE is paying 
at a lower rate, which doesn't make sense to me because, 
ostensibly, it is linked to Medicare and therefore should meet 
the needs. But if it is not, that needs to be assessed as well.
    And with that, I will turn it over to Ranking Member Kelly.
    Mr. Kelly. Thank you, Chairwoman Speier.
    And I am glad she asked. We are pretty much lockstep on 
this. And I just want you guys to know, that is a lot of 
billets that are going away. And you talk about near-peer and 
future threats.
    Let me tell you what. Civilians don't go downrange when we 
hit them downrange. It takes guys and girls in uniform to get 
our soldiers to the right level of care in that magic hour. And 
if they are not there, we have soldiers, sailors, airmen, and 
Marines that die. And so we need to make sure that we are 
looking at each and every one, we need to scrutinize every 
single medical professional we can.
    And then going back to my point with Chairwoman Speier, we 
talk to female combat soldiers, and there is a lack of medical 
professionals that are able to provide specific, whether it be 
medics or OB/GYNs or things that can apply specific medical 
procedures for women, and we need to make sure we are 
addressing that. So we shouldn't just be subtracting, we should 
be adding in some areas and saying, hey, we can get rid of 
these folks, but we need more in this area. So I ask that you 
do a comprehensive review.
    As I mentioned in my opening statement, I am extremely 
concerned about the lengthy delays for routine behavioral 
health appointments and the shortage of mental health 
professionals. The services have told us for years that low pay 
and complex hiring processes are to blame.
    What are the services and DHA doing to fix this issue? And 
I think if either Mr. McCaffery or Lieutenant General Place can 
answer this, I will just stick with you so I can get more 
questions in.
    General Place. Sir, we agree with you, the challenges, some 
of it are within the regulations, requirements that we have of 
hiring civilians into any part of our program. Certainly in 
high-yield areas like mental health it is even more of a 
problem.
    We do have a wide range of incentives and bonus pays that 
we apply to them. In some areas, they are relatively effective. 
In other areas, they are just not.
    The reality is across the systems, I can give you examples, 
I would prefer not to, but in rural America in particular it is 
very difficult to find these sorts of things irrespective of 
the incentives that we put against it. So for a worldwide 
organization, that is the challenge that we face.
    Mr. Kelly. We have heard from several families and veteran 
service organizations that increased copays for specialty care 
visits, like care for autism, have made this care unaffordable 
for many military families. In a recent report to Congress, DOD 
stated that approximately one quarter of military beneficiaries 
with household incomes below $50,000 reported postponing 
primary care sometimes, often, or usually.
    This is unacceptable. What has the Department done to fix 
this?
    Secretary McCaffery. I am not aware that, you mentioned 
with regard to increasing cost shares for certain services, 
that that has been identified as a barrier in terms of seeking 
primary care appointments, other appointments.
    I know one of the things that we have done at DHA last 
year, we are continuing to look at it, is indeed have there 
been a difference in terms of utilization of services based 
upon some of the increased co-shares. I don't believe we have 
finished that analysis. But that would, I think, inform what 
would be the next steps to mitigate.
    Mr. Kelly. And I don't want to interrupt you, but you guys 
owe us an answer on the record. That is definitely, that is 
exactly and specifically, and if you need me to give you the 
question again after so we can get specific replies. But we 
can't afford.
    [The information referred to can be found in the Appendix 
on page 103.]
    Mr. Kelly. Our families of our soldiers and our soldiers or 
airmen or sailors are the most important things that we have, 
and we have got to make sure that we don't put any impediments 
to primary care for those folks.
    And for Mr. McCaffery or Lieutenant General Place, I want 
to ask you about MTF realignment process. Can you explain what 
you are doing to ensure the civilian healthcare network can 
absorb the patients that would be displaced from the MTFs? 
Because I know as early as 2017, I was in Italy, and we were 
talking about shutting down in Naples where there was no 
primary care available on the local economy. So tell me how you 
are going to address that, please.
    Secretary McCaffery. Yeah. So what you are referring to is, 
as you mentioned in your opening statement, one of the things 
that Congress directed the Department to do in NDAA 2017 was, 
for lack of a better word, was they asked us to optimize our 
direct care system. And what I mean by that is to look back and 
say the essential purpose of our medical treatment facilities 
is to serve as training platforms for our providers and to 
provide access to care to Active Duty so that they can do their 
jobs.
    And so the ask was, looking at a particular MTF and the 
services, the capabilities they have, how does it tie to that? 
How does it tie to supporting that mission? And part of that is 
there may be areas where there is no civilian network, and so 
you need to have an MTF there. But there may be places, not 
everywhere, but there may be places where the civilian network 
is robust, we can provide care to non-Active Duty at less cost, 
and that helps optimize the use of that MTF.
    Mr. Kelly. We are over time, Mr. McCaffery, but I do want 
to make one final point. We were just at Joint Base Lewis-
McChord, and we have oversaturated that based on civilian 
capacity that was there. And so we have sent all our people 
with problems, with the identical problems there because they 
had it, and now we have oversaturated the civilian market. We 
have to pay attention to second- and third-order effects.
    With that, I have to yield back, Chairwoman.
    Ms. Speier. Thank you.
    Congresswoman Davis.
    Mrs. Davis. Thank you. Thank you, Madam Chair.
    And thank you to all of you for being here, for your 
dedication.
    We know this is really complex. When any large organization 
tries to integrate in a different way it is going to be very 
difficult. But I wonder if you could, for a moment, I think 
actually, Mr. McCaffery, you sort of just summed up, I think, 
what the goals, what the expectations were to a certain extent. 
But what I am hearing, and I think what we are concerned about, 
is that perhaps the push for cost savings could overshadow not 
just efficiencies, but services to beneficiaries.
    And my understanding is that there is some difference in 
the way the different services see this. And could you talk, 
maybe just going down the line a little bit, was there a 
difference in what you were trying to accomplish through this, 
and how were those differences expressed?
    Secretary McCaffery. Sure. And, Congresswoman Davis, I 
appreciate your opening statement about this being hard.
    My background is in private sector and public sector 
healthcare, and what we have talked about in terms of this MTF 
transition is really, in essence, like a merger, a merger of 
separate healthcare systems. It is a big, heavy lift.
    And anyone that would think, whether it is the military or 
any other organization, that wouldn't have challenges, wouldn't 
have contention about that change, they are not speaking 
realistically.
    Have we had those? Yes, we have. But that being said, I 
believe we are in an excellent spot in terms of how we have 
managed this. We have already started it. A year ago we moved 
31 facilities under the DHA, and as you heard from the panel, 
we are actually working in direct support relationship with 
each of the military departments to manage this transition in a 
way that we don't let it affect our Active Duty or our 
beneficiaries.
    Number two, the issue you mentioned about, is this about 
cost savings or efficiency? I would say it is about 
effectiveness. I think Congress recognized in 2017 that we 
could be more effective as a military medical enterprise if we 
didn't have four separate systems, but we had a consolidated 
system that could respond to the mission requirements as an 
enterprise, that we could have more standardization across the 
system, not just for our beneficiaries and their experience of 
care, but most importantly, for how it affects operational 
missions. Meaning, the fact that you could have the same 
equipment or devices that our uniformed providers are using in 
the MTFs are the same ones they are using downrange.
    So this is, to me, more about effectiveness, of making the 
Military Health System even more successful in meeting the 
mission, as opposed to--do I think there is going to be savings 
out of it? Yes. I think you get that out of that consolidation 
and standardization, but the focus is on effectiveness.
    Mrs. Davis. If anybody else wants to comment on that.
    I think the difficult thing is that we are dealing with 
people, right, employees who have to sort of work through what 
this is going to mean to them. And so I am wondering a little 
bit too about how you are messaging for them, because if you 
are losing that many billets, that is having an effect on 
people. And I think it does translate into beneficiary 
services. And I know as well, I mean, having served on the 
MILPERS [Military Personnel] committee at the height of our 
wars, I mean, from 2001 until today, there were so many 
families that were ready to walk because initially they were 
not getting the support that they needed.
    And so talk a little bit more about, I mean what comes 
together is that there are needs that are difficult and 
difficult to work through in a very short period of time. What 
is it today that you would like to share with us that is going 
to get this job done perhaps a little faster?
    Secretary McCaffery. To get the transition done faster?
    Mrs. Davis. Well, I think to help with the transition while 
at the same time respecting the men and women not just who 
serve, but all the people who are part of the system. How are 
they going to be part of it?
    Secretary McCaffery. So right now, General Place and each 
of the surgeons general are actively part of this transition of 
moving administration of the MTFs to DHA is about, well, how do 
we make sure that that knowledge and their resources that are 
now in the services get moved over to the DHA. And we are 
talking about people. It is easier for us to move uniformed 
people around, but the civilians are different.
    And so what we are doing is we are working together to as 
much as possible allow a clean transfer of folks doing certain 
responsibilities in the service medical headquarters, bring 
them over to DHA. And where we are not being able to do that, 
look at different tools that we can do management directive 
transfers so that we ensure not only does DHA get that people 
resource that we need, but it is also at the same time ensuring 
that those employees that are doing that mission continue to do 
that mission but under a different management.
    Mrs. Davis. Yeah. I appreciate that. My time is up. I am 
going to turn it back to the chairwoman. But just sort of 
hearing from all of you as well in terms of, like, so what do 
you have to do to make sure that that happens and we are not 
just saying we are going to do it, but we are going to act on 
what we say. Thank you.
    Ms. Speier. Thank you.
    Dr. Abraham.
    Dr. Abraham. Thank you, Madam Chair.
    Dr. Friedrichs, I listened to your resume, and I know where 
you went to medical school, and I know in your heart of hearts 
you do understand that LSU [Louisiana State University] will be 
the national champion this year.
    General Friedrichs. Absolutely, sir. I strongly endorse 
that.
    Dr. Abraham. On a side note, we were discussing with you 
ladies and gentlemen that our veterans are being moved to the 
civilian population, and I still practice pro bono in a medical 
practice that certainly takes those wonderful people. But we 
still have problems with TRICARE West and others not being 
accepted in the civilian--and I have taken this up with the 
Veterans' Affairs Committee where, of course, jurisdiction 
lies.
    But you need to be aware that when we move these veterans 
from an active military situation to a civilian situation, it 
becomes problematic that if that particular insurance is not 
taken by civilians, those patients, those veterans are denied, 
unfortunately, care in some places. We, of course, take them 
regardless, but some practices can't afford to do that.
    And toward General Kelly's point, there is a barrier, Mr. 
Secretary, when that copayment is higher for certain 
specialties as to those families that may not can afford if it 
goes from 10 to 25 to 50 or whatever. So that is something that 
we have to continue to address.
    My question, and I will start with all the surgeon generals 
here, just please explain any inefficiencies or structural 
difficulties that you have with DHA at this time.
    And, General Place, I will start with you, sir.
    General Place. I don't think there is any structural 
problems with DHA. I see a private process that enables us to 
come together to have overlap. One of the problems with overlap 
is that takes more time. It is crucial to not have gaps and 
drop a soldier, drop a family member, drop a retiree.
    So to Mrs. Davis' point before, and I get that we want to 
move fast, but not at the expense of one of our service members 
or their family. So that, if anything, I see that as the 
problem, that is the challenge, is the timeliness, but it is 
based on not wanting to drop anyone through the system. I think 
we are set up well.
    Dr. Abraham. General Hogg.
    General Hogg. Yes, sir. So I believe we are working well 
together in trying to address some of the difficulties. This is 
hard.
    Dr. Abraham. I understand.
    General Hogg. It is very challenging to bring all us 
together at one time. And we are working well together.
    I would articulate that I like to say, I would like to 
transition before I transform. So let's get the Defense Health 
Agency on its feet with 702 to where they can truly take over 
authority, direction, and control of the military treatment 
facilities, and then we can start finding those efficiencies 
that I know we can find. But if we try to do both at the same 
time, I do have concern that we might, we might miss some very 
important things.
    Dr. Abraham. General Dingle.
    General Dingle. I would echo the same comment. I believe 
that it has to be focused and deliberate, that we must focus on 
the medical treatment facilities transferring, and the 
electronic health record, get that correct before we do 
anything else. And that is my position.
    Dr. Abraham. The EHRs [electronic health records] are 
problematic, as we know. That is why about half of the gray 
hair I have on my head is there now, dealing with that.
    Admiral.
    Admiral Gillingham. Yes, Congressman.
    I would say as the new kid on the block, having been in 
this position for about 5 weeks, I am incredibly impressed by 
the collaboration that exists with my partners.
    I would say in terms of the structure, I think the 
establishment of the direct support agreements has been a very 
important step to ease that transition rather than just a 
complete turn the switch in October.
    So I would say that continuing that work, but having clear 
road map for hand-off of those functions, is a critical step 
going forward.
    Dr. Abraham. General.
    General Friedrichs. Thank you, sir.
    And I would echo that. From the Joint Staff perspective, 
one of the great strengths of DHA has been how they have helped 
us to better collaborate in the combat support arena, things 
like the Joint Trauma System. We recently hosted a meeting with 
the combatant command surgeons in which they highlighted the 
significant progress that we have made in what was already a 
world-class Joint Trauma System, making it even better as we 
continue to work more closely together.
    So I think there is great progress. Obviously, much more 
work to be done. There will always be opportunities for 
improvement.
    Dr. Abraham. Well, I am glad to hear the cohesion.
    Madam Chair, I just request we enter into the record this 
article on Military Times, the military needs for a unified 
command. And that is from Brad Wenstrup.
    Ms. Speier. Without objection.
    [The information referred to can be found in the Appendix 
on page 97.]
    Dr. Abraham. Thank you.
    I yield back. I am out of time.
    Ms. Speier. General Friedrichs, one of the articles that 
our good friend Dr. Wenstrup had brought to our attention that 
was put out by U.S. News & World Report spoke about how 
surgeons in the military are not getting the kind of experience 
that they should be getting in order to be more proficient, 
that they are getting about 20 percent of what a surgeon in 
civilian workforce would be getting in terms of the number of 
cases they handle a year.
    And you just spoke about the trauma care issue. So I am 
curious how we are going to address the fact that they are 
lacking in the opportunities to handle enough surgeries and be 
prepared then in terms of readiness when they are out on----
    General Friedrichs. Thank you, ma'am.
    And I would say from the Joint Staff perspective, we define 
the requirement, we describe what the combatant command 
requirements are and rely on the services and the Defense 
Health Agency to organize, train, and equip to meet that 
requirement.
    I believe as a surgeon that the article captured a number 
of points on which we are already working. One of our 
responsibilities in the Joint Staff is joint capability 
development. And we have been working on improving through the 
Joint Trauma System a number of areas, whether it is expanding 
opportunities for currency or expanding equipment, improving 
equipment availability, for several years now.
    Those articles capture very valid concerns that are 
expressed by some surgeons. I can tell you, I was in San 
Antonio 2 weeks ago at the Committee on Trauma, which is the 
assemblage of our senior leaders, and I heard a much more 
optimistic story of progress being made across the services. 
And so I would respectfully ask if my colleagues from the 
services could also talk about what they are doing on that.
    Ms. Speier. All right. I want to give Congresswoman Trahan 
her opportunity first. We will come back to this issue. Thank 
you.
    Mrs. Trahan. Thank you. Thank you, Madam Chairwoman.
    I am going to switch gears. I am not sure this is going to 
really fall with the 5 minutes, but I am going to give it a 
shot, given that I have got so many surgeon generals and 
military healthcare professionals in front of me.
    I wanted to talk about suicide for our Active Duty members. 
Data shows that there are approximately 60 percent of military 
personnel who are experiencing mental health problems and they 
are not seeking help.
    And when I reviewed the medical standards for appointment, 
enlistment, and induction, it precludes things like sleep 
disorders, ADHD [attention deficit hyperactivity disorder], 
depressive disorder, anxiety disorders. So I don't think it is 
any surprise that there are studies that suggest that many are 
skirting the rules to enlist.
    And I am wondering, can you briefly touch upon maybe the 
cognitive assessments taken on service members as they join? 
And also what is preventing service men and women to self-
report potential risk factors like sleeplessness and 
depression?
    Ms. Speier. It is not a good sign that none of you are 
responding here.
    Secretary McCaffery. The reasons, just in terms of some of 
the questions that you are asking with regard to military 
department processes, in terms of accession, standards, I think 
one of the surgeons would be most able to kind of respond to 
some of those specifics.
    General Dingle. I will start.
    Yes, ma'am, it definitely is a very important aspect. So at 
the point of accessions, behavior health screenings, physical 
screenings are very important, and you are absolutely correct 
that we can improve it to make sure that we are not missing it 
and then taking it on when they come on to Active Duty.
    In reference to why are they not reporting, it has been a 
challenge in removing the stigma. It is imperative that we 
educate and that we change the climate and cultures of commands 
and organizations so that soldiers, sailors, and airmen are not 
afraid to report because of retribution or impact on their 
career.
    And so that is the bottom line why service members do not 
report. They do not want it to impact their careers.
    However, one of the greatest things I saw at the DOD/VA 
Suicide Prevention Conference this summer was that we have to 
move to prevention, getting ahead of the act, by changing the 
culture, and we change that culture by removing the stigma and 
education and a holistic approach from the command itself.
    General Hogg. Yes, ma'am.
    So in the Air Force, we are actually seeing an increase in 
people coming to mental health because of the outreach that we 
are doing. We are embedding our mental health into units where 
they can build the relationship with those providers and they 
feel more comfortable coming in to get care.
    The other thing that we are doing is, a lot of this is 
really giving people the capability to handle stress without 
crisis. And so in our basic training military capacity, we are 
actually providing classes to our new recruits on how to handle 
stress and what are the ways to seek care if needed and reach 
out and touch people.
    Admiral Gillingham. And, Congresswoman Trahan, I would just 
say from the Navy perspective, we very much endorse embedding 
mental health personnel at the deckplate and in stressful 
training commands. So one-fourth of our mental health 
professionals are actually in the operational force. And so we 
have seen a commensurate increase in access and decrease in 
stigma.
    The other benefit is that those mental health professionals 
do tremendous training for the senior officers in those, for 
example, submarine squadrons, so that they are extenders in 
terms of identifying those at risk. And similar to the Air 
Force, we are piloting teaching meditation to new recruits at 
boot camp as a way to help deal with stressful situations.
    Ms. Speier. Congresswoman, was your question actually 
answered? I thought what you were asking was, when recruits are 
reluctant to identify these conditions, how do you--how are you 
able to assess that as they are going through the training 
process? Is that what your question was?
    Mrs. Trahan. Yes. So, one, I think it is great to sort of 
diagnose and help embed and to treat people who are suffering 
from mental illness. And culture, some organizations do it 
better than others when it is time to change culture.
    My question is--and certainly we have got generations of 
young people who are taking medication to prevent sleep 
disorder, to prevent ADHD. They are working. Is there any 
discussion around--my fear is that people are going off their 
medication when they enlist because that is a requirement, and 
that can cause great mental--that can obviously cause harm and 
mental disorders to flare up in nontraumatic situations even.
    So I am wondering if there has been any discussion around 
revisiting some of these protocols or if there has been any 
sort of study or a discussion around that being a root cause 
for some of the mental health problems and suicide rates that 
we are seeing in our nondeployed Active Duty service men and 
women.
    General Hogg. So not to my knowledge, but it is certainly 
something that we can take back and take a view and see if we 
have something that we can improve upon.
    [The information referred to can be found in the Appendix 
on page 103.]
    Ms. Speier. You know, Mrs. Trahan, I think that you have 
touched on an issue that probably deserves having a briefing 
on, because there is an ability for people to be very 
functional on drugs to combat ADHD. And yet I am sure that if 
that was identified in an application before a recruiter, that 
person would be declined the opportunity to serve.
    So maybe we need to just have a generalized discussion on 
whether or not the basis on which individuals are allowed to 
enlist meets the medical technology and advancements we have 
made relative to drugs and other things.
    Mrs. Trahan. I would love to attend that hearing. Thank 
you, Madam Chairwoman.
    Ms. Speier. All right.
    Congressman Bacon.
    Mr. Bacon. Thank you, Madam Chair.
    I want to thank all the witnesses for being here today and 
for your commitment to the health and readiness of America's 
most important weapon system. That is our warriors and their 
families.
    I would like to focus for a moment on a medical readiness 
challenge that concerns me; perhaps an opportunity as well.
    Most Americans would be surprised to learn that World War I 
more soldiers actually died due to disease than to enemy 
action, largely as a result of the 1918 influenza epidemic or 
pandemic.
    Today we know that our enemies are relentlessly pursuing 
ways to kill Americans in large numbers. We also know that 
naturally occurring infectious diseases in our increasingly 
interconnected world have the ability to spread faster than 
ever. The risk of infectious diseases is significant and 
growing, not only for our general population, but also for our 
defenders in the Armed Forces and our first responders.
    So as these threats grow, I am concerned our capacity to 
prepare, detect, and respond with specialized care for 
chemical, radiological, biological infectious disease is far 
less than we need and may actually be declining.
    So my question is to General Friedrichs. If we have time, 
we will come back to others.
    But my question to you, General Friedrichs, is as you 
contemplate the 21st century force health protection threats 
facing our military and the shrinking of our uniformed medical 
service, how do we better position the military and our 
civilian health systems to work together to address this 
mission?
    General Friedrichs. Sir, thank you very much. And I would 
offer several observations.
    First, absolutely agree with your points about the rapidly 
evolving threats. There is no question that the threats that we 
faced in previous conflicts are not the threats we will face in 
the future, and we must continue to evolve our detection 
capability, our attribution capability, our ability to prevent 
the effects of those agents that are being used, and then to 
treat those once they are exposed.
    All of that has worked. It must continue. And it will 
require a robust, whole-of-government cooperation, partnering 
across the Department of Health and Human Services, the 
Department of Homeland Security, and the Department of Defense.
    But more importantly, we are grateful that we have partners 
at the State level who have recognized these threats and have 
joined in those partnerships to develop new capabilities. That 
sort of partnership is imperative because the threat is not 
just somewhere else. It is not just in another continent. It 
can just as easily happen here. It can be a pandemic that 
occurs on our own soil or an attack on our own soil.
    To your specific comment about the capabilities that we 
need, as these threats evolve we must develop new detection 
capabilities, we must develop new training capabilities for our 
medics, we must develop the ability to have better treatments 
that allow us to function wherever that new agent is used as we 
go forward. And that is important work which is going to 
require partnership, as I said, across the whole of government 
and with key State partners.
    Thank you, sir.
    Mr. Bacon. So we have facilities in Omaha like the 
University of Nebraska Medical Center [UNMC] that is the 
world's center of excellence for Ebola, as an example. So let 
me just follow up and ask you, how do you take advantage of 
civilian centers of medical excellence, like UNMC, in 
developing solutions? Do you see a role for more creative 
public-private partnerships like we now are doing in 
communities like Omaha with the new VA medical center?
    So appreciate your insights on that.
    General Friedrichs. Sir, first, thank you for the question. 
And more importantly, thank you for the community support 
across the State of Nebraska. That was not just an Omaha 
initiative, that was a statewide initiative that in many 
respects is a model of public-private partnership.
    The work that has occurred across the agencies in order to 
work with the Nebraska community does set a model that we can 
use in the future going forward because this is not solely a 
military problem. We are part of our Nation's response, but we 
cannot be the only response.
    It begins with local capabilities, local leaders who 
recognize the threat, and then partner with State and Federal 
experts to develop those capabilities that we can use, whether 
it is a local event or a national event or, unfortunately, as 
may occur in the future, an international event.
    I think that the capability that has been developed for 
Ebola, the partnership for the VA hospital, some of the 
cutting-edge research that is being done there in Nebraska is 
exactly the sort of work in collaboration that we need to move 
forward in the future.
    Mr. Bacon. Thank you.
    And, Madam Chair, I see an opportunity for public-private 
partnerships working together to benefit the whole country and 
beyond just the military.
    I have a follow-up for General Hogg, if I may. Don Bacon is 
going to ask her a question here. We have been working off and 
on together for a long time.
    So have we already had cuts made at the bases at the 
medical centers? Have those cuts already occurred?
    General Hogg. No, sir, they have not.
    Mr. Bacon. Because I have been getting more and more 
reports from concerned constituents, retirees primarily, that 
feel like they are being pushed out, made to go to the VA, and 
not allowed to do their TRICARE.
    So these phone calls I am getting are not related to the 
proposal that is going on here. Is that what I am hearing?
    General Hogg. Right. Yes.
    Mr. Bacon. Okay. Thank you.
    Ms. Speier. All right. We are going to do a second round 
for those that are interested in staying to ask more questions.
    I would like to go back to that question that I asked about 
surgeons and their ability to have enough experience with cases 
and what we are doing to try and--if, in fact, the average 
surgeon has 500 cases a year and the average surgeon in the 
military has only 20 percent of that, that is a real vacuum, I 
think.
    So let's start with you, Lieutenant General Hogg.
    General Hogg. Yes, ma'am.
    In the Air Force we have for a long time had what we call 
training affiliation agreements where we send out our medics to 
civilian or other Federal institutions to get those touches, 
what I like to call volume acuity and diversity of cases, 
because we know in our direct care system we won't have that.
    And so for a long time we have been sending our specialized 
medics, trauma surgeons, orthopedic surgeons, nurses out into 
civilian facilities to get that. Nellis is a good--UMC 
[University Medical Center of Southern Nevada] is a good 
example of that, Baltimore Shock Trauma is a good example of 
that, and many others.
    We are also now having some success in getting our enlisted 
medics into those treatment facilities in order to have the 
touches that they need.
    One of the difficulties that we have is gathering the data 
on exactly how much----
    Ms. Speier. All right. So I would like to get to the other 
services.
    Could you just provide that data to us? Because in part, 
General Friedrichs, I think what I would like to see is a 
response to those articles as to where we are falling short and 
where we have actually made some advances.
    General Dingle.
    General Dingle. And ma'am, we are coming on a critical 
point, because what we have also done as a collective joint 
work group, we have identified what is called those knowledge, 
skills, and attributes that are required for surgical 
proficiency; and not just surgical proficiency, but all of our 
specialties across the militaries.
    Within the Army, we then build on top of that with what we 
call ICTLs, Individual Critical Task Lists. So for that trauma 
surgeon, how many procedures do you need, as you mentioned? And 
then we, for the first time in our history, are tracking and 
documenting those as it goes towards readiness. And we will 
continue to build upon those internally with the MHS.
    Ms. Speier. So you recognize that there is an issue.
    General Dingle. Yes, ma'am.
    Ms. Speier. And you are attempting to address it.
    General Dingle. Yes, ma'am.
    Ms. Speier. Admiral.
    Admiral Gillingham. Chairwoman Speier, I would agree, yes, 
we do. We are approaching this in two different directions.
    Internally, within the direct care system, you may be aware 
that Naval Medical Center Camp Lejeune was designated a trauma 
center, and we are seeing tremendous value, both within Lejeune 
and also to the local community.
    And then externally we also have existing partnerships, 
which also include our corpsmen, which we all recognize at the 
tip of the spear are some of the most important part of the 
trauma response.
    Ms. Speier. Okay. Thank you.
    What we have seen since the budget year 2015 is an actual 
reduction in the cost of providing military health by about at 
least a billion dollars.
    So I guess to you, Mr. McCaffery, where is that money 
going?
    Secretary McCaffery. So is the question with regard to a 
change from fiscal year 2019 to what the President's budget 
proposed for 2020 or----
    Ms. Speier. No. I think staff has looked back at the 
Defense Health Program spending since 2015, and the program has 
had a decrease in funding and appears that it is costing less 
money and that the savings, whether it is a billion or 3 
billion, we have seen different figures, there is a savings of 
about a billion to 3 billion, and I want to know where that 
money is going.
    Secretary McCaffery. So some of the data I am looking at 
right now, and I am looking at the Defense Health Program [DHP] 
appropriation, so that is what is funding our direct care 
system, the purchase care system, some of the R&D [research and 
development], what I am looking at for fiscal year 2015 shows 
that DHP plus military construction for health facilities is 
about 33 billion. It dipped a little bit in 2016, 33 billion in 
2017, 34 in 2018, and just under 35 in 2019.
    So I am not sure if we are looking at different numbers 
or----
    Ms. Speier. We will have our resident expert.
    Mr. Diehl. Mr. McCaffery, the question is really the 
unified medical budget at the DHP.
    Secretary McCaffery. Oh, okay.
    So I am looking at that now for the same figure. Unified 
medical budget in 2015, I have 48 billion. It then dipped a 
little under 48 billion, then 49 billion in fiscal year 2017 
and 50 billion in 2018, and a little over 50 billion, at least 
enacted, for fiscal year 2019.
    Now, I know in the fiscal year 2020 proposed budget, the 
President's proposed budget has it down at 49 billion. But my 
understanding, and I could be wrong, is every year Congress 
adds in roughly a billion, between, I think, 800 million and a 
billion, in additional R&D dollars. That is not in the base 
budget proposal in the President's budget and so that probably 
is one explanation for a delta between what was actually 
enacted in fiscal year 2019 versus what the President proposed 
in 2020. But I can go back and double check and confirm that.
    Ms. Speier. So the question becomes, if it is basically 
stagnant, is that actually savings, because we are not seeing a 
cost of living increase? I don't want to take any more time. 
Maybe we can have a subsequent conversation on that.
    [The information referred to can be found in the Appendix 
on page 103.]
    Ms. Speier. Ranking Member Kelly.
    Mr. Kelly. Thank you, Chairwoman Speier.
    And just real quick, and I think you answered this, Admiral 
Gillingham, but the embeds you were talking about on behavioral 
health, you are also doing that with your corpsmen with the 
Marines that are forward. Is that correct?
    Admiral Gillingham. Yes, sir, that is across----
    Mr. Kelly. Very good. I am satisfied with your answer. I 
just want to make sure we are taking care of our Marines.
    Admiral Gillingham. Yes, sir.
    Mr. Kelly. And then, Lieutenant General Dingle, I didn't 
hear the Army talk about embeds at all. And I would argue that 
the people who are the hardest and need that the most are the 
Army and the Marine Corps, based on the duties and the unit 
types that they have. So what are we doing?
    General Dingle. Mr. Kelly, you are spot on. We did embeds 
many years ago and we continue to champion that as part of our 
behavioral health system of care. Embeds are a very important 
part of our brigade combat teams forward.
    Mr. Kelly. So we are doing that?
    General Dingle. Absolutely, yes, sir.
    Mr. Kelly. But is there a shortage there of behavioral 
health? Because my experience in the Army, and especially in 
the Guard and Reserve, is that there is an extreme shortage of 
professional behavioral health specialists that are in the Army 
units that are filling those MTOE [modification table of 
organization and equipment] slots. We have got the slots, but 
we don't have the docs.
    General Dingle. And what we are doing, again, improving the 
recruitment to try to get those specialties in there. In 
addition to that, within the Army, in addition to those 
bottoms-up--we did a bottom-up review where we looked at the 
mental health requirement and identified even more.
    So as we are looking at H2F, holistic health and fitness, 
it is from a mental health perspective as well as a physical 
therapist and occupational therapist also augmenting our 
brigade combat teams and our divisions forward.
    Mr. Kelly. Have you been down to Bragg lately and seen what 
they are doing down there with our special operators at Bragg 
as far as psychological health and just total package?
    General Dingle. Yes, sir.
    Mr. Kelly. We need to do that across the services, because 
that is all services, and we need to figure out how we can do 
that better across the entire services. I am sure you have been 
down there, too, General, but I just want to make sure that we 
are doing that.
    Second, real quickly, what authorities do you guys need to 
help you assess behavioral health experts? Because we have 
asked you and you guys need to give us what authorities or what 
things do you need in order to get this to where we need to be, 
for accessions of behavioral health specialists.
    Secretary McCaffery. Right. I don't believe there is 
authorities in terms of statute or policy direction. I believe 
you have kind of heard a common theme from everybody, and it is 
also common in the private sector, is resources, resources to 
be able to hire. And even if you have resources, there are 
going to be certain areas that you are going to have a hard 
time recruiting, even if you can pay them, recruiting mental 
health providers.
    But I would say it is probably more around resources and 
what else we can do to entice folks to join and provide that 
service.
    Ms. Speier. Will the gentleman yield?
    Mr. Kelly. Yes.
    Ms. Speier. When you say mental health providers, are we 
also talking about marriage and family counselors? I mean, we 
are talking about the whole gamut, it is not just psychiatrists 
and psychologists?
    Secretary McCaffery. Correct. Correct. I can't speak to 
kind of each service in particular, but I know in certain 
classification of mental health providers, we are pretty good. 
I think it is hit and miss based upon the classification of 
provider.
    Mr. Kelly. And then the final thing I want all you guys to 
look at is we are a total force, but docs can make a lot more 
money on the civilian world than they can in the Army, Navy, 
Air Force. I mean, there is a lot more money to be made. It is 
kind of like being in Congress. There are a lot better ways to 
make money than do this job. So you guys do it because you love 
it.
    But there is an opportunity out there in our Guard and 
Reserves, for the Air Force and Navy and Army, there is an 
opportunity because these guys want to serve. I mean, the 
reason people are doctors is because they want to help people. 
It is not about money. But there is a point where they have 
other obligations.
    So let's make sure that each of our services are looking at 
our Reserves and our National Guards and saying, do we pay them 
better? How do we get them in the rotation so that they fill 
behavioral health specialties? Maybe we have those seeing 
soldiers or airmen at Joint Base Lewis-McChord on the weekends 
or maybe they do their 2-week AT [annual training] there and we 
schedule them in.
    So as a whole, as an Air Force or as an Army or DHA, how 
are we integrating, especially behavioral health specialists, 
into the Guard--I mean into the total force--so that we are 
using that to our benefit?
    And maybe we need to pay them a little more, maybe we need 
to make their incentives a little better so that when a guy 
comes off Active Duty or a doctor who wants to serve--everybody 
likes to wear a uniform. I mean, they do. I mean, because it is 
the same thing that makes people want to be doctors that make 
them want to be soldiers. They want to serve. So how do we get 
those guys so they can serve in a capacity and help our total 
force?
    And with that, Chairwoman, I yield back.
    Ms. Speier. Thank you.
    Congresswoman Davis.
    Mrs. Davis. Thank you, again.
    I think what I know I am hearing and what I really wanted 
to ask you about as well is, what is the strategy? What is the 
plan? How do we make certain that as we move further into 
TRICARE for beneficiaries that there is a ``there'' there for 
them and they are not going to lose in the benefits that they 
have already had.
    I know that it is a great source of anxiety for our 
families. And certainly when we go on a full OPTEMPO 
[operations tempo] and deployment, all the pediatricians go to 
war, right, so we don't have them. And it is important that we 
figure that out.
    So for mental health, I mean, one of the questions that I 
was interested in is, we talked a lot while a number of our 
troops and our corpsmen were coming home from the war, some of 
them had developed a real aptitude for being able to help one 
another in the mental health field.
    And I hope, and, again, part of this really thinking ahead 
about it is, how do we make sure and identify those people--and 
I think the ranking chair mentioned this--that are coming out 
of the service that perhaps at another time they would have 
never thought about going into the behavioral health field, but 
they are now.
    We talked a lot about social workers a number of years ago. 
How does the military identify those people who, with proper 
training and with loan forgiveness, that they can do that?
    And so I am hoping that perhaps we think a little bit more 
about the future, because there is no way in the world that we 
are going to be able to rely on the civilian world to satisfy 
the needs that we are going to have.
    And the other thing is, just quickly, finding a better 
way--and we have some wonderful folks in San Diego that have 
really looked into this because of a family suicide. How do we, 
within our system of privacy, HIPAA [Health Insurance 
Portability and Accountability Act], whatever, make certain 
that families can be more involved in the mental health of 
their loved ones? It is a deep, dark secret sometimes that 
somebody needs help and it shouldn't be that way.
    As a parent you feel like I want to be a partner here, but 
I don't know how. And there are some men and women in the 
services who are not going to call their families and tell them 
they are struggling. But maybe there is a better way of doing 
that. And I know the VA has been working on that. So thinking 
about how do we do a better job.
    But certainly our spouses, and I remember talking to so 
many spouses about this, yeah, they were afraid to share the 
fact that their husbands were screaming in the night, because 
they were afraid that they would be kicked out of the service. 
They need to be involved as well. And certainly having good 
practitioners to help them out as well.
    So I hope that all those issues will be looked at. And we 
were talking about that, the issue that I think, Admiral 
Gillingham, you would be aware, too, in San Diego, we really 
did not have the patients for our surgeons to be able to help 
there, and so they go to L.A. County Hospital. That is where 
they go for gunshot wounds, honestly. And that is what we have 
to do sometimes in partnering.
    But just as it has been difficult for you all to work 
together to have this change, it is not so easy for them as 
well, although our military has often been trained in the 
civilian world and back and forth, and we train them very well.
    Sorry. I think my time is almost up. Maybe you gave me more 
time.
    Ms. Speier. You have another minute.
    Mrs. Davis. Okay.
    Ms. Speier. You can actually have them answer you.
    Mrs. Davis. Yes, please, please.
    So is there that kind of planning that we are really 
looking at all the parameters possible to be able to serve our 
men and women?
    Secretary McCaffery. Let me start with one of the first 
questions you asked, in terms of where does the TRICARE 
program, where does our partnership with the civilian sector 
fit in to where we are going in terms of reforming the whole 
system, because that is a key, it is a linchpin.
    And even though the current TRICARE contract is only a 
little less than 2 years on board, we are already starting the 
effort in terms of the next generation, the next procurement, 
because just for what you said, it has to be critical to 
support the change in the system.
    So if we are going to be consolidating all of our MTFs 
under one management under the same roof that manages the 
TRICARE program, we need to make sure that we are requiring 
more from our contractors, both to make sure we get what I 
would call the readiness-related caseload we need into our 
system, for all the reasons we have talked about in terms of 
keeping our surgeons, our providers current, so we need to be 
able to do more of that, we need to make sure that we do have 
the adequate networks to support our families and our 
beneficiaries when, indeed, we are making changes to the system 
and we realign services in certain areas in terms of what MTFs 
are providing, we need to make sure that we have that 
partnership with those contractors to make sure that that 
capability doesn't go away. You may not get something from a 
uniformed provider, but we have to make sure you get it from a 
provider.
    So I think those are some key things that we are looking at 
as to what we need to do to support the reform going forward.
    Mrs. Davis. And looking at increased pay obviously is going 
to be an issue.
    Ms. Speier. All right.
    Dr. Abraham.
    Dr. Abraham. General Friedrichs, educate me, sir, please. 
You said Lejeune has been designated a trauma center?
    Oh, I am sorry, Admiral. Is that true? Is it a Level 1?
    Admiral Gillingham. Level 3, sir, with aspirations for 
Level 2.
    Dr. Abraham. And so you are seeing civilians in that 
capacity?
    Admiral Gillingham. Yes, sir. That is correct.
    Dr. Abraham. You have worked out getting the ambulance 
through the gate, insurance, and all that stuff? Okay.
    Admiral Gillingham. Yes, sir.
    Dr. Abraham. The reason I ask is I know that the armed 
services' surgeons are not getting enough cases or certainly as 
many as they desire. And I know that in some cases you are 
meeting some headwinds from the civilian docs taking their 
cases. And so we understand the dynamics there of there is just 
a set number of trauma patients and everybody wants to have 
their gloves on and hands in fixing that patient.
    So I think it is a wonderful concept of designating as many 
camps as we can as trauma centers so we can get that expertise 
that you people need with your doctors in play, so it is a good 
concept.
    Mr. Secretary, just one question for you. Do you see value 
in placing the DHA under a unified operational command?
    Secretary McCaffery. I mean, I think one of the things that 
Congress has asked us to do and we are in the kind of final 
stages was actually to look at, is it feasible to morph DHA 
into a unified health command, a defense health command. And we 
are putting together what we think could be feasible options.
    The key thing is what would we want to get out of that. I 
mean, it could be is it because we want to have more clear 
command authority over all medical forces across the services? 
Is it efficiency? And that is the thing that I think you have 
to determine first before you can assess whether that is the 
right direction.
    But the one thing I think there is unanimity within the 
Department is we don't believe this is the time for us to go 
down that path, only in that you have heard us all talk about 
the enormous change we have already launched. And our feeling 
is, it is better to see how does DHA function with their new 
responsibilities before we were to talk about would you convert 
that or change the Defense Health Agency into an even larger 
command across the Department.
    So we do think it is worthwhile looking at, but we want to 
revisit that in probably the next 3 to 4 years once we have 
some more stability in the system.
    Dr. Abraham. Thank you.
    Madam Chair, I yield back.
    Ms. Speier. Thank you.
    I think it was you, Lieutenant General Hogg, who said that 
it is really important for us to bring all of these services 
together under one roof before we start moving forward on some 
of these other aspects. I am presuming you mean these billets 
as well. Is that correct? Or is that something you are going to 
implement while this process is going on?
    General Hogg. So the billets are from the Air Force, higher 
Air Force level. And the plan right now is, while they are 
there, we will not reduce the faces until the system can handle 
the workload.
    Ms. Speier. All right.
    And how about you, General Dingle?
    General Dingle. Yes, ma'am. We, likewise, the billets have 
been identified, and we are coming together working with the 
DHA to see impacts of billets. However, we also have a large 
number of unfilled billets that we are looking at this fiscal 
year.
    Ms. Speier. Are you going to hold off reducing the billets 
or are you going to reduce the billets, is what I am asking.
    General Dingle. Our unfilled billets, ma'am, have already 
been converted over. There will be no further reductions until 
we do the complete analysis with the DHA.
    Ms. Speier. Well, what happens if those billets are mental 
health professionals? I mean, one of the issues that we have 
talked about a lot today is the fact that we need more mental 
health providers. So arbitrarily, if you are just going to not 
fill these unfilled billets, don't you have to make an 
assessment as to whether or not they are important to be 
filled?
    General Dingle. Yes, ma'am. And one thing, a little more 
detail, as we have done conversion of billets, some of the 
billets we have converted are, in fact, goes towards holistic 
health and fitness, mental health providers, but on the 
operational force side of the house.
    The empty billets that are in the MTF side of the house, 
again, are unfilled, and as we move them to the operational 
force we have done bottoms-up review in which we have, in fact, 
identified more medical requirements for our operational force 
that we will move to recruit to fill those billets in.
    Ms. Speier. All right.
    Admiral.
    Admiral Gillingham. Yes, ma'am. For the Navy, the faces 
remain in the billets and looking very carefully at the impact 
on DHA.
    I will say to your point about mental health, very few of 
the planned reductions were in mental health billets.
    Ms. Speier. All right.
    Mr. Kelly. Would the gentlelady yield?
    Ms. Speier. Of course.
    Mr. Kelly. I just want to make sure, I get the unfilled 
billets, but from a lot of years of experience, the unfilled 
billets are generally the low-density, hard-to-get billets. And 
I just want to make sure that those aren't the behavioral 
health and the OB/GYNs and all the areas we have trouble 
getting enough people that we are not just, because those 
billets aren't full, that those are the slots or the people 
that we are going, so we are not going out and recruiting 
those. If that makes sense.
    We have got to make sure that we are not, just because we 
don't have a filled billet with a behavioral health specialist, 
that we don't do away with that slot. We have got to fill that 
slot. We have got to do away with another slot when it goes 
away.
    And I yield back.
    Ms. Speier. Let me also make note of the fact that when we 
were visiting the bases, it was astonishing to both of us that 
there was such a high incidence of autism among the families of 
service members, many of whom were officers as well.
    I actually think we need to do a review and determine if 
this is just isolated or is it reflective of the general 
population or is there something environmentally or something 
else that is creating this incidence of autism and our ability 
within the military system and the health system to provide the 
services to these families.
    And finally, there is a lot of talk today about 
effectiveness and readiness and efficiency. What was left out 
of all of those terms is the fact that it is not just for that. 
The families are a huge component of the healthcare system 
within the military. And if we don't have a robust system that 
provides the services, I think we are going to have a problem 
with retention.
    And so, it is really important that we have the quality of 
healthcare that each of these families deserves. And if we are 
falling short there, we are falling short in many other areas 
as well.
    So with that, if there are not any further comments to be 
made, thank you very much for your service and for your 
participation here tonight. And we stand adjourned.
    [Whereupon, at 4:56 p.m., the subcommittee was adjourned.]

     
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                            A P P E N D I X

                            December 5, 2019
      
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              PREPARED STATEMENTS SUBMITTED FOR THE RECORD

                            December 5, 2019

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                   DOCUMENTS SUBMITTED FOR THE RECORD

                            December 5, 2019

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              WITNESS RESPONSES TO QUESTIONS ASKED DURING

                              THE HEARING

                            December 5, 2019

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              RESPONSE TO QUESTION SUBMITTED BY MS. SPEIER

    Secretary McCaffery. Both private health insurance premiums and 
National Health Expenditures per capita rose 25% (or 3.7% annually) 
from Fiscal Year (FY) 2012 to FY 2018. Over this period, the 
Department, with concurrence from Congress, instituted a combination of 
benefit changes, payment savings initiatives, and contract changes to 
offset underlying increases in health care costs (exceptions were FY 
2014 and FY 2015 due to the compound pharmacy anomaly). If not for 
these actions, it is likely that the Defense Health Program (DHP) would 
have continued to rise. While continued efforts are being made to 
contain healthcare cost growth, recent trends in Private Sector Care 
claims indicate that DHP is likely to experience growth more in line 
with National Health Expenditure (NHE) in Private Sector Care. 
Comparing current year President's Budget (PB) requests to prior year 
enacted budgets can be misleading. As you mentioned in your question, 
the DHP typically receives about $1 billion dollars above the PB 
request in our Research Development Test & Evaluation accounts. 
Comparing PB request to PB request will often provide a more accurate 
depiction of changes within the portfolio. Comparing prior fiscal year 
enacted position (which includes Congressional additions) and the 
current year President's Budget (without Congressional additions) it 
may erroneously suggest reduced resource requirement.   [See page 26.]
                                 ______
                                 
              RESPONSE TO QUESTION SUBMITTED BY MR. KELLY
    Secretary McCaffery. The Department has conducted analyses as to 
whether increases in beneficiary copayments since January 1, 2018 have 
triggered barriers to seeking primary or specialty care or if the 
increased copayments have resulted in significant changes in 
beneficiary utilization. There are two important factors to consider on 
this issue. First, TRICARE Select and TRICARE Reserve Select enrollees 
are required by law to have higher out-of-pocket costs as compared to 
TRICARE Prime enrollees. Active duty family members who choose to 
enroll in TRICARE Prime pay $0 enrollment fees and $0 copayments. 
Second, all military families are protected by the annual catastrophic 
cap (CATCAP). Our analysis found more active duty family members 
(0.09%) in TRICARE Select reached their catastrophic cap of $1,000 
while fewer retirees and retiree family members in TRICARE Select 
reached their CATCAP of $3,000. Our analysis of the utilization for 
``Therapy Services,'' since the increase in the beneficiary out of 
pocket expense for such services, revealed there was an inconsistent 
effect on unique users, visits per user, and median number of visits 
per user, even for ADFMs enrolled in TRICARE Prime who continued to 
have $0 copays. As intended with the first increase in the TRICARE 
Prime retiree copayment since the beginning of TRICARE in 1995, there 
was a cost-shift from Government to retiree beneficiaries enrolled in 
TRICARE Prime. Overall, the total out of pocket costs compared from CY 
2017 to CY 2018 were neutral for TRICARE Select enrollees, although 
there were some beneficiaries that would see an increase in costs while 
others would see a decrease. Any significant changes to the fixed 
copayment structure for outpatient network visits or the amounts 
themselves require statutory and/or regulatory changes. The copays for 
Group B (sponsor joined the military after January 1, 2018) are 
designated by law, and the Department has no flexibility for both 
TRICARE Select and Prime copayments. For TRICARE Select Group A 
beneficiaries (sponsor joined the military before January 1, 2018), the 
Department is examining options to address ``affordability'' concerns. 
These include short term policy changes under current regulatory 
provisions that allows the Director, Defense Health Agency to decide 
whether it is practicable to use a fixed amount to determine 
beneficiary co-pays as well as longer term options such as pursuing 
changes to statute and/or regulation.   [See page 16.]
                                 ______
                                 
              RESPONSE TO QUESTION SUBMITTED BY MS. TRAHAN
    General Hogg. No, the Air Force Medical Service is not aware of any 
significant trends or evidence which suggests recruits are going off of 
their medications to enter the Air Force. We encourage all recruits to 
be forthright about their medical history and highly encourage them to 
continue to take any prescribed medications. Full disclosure of all 
medical conditions and required medications are vital to ensuring the 
health of our recruits and active duty members. The Tri-Service 
Accessions Medical Staff Working Group (AMSWG) meets quarterly to 
discuss and update the accession medical standards that are listed in 
DOD Instruction 6130.03, Medical Standards for Appointment, Enlistment, 
Induction Into the Military Services. There have not been any 
discussions about changing the standards for Attention-deficit/
hyperactivity disorder (ADHD) and sleep disorders in the recent working 
groups. In 2017, Air Force medical waiver policy was adjusted to allow 
for more opportunities for members with ADHD to enter the Air Force 
with a waiver. Furthermore, the Defense Health Board is currently 
conducting an independent review, ``Examination of Mental Health 
Accession Screening: Predictive Value of Current Measures and 
Processes'' that is investigating current policy and protocols on this 
subject. The Air Force has also embedded a Psychology Research Service 
at initial Basic Military Training, that conducts screening of all 
trainees within 72 hours of arrival at Lackland Air Force. The 
Psychology Research Service's Biographical Evaluation and Screening of 
Trainees (BEST) program has been effective in identifying recruits who 
have not previously disclosed recent or problematic mental health 
history, and then directs those Airmen to obtain an evaluation by a 
psychologist.   [See page 22.]

      
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              QUESTIONS SUBMITTED BY MEMBERS POST HEARING

                            December 5, 2019

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                   QUESTIONS SUBMITTED BY MR. GALLEGO

    Mr. Gallego. LTG Place, I appreciate the Department's submission of 
the annual and quarterly reports on the DOD Comprehensive Autism Care 
Demonstration (ACD). I understand that there are some questions about 
the metrics used in the 2018 ACD annual report to Congress and the two 
most recent 2019 quarterly reports and whether those metrics are being 
appropriately applied to determine the effectiveness of health outcomes 
under the ACD program. DOD seems to acknowledge the shortcomings of the 
Pervasive Developmental Disabilities Behavior Inventory (PDDBI) in the 
reports, yet it relies on that flawed data to draw conclusions about 
the effectiveness of the ACD in these recent reports to Congress. I 
also understand that some believe that the way in which the Department 
is applying the PDDBI is also inaccurate, particularly for purposes of 
determining effectiveness of the ACD.
    Are there other measures of effectiveness that do not have the 
flaws that the Department acknowledges the PDDBI has that can be used 
for purposes of measuring the ACD? What are those other measures of 
autism treatment effectiveness? Might those measurements be used in 
future reports to Congress?
    General Place. TRICARE currently uses three instruments to measures 
outcomes in the ACD. In addition to the PDDBI, which is administered at 
baseline and every six months, the Vineland Adaptive Behavior Scales 
(Vineland) and the Social Responsiveness Scales (SRS) are administered 
at baseline and every two years. These three measures were selected 
after 18 months of consultation with ABA providers, MTF providers, 
leading researchers in the field, and other stakeholders. Specifically 
for the PDDBI, a measure aimed at accessing response to treatment, was 
recommended at the October 2017 ABA Provider Round Table by Dr. Gina 
Green, CEO of the Association for Professional Behavior Analysts and 
other leaders in the field. Based on our review of the input received, 
and research in the field, the PDDBI is an appropriate instrument to 
use as one indicator of whether beneficiaries with ASD are making 
progress. It is important to understand what we are reporting in the 
quarterly and annual reports regarding the outcome measures. DHA is 
reporting a summary of individual change scores for each beneficiary 
with two or more outcome measure data points. Meaning, that we are 
reporting that approximately 70% of children saw no meaningful change 
after 12 months of ABA services. That data point alone indicates that 
these individual children require some change to their treatment plan. 
The ``flaws'' to the reported data include information to further 
define the individual child, i.e., age, intensity of services, and 
duration of total care. Including this information may help us better 
identify those beneficiaries most likely to benefit, and future reports 
will include more data points, but it was important to start to report 
the existing data which shows that for many of the children in the ACD, 
no meaningful change across the board was occurring. As stated in each 
report to Congress, the PDDBI data alone is not being used as a stand-
alone determining factor of the effectiveness of the ACD. No policy 
decisions have been made regarding access to or discharge from the 
demonstration. Proposed manual changes aim to provide enhanced 
oversight and support for each individual child and family to ensure 
that after each authorization period (every six months), a clinical 
review is performed and treatment impact is thoroughly assessed so that 
ineffective treatment does not continue and services best serve the 
needs of the individual child.
                                 ______
                                 
                    QUESTIONS SUBMITTED BY MR. GAETZ
    Mr. Gaetz. DHS recently released a RFI on utilizing community 
pharmacies to expand access to the pharmacy benefit for TRICARE 
beneficiaries. Currently, for brand name maintenance medications 
TRICARE beneficiaries are required to use mail order or go to a MTF to 
obtain their prescriptions. If access to these brand drugs at community 
pharmacies is restored, it would help address long wait times at MTF 
pharmacies and improve access to other important health care services 
provided by pharmacists such as immunizations and health screenings. 
Can you provide an update on the progress of the RFI and a timeline for 
standing up a pilot program to test outcomes?
    Secretary McCaffery. As part of the TPharm5 acquisition strategy, 
DHA released an RFI in Aug 2019 to garner industry inputs related to a 
possible preferred network. At this time, however, DHA has not 
established an approach or timeline for implementing changes to the 
current TRICARE retail pharmacy network structure nor has there been 
any decision to conduct a pilot to test outcomes. DHA subsequently 
released a draft RFP on 2 Dec 2019, which closed out on 17 Jan 2020, to 
solicit further industry feedback that will be considered when 
finalizing the TPharm5 requirements. A focus area in the draft RFP is 
to identify innovative approaches and commercial best practices for 
Retail Pharmacy Network Access.
                                 ______
                                 
                  QUESTIONS SUBMITTED BY MR. MITCHELL
    Mr. Mitchell. The Defense Health Agency recently released a request 
for information (RFI) on utilizing community pharmacies to expand 
access to the pharmacy benefit for TRICARE beneficiaries. Currently, 
for brand name maintenance medications TRICARE beneficiaries are 
required to use mail order or go to a military treatment facility to 
obtain their prescriptions rather than a retail pharmacy. Can you 
provide an update on the progress of the RFI and a timeline for 
standing up a pilot program to test outcomes?
    Secretary McCaffery and General Place. As part of the TPharm5 
acquisition strategy, DHA released an RFI in Aug 2019 to garner 
industry inputs related to a possible preferred network. At this time, 
however, DHA has not established an approach or timeline for 
implementing changes to the current TRICARE retail pharmacy network 
structure nor has there been any decision to conduct a pilot to test 
outcomes. DHA subsequently released a draft RFP on 2 Dec 2019, which 
closed out on 17 Jan 2020, to solicit further industry feedback that 
will be considered when finalizing the TPharm5 requirements. A focus 
area in the draft RFP is to identify innovative approaches and 
commercial best practices for Retail Pharmacy Network Access.
                                 ______
                                 
                   QUESTIONS SUBMITTED BY MRS. LURIA
    Mrs. Luria. Last spring, the hospital at Langley Air Force Base was 
preparing to close their in-patient and OB/GYN services. One third of 
births in this hospital are by Active Duty women, including me. The 
inadequate outpatient OB capacity on the peninsula is a direct 
readiness issue for our service members, especially considering those 
who may execute permanent change of station orders during a pregnancy. 
Though transferring care between military treatment facilities is 
seamless, it is challenging if civilians perform their care.
    How will the transition to DHA consider the capacity, efficiency, 
and efficacy of MTF capabilities when determining which facilities to 
close under the Section 702 study?
    Secretary McCaffery. The Quadruple Aim Performance Process is DHA's 
strategic planning and resourcing process. It is one mechanism which 
provides the opportunity to assess capacity, efficiency, and efficacy 
at the facility-level. The following bullets outline this strategic 
planning process specific to capacity, efficiency, and efficacy of an 
MTF.
      MTF Directors identify and communicate capacity issues 
through their yearly performance plans and their respective mitigation 
plan to address those capacity issues. These capacity issues can be 
solved a number of ways--either through organic capacity growth, 
initiating a partnership with a VA hospital, or leveraging the civilian 
network (where allowable capacity exists).
      DHA Markets and HQ will review performance of MTFs and 
Markets through periodic performance reviews to help identify which 
MTFs and Markets are underperforming key performance measures/metrics. 
The performance reviews not only review quality and production 
indicators, but review the financial performance through the Integrated 
Resourcing (IR) process. The IR process allocates funding to MTFs based 
on their production outcomes. This helps identify where an imbalance on 
return on investment could exist. The bi-directional communication and 
review in the QPP enhances the DHA's ability in making data-driven 
decisions, based both on enterprise-level dashboard performance and the 
local challenges from the patient-care perspective on the ground.
    Mrs. Luria. Many of my constituents are noting changes in the 
medicines carried in local pharmacies, often requiring family members 
and retirees to use other sources and incur a co-pay.
    How will DHA measure and control out-of-pocket costs to these 
beneficiaries? What assistance or authorities need to you need to help 
manage these costs?
    Secretary McCaffery. The DHA is very much aware of the impact of 
copays on the beneficiary at the retail and mail order points of 
service. The copay structure of our benefit is intended to encourage 
consideration of the most clinically and cost effective agent. The DOD 
Pharmacy & Therapeutics (P&T) Committee recommends formulary status 
changes to the TRICARE Uniform Formulary on a quarterly basis. The 
Uniform Formulary is the list of all TRICARE covered drugs. These drugs 
are further categorized into three Tiers for the retail and mail order 
points of service; Tier 1 drugs (generic and preferred brand-name 
medications), Tier 2 (non-preferred generic and brand name 
medications), and Tier 3 (non-formulary medications that have 
associated step therapy and prior authorization requirements). All 
Military Treatment Facility pharmacies are required to stock a set of 
core formulary medications, but may stock additional Uniform Formulary 
items based on the local MTF requirements. For example, a small primary 
care facility will stock fewer medications than a larger facility with 
subspecialty clinics as a broader range of medications is required to 
treat that group of beneficiaries. All MTFs conduct local P&T Committee 
meetings to determine what medications should be stocked by that MTF. 
Medications are added and removed based on local requirements and some 
impacted patients can opt to switch to a medication that is stocked by 
the MTF pharmacy, or elect to take their prescription to either the 
retail or mail order point of service and pay the applicable copayment. 
Formulary status changes and contingent copay changes are constantly 
monitored and assessed by the DOD P&T Committee to provide the most 
effective drugs at the lowest copayment level possible. Across all 
points of service, 42% of pharmacy beneficiaries do not pay any 
copayments, 43% pay less than $200 per year ($17 per month), and only 
2% of all beneficiaries pay >$600 per year ($54 per month) in 
copayments. Pharmacy copayments are aggregated with medical benefit 
copayments and count against the catastrophic cap of $1,500 per 
individual or $3,000 per family per year. Once a beneficiary reaches 
the catastrophic cap, they no longer pay pharmacy copayments.
    Mrs. Luria. In my district, a personal connection between a VA 
medical center provider and a DOD medical provider allowed them to 
transfer an ailing veteran to the more-capable DOD facility to receive 
life-saving care. There are several dual-use or partnering facilities, 
like the VA host-DOD tenant construct in Pensacola, the Federal 
Healthcare Facility in Great Lakes, and the peer-to-peer co-habitation 
model in Charleston SC.
    How will DHA seek to partner with the VA to improve care, gain 
efficiency, and broaden the care available to our service members and 
their families?
    Secretary McCaffery. The DOD and VA have constantly sought 
opportunities for greater sharing of medical resources to include 
facility space, shared services, and equipment. DHA will continue this 
effort to expand upon the existing 130 sharing agreements with 472 
shared services across 148 facilities. Specifically, the DHA is 
partnering with the VA on completing Joint Market Assessments, seeking 
statutory change to allow joint facility planning, and expanding on 
efforts to support military provider readiness. The VA is currently 
collaborating with the DOD Market Visioning Studies (Strategic Market 
Assessments) to complete the VA Market Assessments as outlined by VA 
MISSION Act (2018) Sec. 106(a). The market assessments provide 
opportunities for creating high performing healthcare networks by 
evaluating market demographics, estimating demand/supply, and assessing 
quality, satisfaction, accessibility, cost, facility condition, and 
mission impact. Where there is a DOD presence in the VHA Health Care 
Market, DOD is participating in preliminary analyses, site visits, and 
market assessment interviews. DOD is also providing capacity data to 
fulfill the requirements outlined in MISSION Act (2018) 
Sec. 106(a)(1)(D), which states ``Each Market Area Assessment . . . 
shall include the following . . . (D) an assessment obtained from other 
Federal direct delivery systems of their capacity to provide health 
care to Veterans.'' The outcomes from each of the market assessments 
will drive market optimization and capital plans that align with the 
regional Veterans Integrated Service Network (VISN) and National DOD-VA 
Strategic Plans. The 96 VHA Market Assessments are scheduled for 
completion in the Fall of 2020, and will then be reviewed by DOD and VA 
leadership. Subsequently, opportunities that meet the recommendation 
criteria established by the VA Secretary (MISSION Act (2018) Sec. 203, 
Due: May 2021) will be delivered to the VA and Asset Infrastructure 
Review (AIR) Commission for consideration. The VA and DHA are currently 
establishing a deliberate process to increase VA purchased care patient 
referrals to military treatment facilities with excess capacity to 
support Graduate Medical Education and wartime skills maintenance. The 
VA and DHA are developing a timeline and basic milestones to develop 
and use a data-driven process to analyze, select, and test one or more 
sites where the goal to meet military medical provider readiness skills 
(skill level 1&2) for specific clinical specialties, is achieved 
through increased VA patient access to care inside an MTF via VA-DOD 
collaboration utilizing the healthcare resource sharing program under 
Title 38, 8111 and Title 10, 1104. The key clinical specialties the 
group agreed to look at are: General Surgery, Orthopedic Surgery, 
Cardio-Thoracic Surgery, Neurosurgery, Vascular Surgery, Emergency 
Medicine, and Ophthalmology.
    Mrs. Luria. The shift to DHA is assumed to deliver an efficiency 
within DOD by consolidating some functions from the three services into 
one agency.
    What is the size of that efficiency? How many billets have been 
reduced from the services to establish DHA, and specifically, what is 
the net change in Flag & General Officer and SES medical and medical 
service billets since FY14? What is your prediction for the future?
    Secretary McCaffery and General Place. NDAA 2017 directed the 
establishment of the DHA's role in oversight and management of MTFs and 
consolidation of HQs activities. From the FY 2017 PB which began 
implementation of NDAA 2017 to the FY 2021 PB (five budget cycles) 
there was a reduction of 833 civilian FTEs in the DHP (not transferred 
or reprogrammed elsewhere). These reductions covered multiple PEs 
across all three Services. Two of the senior positions required by the 
law, Assistant Director for Health Care Administration (AD HCA) and the 
Deputy Assistant Director for Financial Operations (DAD FO), could not 
be addressed within existing funded position and were funded as growth 
over existing senior billets. A review of future changes across the 
Military Health System, including senior level billets, is underway.
    Mrs. Luria. The shift to DHA is assumed to deliver an efficiency 
within DOD by consolidating some functions from the three services into 
one agency.
    What is the size of that efficiency? How many billets have been 
reduced from the services to establish DHA, and specifically, what is 
the net change in Flag & General Officer and SES medical and medical 
service billets since FY14? What is your prediction for the future?
    General Hogg. I will defer to the Department of Defense regarding 
specifics on the projected overall magnitude of efficiencies associated 
with establishment of the Defense Health Agency. To establish the 
Defense Health Agency Headquarters, 405 military and 79 civilian 
billets were transferred from the Air Force Medical Service. Since 2014 
there has been no reduction in the number of Air Force Medical Service 
Flag/General Officers. The Air Force Medical Service has no permanent 
authorized Senior Executive Service (SES) civilians. In the future, we 
believe the Defense Health Agency will produce savings as the 
organization matures and duplication of functions between military 
services are identified, and standardized with best practices.
    Mrs. Luria. The shift to DHA is assumed to deliver an efficiency 
within DOD by consolidating some functions from the three services into 
one agency.
    What is the size of that efficiency? How many billets have been 
reduced from the services to establish DHA, and specifically, what is 
the net change in Flag & General Officer and SES medical and medical 
service billets since FY14? What is your prediction for the future?
    General Dingle. The shift to DHA is assumed to deliver an 
efficiency within DOD by consolidating some functions from the three 
services into one agency.
    What is the size of that efficiency? Defer this response to the 
Defense Health Agency (DHA) and Health Affairs (HA).
    How many billets have been reduced from the services to establish 
DHA? We have divested and transferred 543 billets from medical HQs and 
regions to the DHA in FY19. These billets provided functions and 
capabilities for administering and managing MTFs.
    Specifically, what is the net change in Flag & General Officer and 
SES medical and medical service billets since FY14? There has been a 
net gain of one (1) FO/GO from FY14 to FY20. In FY14 we had 15 FO/GOs 
and as of FY20 we have 16, the increase accounts for selection of the 
Director, DHA. There has been a net loss of four (4) SESs from FY14 to 
FY20. In FY14 we had five (5) SESs and as of FY20 have one (1) SES on 
hand.
    What is your prediction for the future? The Army is committed to 
supporting the current MTF transition plan but predicts challenges will 
become apparent from the merger of the multiple service health care 
systems. The transition is one of the most complex and difficult ever 
undertaken in healthcare delivery, requiring a detailed transition plan 
to ensure this critical mission is handed off to DHA successfully 
without mission degradation.
    Mrs. Luria. Medical readiness is a fleet commander imperative.
    How will the shift to DHA change your ability to provide medically 
ready individuals and service members to the fleet commanders?
    What impediments do you see to improving on your current 
capabilities and capacities to prepare sailors for their missions?
    Admiral Gillingham. MHS transformation has provided Navy Medicine 
an unmatched opportunity to refocus on our true mission of readiness--
ensuring Sailors and Marines are medically ready to meet their 
demanding responsibilities in the Fleet and Fleet Marine Force; and, 
providing a ready One Navy Medicine force that is trained to achieve 
maximum life-saving capabilities and survivability along the continuum 
of care. With the shift you refer to, the military medical treatment 
facilities (MTFs) are now under the authority, direction and control of 
the DHA. These facilities, however, remain important training platforms 
for Navy Medicine personnel to gain and maintain clinical experience. 
MTFs, along with other partnerships that enhance wartime critical 
skills, are necessary to maintain the readiness of our assigned medical 
forces and execute Service requirements and programs. Associated with 
the transition, I do not anticipate significant impediments associated 
with our work ahead in meeting operational requirements. I do, however, 
recognize that an organizational change of this scale is inherently 
complex. All of us know we have shared responsibilities to ensure that 
both the Services and the DHA are successful and we will continue to 
work together to meet our goal of an integrated system of readiness and 
health. I want to assure you that within Navy Medicine, we will 
continue to chart a course that focuses on providing well-trained 
medical experts, operating as high performance teams to project medical 
power in support of Naval superiority.
    Mrs. Luria. The shift to DHA is assumed to deliver an efficiency 
within DOD by consolidating some functions from the three services into 
one agency.
    What is the size of that efficiency? How many billets have been 
reduced from the services to establish DHA, and specifically, what is 
the net change in Flag & General Officer and SES medical and medical 
service billets since FY14? What is your prediction for the future?
    Admiral Gillingham. I will defer to the Department of Defense 
regarding specifics on the projected overall magnitude of efficiencies 
associated with establishment of the Defense Health Agency and the 
substantive reforms directed in the FY2017 and FY2019 National Defense 
Authorizations. Collectively, this legislation represents an important 
inflection point for military medicine and catalyzed our efforts to 
strengthen our integrated system of health and readiness. Within the 
Department of the Navy, our leadership--the Secretary of the Navy, 
Chief of Naval Operations and Commandant of the Marine Corps--
recognizes the tremendous opportunity we have to refocus our efforts on 
medical readiness while transitioning health care benefit 
administration to the Defense Health Agency (DHA). Within Navy 
Medicine, we have made important organizational changes including 
establishing of Navy Medicine Readiness and Training Commands (no 
personnel growth) and restructuring our Bureau of Medicine and Surgery 
headquarters as well as our regional commands. With the DHA assuming 
authority, direction and control of military treatment facilities, Navy 
Medicine headquarters and our echelon III commands will be smaller by 
approximately 43 percent and focused exclusively on readiness 
responsibilities. We are in the process of transitioning 56 military 
and 269 Navy civilians positions to the DHA, In addition, we anticipate 
approximately 8,000 civilian personnel at Navy MTFs will be reassigned 
as DOD employees. Presently, there are fewer Navy Medicine flag 
officers (both active and reserve components) than in FY2014. These 
reductions are not the result of the DHA transition.
    Mrs. Luria. The shift to DHA is assumed to deliver an efficiency 
within DOD by consolidating some functions from the three services into 
one agency.
    What is the size of that efficiency? How many billets have been 
reduced from the services to establish DHA, and specifically, what is 
the net change in Flag & General Officer and SES medical and medical 
service billets since FY14? What is your prediction for the future?
    General Friedrichs. I defer to the DHA and the services to provide 
the appropriate response.

                                  [all]