[Senate Hearing 117-]
[From the U.S. Government Publishing Office]


 
       DEPARTMENT OF DEFENSE APPROPRIATIONS FOR FISCAL YEAR 2022

                              ----------                              


                        TUESDAY, APRIL 20, 2021

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 9:31 a.m. in room SD-192, Dirksen 
Office Building, Hon. Jon Tester (chairman) presiding.
    Present: Senators Tester, Baldwin, Shelby, and Boozman

                         DEPARTMENT OF DEFENSE

                         Defense Health Program

STATEMENT OF DR. TERRY ADIRIM, ACTING ASSISTANT 
            SECRETARY OF DEFENSE FOR HEALTH AFFAIRS


                opening statement of senator jon tester


    Senator Tester. I am going to call this committee meeting 
to order. I want to welcome Dr. Adirim, General Dingle, General 
Hogg, Admiral Gillingham for your testimony here today and 
especially for your service to this country. Thank you all.
    Nearly 9.5 million Americans from private to general, from 
servicemember to spouse, from recruit to retiree depend on you 
for healthcare services that you oversee. Your job is a 
difficult one because so many people are depending on you to 
have the right medical professionals, and the right treatment 
at the right time because their lives count on it.
    Over the last few years, the Department of Defense and 
Congress have made significant investments in our military's 
readiness, but there is no readiness issue more important than 
continuing to ensure the physical and mental health of the 
force.
    Like our witnesses, this subcommittee is committed to doing 
our part to ensure that the military force we have is as 
healthy as possible. This means meeting the medical needs of 
servicemembers and their families at home and abroad.
    This challenge is even more important as we are dealing 
with a global pandemic. I would like to know more about how the 
DOD is dealing with COVID, both in the terms of impact to 
troops and their families and whether the military healthcare 
system is adequately funded for this emergency.
    Once again, I want to thank you for your service and for 
your work to better the lives of our personnel entrusted to 
your care. It is an essential part of maintaining a ready 
force, and I look forward to your testimony.
    Senator Shelby.


                 statement of senator richard c. shelby


    Senator Shelby. Thank you, Mr. Chairman. Thank you for 
holding this hearing.
    I want to, like you, welcome our witnesses today, and I 
want to thank them for being here today to review the Defense 
Health Program.
    The pandemic has tested our military and its health system 
profoundly, and I would like to applaud the Defense Health 
Program's work and achievements during this extremely trying 
time.
    Our warfighters, I believe, are our greatest defense asset, 
and their readiness and capabilities depend on a strong and 
sustainable military healthcare system. Our military's health 
system is responsible for providing care to 9.5 million 
servicemembers and their beneficiaries who deserve the best 
quality of care that we can provide.
    In order to guarantee that standard, Mr. Chairman, we must 
ensure that the system is appropriately resourced, something 
this committee has prioritized. The military health system has 
undergone substantial transformation over the last several 
years, and I look forward to hearing about the challenges each 
of you have faced in this transition and how you have worked 
together to overcome them.
    In addition to providing healthcare, our military's health 
system also conducts medical research on a wide variety of 
topics such as cancer, infectious diseases, traumatic brain 
injury, and burn research, just to name a few. Funding for 
these important research efforts has grown from $210 million in 
1992 to nearly $1.5 billion last year. That is a substantial 
investment and I believe one that does not take into account 
the billions of dollars that we also provide annually to the 
National Institutes of Health to conduct research in many of 
the same areas.
    What is more, the President's budget request proposes to 
create the Advanced Research Projects Agency for Health at NIH 
(National Institutes of Health). This new $6.5 billion 
federally funded research agency will focus on cancer research 
and other diseases such as diabetes and Alzheimer's. With all 
this seeming duplication of research dollars, I question at 
times whether DOD's (Department of Defense) medical research 
investments are truly focused on addressing our warfighters' 
health and readiness concerns or simply investing in scarce 
defense resources and medical research that is also underway at 
NIH.
    So, while we can all agree that this research is necessary, 
I hope our witnesses can provide a clear explanation regarding 
defense medical research dollars, what they are doing that NIH 
funding cannot or is not doing. In other words, is there 
duplication here, and if so, how do we get away from it?
    Thank you for holding this hearing, Mr. Chairman.
    Senator Tester. Thank you, Senator Shelby.
    Now we will go to opening statements. I would ask that each 
of you limit your opening statement to 5 minutes each. Your 
entire written statement will be put in the record, and we will 
start with you, Dr. Adirim. You have the floor.


                 summary statement of dr. terry adirim


    Dr. Adirim. Good morning. Chairman Tester, Vice Chairman 
Shelby, distinguished members of the subcommittee, I am honored 
to represent the military and civilian medical professionals in 
the Military Health System who are serving around the world and 
here at home, delivering healthcare in support of our 9.6 
million beneficiaries as well as support to millions of 
Americans throughout the United States.
    My testimony will provide the subcommittee with information 
on major activities that will inform our budget proposal for 
the coming fiscal year. The most significant issue looming over 
all of our projections is the national response to the COVID-19 
pandemic.
    Secretary Austin has made clear that the greatest proximate 
challenge to our Nation's security is the threat of COVID-19. 
The Department has, and will continue to, act boldly and 
quickly to support Federal Government efforts to defeat this 
disease.
    My written testimony provides a comprehensive review of the 
critical health support the Military Health System is providing 
worldwide in support of our primary mission and as part of the 
whole-of-government response to the COVID crisis.
    We remain deeply appreciative of the fiscal year 2020 
supplemental appropriation of $2.2 billion as part of the CARES 
Act that covered the significant costs incurred during the 
initial months of the response.
    In fiscal year 2021, however, costs attributable to the 
pandemic continue to accumulate. As of March 31, 2021, our 
midyear review of the Defense Health Program identified likely 
shortfalls as part of the ongoing pandemic response projected 
at over $1.8 billion, $1 billion of which is private-sector 
costs.
    In addition, the financial impact of our military support 
to the FEMA (Federal Emergency Management Agency) missions, 
which remains ongoing, are still being assessed. We are working 
within the Department to try and mitigate these shortfalls that 
are challenging.
    The Department continues to focus on internal business 
process improvements to find greater efficiencies and remains 
vigilant about variation in year-to-year expenditures. We are 
appreciative that Congress continues to grant the Department 
carryover authority each year. We are also grateful for this 
committee's long-term advocacy and support for our military 
medical research program. Military medical research advances 
the state of medical science in those areas of most pressing 
need and relevance to today's emerging threats, which includes 
the COVID pandemic.
    When released, our fiscal year 2022 budget will present a 
balanced, comprehensive strategy that aligns with the 
Secretary's priorities to include the ongoing response to the 
pandemic. We look forward to working with you over the coming 
months to further refine and articulate our objectives in a 
manner that improves value for everyone: our warfighters, our 
combatant commanders, our patients, our medical force, and the 
American taxpayer.
    Thank you for inviting me here today to speak with you 
about military medicine, our response to the global pandemic, 
the essential integration between readiness and health, and 
about our plans to further improve our health system in support 
of the National Defense Strategy on behalf of our uniform 
servicemembers and the families we serve.
    Thank you.
    [The statement follows:]
          Prepared Statement of Dr. Terry Adirim, MD, MPH, MBA
    Chairman Tester, Vice Chairman Shelby, distinguished Members of the 
Subcommittee, I am pleased to represent the Office of the Secretary of 
Defense to discuss the Defense Health Program (DHP) and its 
contributions to the health affairs of the Department. I am honored to 
represent the dedicated military and civilian medical professionals in 
the Military Health System (MHS), which provides direct support to our 
combatant commanders and delivers health care for our 9.6 million 
beneficiaries.
    This hearing is occurring in advance of the formal release of the 
President's FY22 full budget. My testimony will provide the 
Subcommittee with information on major activities that will inform our 
budget proposal for FY22 as well as issues affecting FY21 execution. 
The most significant issue, looming over all of our projections, is the 
national response to the COVID-19 pandemic. Our national success in 
reducing the spread of the virus, and vaccinating our population, will 
affect every aspect of our health care costs. For that reason, my 
testimony will begin with the current state of the DoD response to 
COVID-19.
                           covid-19 response
    The past fourteen months have represented a unique and challenging 
period for our Nation as we've confronted and responded to the COVID-19 
pandemic. In line with the President's priorities, Secretary Austin has 
made clear that the greatest proximate challenge to our Nation's 
security is the threat of COVID-19. The Department has, and will 
continue to, act boldly and quickly to support Federal government 
efforts to defeat this disease. The MHS is providing critical health 
support worldwide to our military forces, supporting other Federal and 
state entities as part of a whole-of-government response to this 
crisis, and continuing to meet other strategic, global mission 
requirements, while sustaining high quality health services to our 
military Service members and their families.
    Beginning with the declaration of a global pandemic in March 2020, 
the MHS provided essential crisis response services in support of 
military leaders and civilian demands. Though this summary is not all-
inclusive, I will briefly mention several critical initiatives that 
contributed to the national response and also generated additional 
expenditures for the Department.
    Surveillance and Laboratory Testing. Soon after the pandemic began, 
the Secretary of Defense established the DoD Coronavirus Task Force 
that included a Diagnostics and Testing Line of Effort. The Department 
grew its laboratory testing capacity from 16 operational laboratories 
in late March 2020 to 189 operational laboratories by March 2021, and 
increased on-hand SARS-COV-2 tests from approximately 200,000 to over 
1.8 million. To date, the Department has conducted well over 3 million 
tests and has tests on-hand to conduct more than 100K tests per week. 
Testing is a key public health intervention that has helped to limit 
the spread of SARS-COV-2 within the military. Coupled with other public 
health measures like social distancing and masking, military 
installations have consistently lower positivity rates than their 
surrounding communities.
    Even as vaccination efforts continue to increase, testing will 
remain a key pillar of our public health strategy to battle this 
disease and maintain a ready force. Screening through antigen and PCR 
testing using a variety of testing strategies in a post-vaccination 
environment will continue as part of the Department's COVID-19 risk 
mitigation strategy to drive cases down toward zero. The Department is 
also committed to whole genome sequencing and identification of 
variants of concern and interest and to understanding their prevalence 
among our Service members and other beneficiaries. The Department has 
already committed the resources and funding to more than double the 
number of specimens the Department can sequence and analyze each week.
    Clinical Support for Treatment and Therapeutics. Early in the COVID 
response, the Defense Health Agency (DHA) developed and released the 
first DoD COVID-19 Practice Management Guide (PMG) to provide 
clinicians and Military Treatment Facilities (MTFs)--our military 
clinics and hospitals--with a single document on best practices 
informed by the latest evidence, and guidance across all clinical care 
specialties. The PMG has been continually updated and rereleased, with 
the most recent version (Version 7) published in March 2021. The DHA 
also established a Joint Registry for COVID-19. Using the Joint Trauma 
Registry as a foundation for this effort, the COVID Registry collects 
and assesses clinical information on COVID patients, in order to inform 
our military medical community on the rapidly evolving science behind 
this disease. In April 2020, DHA also put forth the Health Protection 
Condition (HPCON) Guidance in a COVID-19 Environment, which contained 
CDC informed guidance to support MTFs in healthcare delivery in 
response to COVID-19, based on the locally-determined risk level.
    In June 2020, DHA began an effort to collect donated units of 
plasma from patients who had fully recovered from COVID-19 to support 
development of an effective treatment against the disease. Again, the 
DHA relied on the COVID-19 registry to identify potential donors, as 
well as capture the use of, and outcomes from, convalescent plasma on 
hospitalized COVID patients. In August 2020, after receiving Emergency 
Use Authorization (EUA) from FDA, COVID-19 convalescent plasma was made 
available to MTFs for investigational treatment of COVID-positive 
patients who met established criteria in accordance with approved 
protocols.
    The MHS worked closely to implement other, FDA-approved treatments 
for COVID. In September 2020, shortly after Veklury (remdesivir; first 
FDA-approved treatment for COVID- 19) received an expanded EUA, the 
medication was rapidly pre-positioned throughout DoD to ensure 
availability to hospitalized patients with suspected or laboratory-
confirmed COVID-19, irrespective of their severity of disease. 
Similarly, in November 2020, after receiving an EUA from FDA for COVID-
19 monoclonal antibody treatment, DHA developed and disseminated 
specialized guidance to assist MTFs and healthcare providers regarding 
patient care considerations when administering this treatment for mild 
and moderate cases.
    Individual Medical Readiness. COVID-19 did affect medical readiness 
within the military. The Department uses a concept called Individual 
Medical Readiness (IMR) to measure medical readiness, which consists of 
six elements. These are Dental Readiness, Immunizations, Medical 
Readiness Labs, Deployment-Limiting Medical Condition (DLMC) Status, 
Periodic Health Assessment (PHA), and Individual Medical Equipment. In 
2015, the DoD Total Force Medically Ready (TFMR) goal was set at 85%. 
Since 2015, the Total Force has consistently met or exceeded the 85% 
goal. With COVID-19 pandemic beginning in the 2nd quarter of 2020, TFMR 
decreased below the Department's 85% goal. As of the 4th Quarter of 
Calendar Year 2020, TFMR compliance was 82.2%; Active Component IMR 
compliance was 82.4% and Reserve Component IMR compliance was 81.7%.
    The COVID-19 pandemic most affected Dental Readiness and 
Immunizations. These IMR requirements can only be completed via in-
person clinic visits. Of note, throughout the pandemic, medical 
readiness for deploying Service Members was prioritized and all 
personnel are required to be fully medically ready prior to deployment. 
Capabilities such as virtual and telephonic medical appointments 
allowed MTFs to continue to provide access to medical readiness support 
services. We expect IMR rates to quickly recover and return to pre-
COVID levels as our vaccination campaign proceeds through spring and 
summer 2021.
    Healthcare Delivery and Deferred Medical Care. In both the direct 
care system and the TRICARE network, the Department has worked to 
ensure beneficiaries receive medically necessary and readiness-related 
care throughout the pandemic and we are currently working to address 
delayed or deferred care. In addition to guidance for MTFs on standard 
processes to provide medically necessary care that could not be 
delayed, the Department significantly expanded the use of Virtual 
Health (VH) to meet beneficiary demand while minimizing unnecessary 
risks for patients and staff.
    MTFs and Markets are increasing the number of available 
appointments to meet patient demand for care and schedule previously 
delayed care. Despite additional workload associated with COVID-related 
deployments and vaccinations, MTF appointment availability is 
approaching pre-pandemic levels and access to appointments for routine 
and follow-up care averages 4.8 days, which is better than the standard 
of 7.0 days or fewer. Likewise, specialty referrals are up from spring 
2020 levels and are approaching pre-pandemic rates. While direct care 
performance on cancer and other preventive screening is lagging 
compared to strong pre-pandemic performance, MTF staff members are 
actively reaching out to beneficiaries to encourage and facilitate 
screening appointments.
    For network care, DHA worked with the managed care support 
contractors to develop strategies to ensure our beneficiaries' ability 
to access care in the network, ensured resources were monitored to 
confirm provider availability, expanded availability of VH and eased 
beneficiary access to providers by extending referral and authorization 
limits and adjusting rules impacting beneficiary cost shares.
    Public Health Planning. The COVID-19 pandemic has highlighted the 
importance of integrated DoD and interagency public health planning, 
which includes conducting realistic exercises with federal, state and 
local public health partners. However, the MHS pivoted quickly and 
effectively in responding to the pandemic across a wide range of 
requirements, both internal to DoD and across the public health 
universe. In the process, we learned lessons and developed associated 
recommendations that can have an immediate and sustained impact on the 
ability of the MHS to support the ongoing pandemic and to prepare for 
future major public health emergencies. Chief among these actions is 
developing even tighter integrated coordination with interagency 
partners such as the National Institute of Health, the Centers for 
Disease Control and Prevention, the Federal Emergency Management Agency 
and other organizations regarding global medical surveillance of cases 
and variants of concern. As a primary partner in the interagency 
scientific community, DoD shares genetic sequencing, seroprevalence 
information and other relevant surveillance data with interagency 
partners.
    Medical Education & Training. The collaborative leadership efforts 
of the Medical Enlisted Training Campus and the Services resulted in 
minimal disruptions in training by maximizing the interoperability and 
capabilities of alternative learning modalities and technology 
adoption. The MHS kept graduation rates on target, and the end-strength 
of enlisted medical career fields healthy and ready to support 
Combatant Commanders. Additionally, the MHS expanded support for 
continuing education credits (CE) for 16 healthcare specialties and 
awarded over 90 thousand continuing education/medical credits. 
Continuing education credits are required for health professional 
licensure and certifications. The Defense Medical Modeling and 
Simulation Office recognized an opportunity to provide immediate 
support in meeting COVID-19 related simulation training gaps/needs of 
the transitioned Markets and associated Military Medical Treatment 
Facilities.
    COVID-19 Vaccine and Immunization Implementation. Since December 
2020, the Department introduced a global immunization campaign to 
deliver expanding supplies of vaccines approved for use under an EUA. 
In December 2020, DHA issued a DHA Interim Procedures Memorandum to 
implement instructions, assign responsibilities, and prescribe 
procedures for the COVID-19 Vaccination Program. DHA continues to issue 
updates on the coordinated strategy for prioritizing, distributing, and 
administering the COVID-19 vaccine, with the most recent DoD 
Vaccination Plan modification (MOD-12) released in April 2021.
    As of April 16, 2021, the Department had administered over 2.5 
million doses of the three vaccines authorized by the FDA under an EUA. 
However, on April 14th, DoD implemented the CDC and FDA recommendation 
to pause administration of the Johnson & Johnson vaccine until federal 
health experts conclude their review of the rare, severe adverse events 
that have occurred in a small number of individuals. Although DoD was 
distributing all of its Johnson & Johnson vaccine to overseas 
locations, the Moderna vaccine still represented the majority of our 
overseas allocation. If this pause extends beyond several weeks, DoD 
will consider adjusting its current allocations to accommodate our 
overseas requirements.
    Adapted from the CDC tiered framework for prioritizing individuals 
for vaccination, the DoD population schema includes persons in critical 
national security positions and deploying forces in the Tier 1 
priorities. Vaccinations are being administered at 350 DoD sites around 
the world, in addition to access to civilian sources for our 
beneficiaries. On April 19, 2021, the Department fully opened vaccine 
appointments to all eligible individuals, consistent with the 
President's direction to all jurisdictions.
    The vaccine remains voluntary for all eligible persons to include 
active duty Service members. The Department has implemented a 
comprehensive outreach and communications effort to encourage all 
eligible persons seek out these highly safe and effective vaccines. We 
are encouraged by the trends in vaccine acceptance, and are confident 
that all individuals over the age of 15 who want the vaccine will be 
fully vaccinated by mid-Summer.
    Defense Support to Civilian Authorities. In addition to the 
comprehensive response in support of the military mission, the Defense 
Department has provided significant expertise, logistics support, and 
personnel to civilian communities. Early in the pandemic, the DHA 
coordinated the delivery of critical inventory from existing strategic 
reserves to the Department of Health and Human Services for 
redistribution to civilian communities. This support included delivery 
of five million N-95 masks and over two thousand ventilators. The US 
Navy deployed the USNS Comfort and USNS Mercy to civilian ports on the 
east and west coasts to provide hospital bed surge capacity for cities 
in crisis. Throughout 2020, Army, Navy and Air Force personnel deployed 
as units to civilian hospitals around the country to augment local 
staff. Military medical personnel took on key positions with Operation 
Warp Speed, and infectious disease experts and medical researchers from 
DoD medical research and development offices collaborated closely with 
the broader American medical research community.
    COVID-19 After Action Review (AAR). The MHS is a learning 
organization, and we are committed to continuously improving our 
performance--whether in battlefield medicine, health care quality and 
safety, or our COVID response efforts. Consistent with the FY21 NDAA, 
Section 731, the MHS established a rigorous AAR process, led by the 
Uniformed Services University of the Health Sciences. This AAR builds 
on the MHS interim AAR process and report established by the ASD(HA) in 
May 2020 and completed in January 2021. The Department will submit a 
substantive, interim report to Congress under Section 731 by 1 June, 
and submit a final report by the close of 2021.
    Effects on the FY21 Budget. We remain deeply appreciative of the 
FY20 supplemental appropriation of $2.2 billion, as part of the CARES 
Act, that covered the significant costs incurred during our initial 
response.
    In FY21, however, costs attributable to the pandemic response 
continue to accumulate. As of March 31, 2021, our mid-year review of 
the Defense Health Program (DHP) identified likely shortfalls as part 
of the ongoing pandemic response, which we are working with the 
Department to resolve. In addition, the financial impact of our 
military support to the Federal Emergency Management Agency (FEMA) 
missions, which remain ongoing, continue to be assessed. The most 
significant cost drivers include higher than projected Private Sector 
Care costs; additional laboratory testing; personal protective 
equipment (PPE) expenditures; and numerous other requirements from 
public health surveillance to antiseptic cleaning of medical 
facilities.
    While there are opportunities to realign funds to meet the 
operational imperative of the pandemic response, actions will still 
create additional risk and financial liability at a later date.
                       mhs reforms and transition
    The FY 2017 National Defense Authorization Act (NDAA) enacted 
sweeping reforms to the organization and management of military 
medicine. The over-arching direction from Congress was to centralize 
and standardize many military health care functions in a way that 
better integrates readiness and health delivery throughout the 
Department. Included among these reforms: the expanded authority and 
responsibility of the DHA to manage MTFs worldwide; and the authority 
to adjust medical infrastructure in the MHS to maintain readiness and 
core competencies of health care providers.
    Following a strategic pause in transition activities due to the 
initial COVID-19 pandemic response, which was directed and then lifted 
by the Secretary of Defense in April and November 2020 respectively, 
the MHS has continued executing the transition of Military Medical 
Treatment Facilities (MTF) to DHA management in accordance with the 
Department's approved, conditions-based execution plan that meets the 
intent of Section 702 of the FY17 NDAA.
    In the coming weeks, we expect to certify all Wave 1 Market Offices 
(i.e, San Antonio, Tidewater, Colorado, Puget Sound, and Hawaii). These 
critical markets account for 34 percent of the MHS' dispositions, 48 
percent of the MHS's direct care expenditures, and 11 percent of the 
MHS's purchased care expenditures--providing tremendous opportunities 
for continued standardization and optimization. Wave 2 Market 
Establishment planning is underway, and we plan to institute an 
intermediate headquarters to manage the remainder of our small 
hospitals and clinics in early June. There are still outstanding 
personnel transfer issues to resolve, however, that place at risk our 
ability to complete this transition by the congressionally established 
deadline of September 30, 2021.
    Section 703 of the FY2016 NDAA directed the Secretary of Defense to 
submit to the congressional defense committees an implementation plan 
to restructure or realign military medical treatment facilities. This 
report was transmitted to Congress on February 19, 2020. The report 
articulated the DoD's decisions to align MTFs to increase the readiness 
of our operational and medical forces and achieve a proper balance 
between meeting readiness requirements and managing the total cost of 
health care in the direct and purchased care systems.
    All restructuring efforts were paused on April 2, 2020 as a result 
of the resources required to respond to the COVID-19 pandemic. The 
Department is revalidating the assumptions made regarding its readiness 
requirements prior to the pandemic, as well as the assessment of 
network capacity to absorb additional patients where we intend to 
proceed with right-sizing plans. The DHA will take a conditions-based 
approach to any transition of medical services. In other words, 
transition will only occur when we are certain that local TRICARE 
networks can provide timely and quality access to health care. If they 
cannot, we will revise our plans.
                       mhs genesis implementation
    The Department continues to proceed with the multi-year 
implementation of its new, Electronic Health Record (EHR), MHS GENESIS. 
Although we paused a number of specific, in-person activities during 
the COVID-19 response, we still delivered the two Waves scheduled for 
completion in 2020, two currently in 2021, and remain on schedule for 
enterprise completion in 2023. As of today, MHS GENESIS supports the 
delivery of safe, high-quality data to patients and providers across 20 
MTFs.
    The value of MHS GENESIS has become even more apparent during the 
COVID-19 response. We were able to implement COVID-specific 
configuration changes in MHS GENESIS within hours on several occasions 
that provided senior military and civilian leaders with timely 
information on COVID laboratory testing results and the health of our 
force and our beneficiaries; the same changes in our legacy systems 
took nearly four weeks to implement.
    MHS GENESIS' mass vaccination capabilities have produced a 
significant improved workflow that allows the Military Departments to 
assess the status of service member inoculations in order to ensure 
readiness. For example, medical personnel at Twentynine Palms, 
California successfully screened 700 active duty Marine records within 
days of going live with MHS GENESIS in September. The process was so 
successful that Cerner made the solution part of its baseline product 
for commercial use.
    DoD and VA continue to closely collaborate on a fully integrated 
EHR with the oversight of the Federal Electronic Health Record 
Modernization (FEHRM) office. The Departments collaborated with the 
FEHRM to launch the joint health information exchange (joint HIE) in 
April 2020, creating a single common gateway through which DOD and VA 
providers can send data to and retrieve data from participating private 
sector partners. With the FEHRM's leadership, the Departments support a 
Federal Enclave providing a single, common record with high 
cybersecurity standards, joint configuration boards to ensure 
standardized workflows, and shared risks, schedules and lessons 
learned.
                 tricare 5th generation contracts (t-5)
    The Department continues to manage the TRICARE Program in a manner 
that seeks to reduce the growth in health care costs while ensuring our 
health benefit remains an exceptional tool for recruitment and 
retention of military personnel and their families. Among the most 
important strategies we pursue is the development of effective TRICARE 
contracts that deliver high-value, patient-centric care designed to 
seamlessly integrate military and private sector care in support of 
readiness and health outcomes.
    The T-5 contracts represent the next generation of contracts that 
provide DHA with the flexibility to adjust network requirements, 
improve professional services support, and adapt care delivery models 
in support of evolving mission requirements and changes in American 
health care delivery. After an extensive, multi-year engagement with 
Department leaders, industry, and other stakeholders, as well as three 
draft Requests for Proposal (RFPs) shared with industry, the Department 
issued the T-5 RFP on April 9, 2021. The goals of this procurement 
support (1) military medical readiness and the readiness of the medical 
force; (2) beneficiary choice; (3) high value care; and the adoption of 
Industry Business Standards.
    The Department looks forward to healthy competition from industry 
and the inclusion of new health care delivery models in the coming 
proposals. As part of the T-5 process, the Department will conduct 
``Competitive Demonstrations'' during the contract's period of 
performance. Twenty-one potential markets are identified in geographic 
areas where MTFs may rightsize, downsize or where DHA provides TRICARE 
Prime but no MTF exists. The RFP also specifies three innovations: 
Virtual Value Networks, Advanced Primary Care, and Care Collaboration 
Tools that will start with T-5 initiation and up to seven other 
demonstrations are planned during the life of the contract. DHA 
anticipates receipt of offeror proposals no later than August 13, 2021. 
The new contracts are planned to begin health care delivery in Calendar 
Year 2024.
                    medical research and development
    The Department is grateful for the long-term advocacy and support 
for its military medical research program. The DHP research, 
development, test, and evaluation (RDT&E) focus is to advance the state 
of medical science in those areas of most pressing need and relevance 
to today's emerging threats, which includes the COVID-19 pandemic.
    We seek to discover and explore innovative approaches to protect 
and support the readiness, health, and welfare of military personnel; 
to accelerate the transition of medical technologies to development and 
acquisition; and to accelerate the translation of advances in knowledge 
into new standards of care and treatment that can be applied in the 
field or in military medical treatment facilities.
    In the coming years, we hope to leverage new technologies to 
include artificial intelligence and machine learning, biotechnology, 
and autonomous systems. The goal is to accelerate the transition of 
medical technologies to development and acquisition programs, and to 
further the translation of new standards of care to support and 
treatment that can be applied in the field or in military medical 
treatment facilities. We will seek to mitigate deployment-limiting 
medical conditions for service members by focusing on injury prevention 
and rehabilitation.
    The MHS continue to employ and strengthen our enterprise-wide 
performance management systems that provide stakeholders--both medical 
and line leadership--at all levels of the military with visibility into 
how we are performing on key metrics. These dashboards show 
longitudinal performance in measures of readiness, health, access, 
quality, safety and cost. We monitor critical indicators of quality and 
safety--that point us toward high reliability as a system of care. 
Access to primary care and specialty care are measured along with 
patient satisfaction to ensure we are meeting patient expectations. We 
have provided Department leadership, MTF commanders and staff with 
visibility into COVID-19 specific measures that include, but are not 
limited to operational hospital bed capacity and surge capabilities, 
timely laboratory test results, PPE inventories, COVID-19 vaccine 
target population and vaccine administration data, as well as important 
private sector care data.
    Our dashboards can be viewed at an enterprise level, by Service, by 
market, and by individual hospital or clinic. We will continue to adapt 
this management system as the MTF transition progresses. Commanders can 
assess their performance against expected benchmarks, against peer 
institutions, and--where possible--against civilian sector performance 
as well. These dashboards help us to both assess how we are doing in 
these areas, and where we need to invest resources, training, or 
management attention in order to achieve further improvement.
                  other significant health initiatives
    There are several other health initiatives that merit comment--
chief among these is access to timely, high quality mental health 
services and related activities to reduce the incidence of suicide 
among our service members, their families, and all beneficiaries. The 
Department is committed to the health, welfare and safety of our 
service members and families and we have undertaken a broad-based 
campaign encouraging service members to seek mental health treatment 
when signs or symptoms occur, help service members and their families 
to identify those signs and symptoms, and to de-stigmatize mental 
health care overall.
    The DoD has invested in a number of programs to increase access to 
mental health care for Service members who are experiencing symptoms of 
a psychological health condition. Service members are eligible to 
receive free, comprehensive behavioral health care (including clinical 
assessment, psychotherapy, and psychiatric treatment) at their local 
military medical treatment facilities. We also have programs that embed 
psychological health providers in operational units to assist Service 
members in their everyday work environments. The primary care medical 
homes provide follow-up when Service members disclose psychological 
health concerns to their primary care provider. Military OneSource is 
our 24/7 resource to connect Service members to information about their 
psychological health, non-medical counseling for stress management, and 
referrals to healthcare providers.
    We have witnessed significant improvements in destigmatization and 
increased use of behavioral health services. Nonetheless, suicide rates 
remain unacceptably high. Suicide is a very complex issue with many 
biological, social, and psychological factors that contribute to 
suicide. In recognition of this complexity, the DoD implements a 
comprehensive public health approach to suicide prevention and 
intervention. The DoD is focused on using every available resource to 
support our Service members.
    For example Service members are screened for symptoms of 
psychological health conditions throughout their service. All Service 
members who are deployed in connection with a contingency operation 
receive a series of deployment health screenings designed to identify 
psychological health concerns, including posttraumatic stress disorder 
(PTSD) that may require referral for additional care and treatment. 
Additionally, all Service members, regardless of deployment status, 
receive a mental health assessment upon separation from military 
service to ensure documentation of any psychological health conditions 
and arrange for appropriate follow-up.
    Currently the DoD and VA are working together in the development of 
a single Separation Health Assessment that will include a Mental Health 
Assessment. This effort will make the separation process more efficient 
and improve the mental health care of our Service members. Clinical 
Practice Guidelines have been formulated for all major clinical 
conditions in mental health, and Joint VA/DoD Clinical Practice 
Guidelines (CPGs) for mental health care facilitate delivery of 
evidence-based mental health care practices and strengthen the ability 
to maintain mental health readiness.
    Beyond individual approaches, the public health approach also 
includes broader efforts, such as those targeted for our populations of 
greatest concern (young and enlisted Service members) and developing 
initiatives to support military families. For example, current efforts 
include interactive educational pilot programs to teach foundational 
skills to effectively deal with life stressors and to address help-
seeking concerns and encourage use of support resources.
    The Department continues to promote initiatives that increase 
awareness of risk factors for suicide, safe storage of lethal means 
(e.g., firearms and medications), and communicate how to intervene in a 
crisis. For example, DoD trained more than 2,000 non-medical military 
providers to provide Counseling on Access to Lethal Means (CALM) to 
Service members and families to increase awareness of risk factors for 
suicide, safe storage of lethal means (e.g., firearms, medications, and 
other lethal means), and how to intervene in a crisis. DoD is expanding 
on this pilot program for other influencers, such as spouses.
                          overall fy22 budget
    The soon-to-be released budget will prioritize our resource 
requirements to address the COVID-19 pandemic and also address health 
care delivery challenges caused by the pandemic.
    The Defense Health Program funding level that will be proposed by 
the Department in the FY 2022 President's Budget re-baselines health 
care program resources based on FY 2020 execution prior to the onset of 
COVID. Some residual risks remain, such as the COVID-related effects of 
previously delayed care that may return, potentially deleterious 
impacts on beneficiaries' health due to delaying or forgoing care, 
unrecognized impacts of COVID-19 among asymptomatic or long-term, 
persistent disease, and the inherent uncertainty in predicting 
healthcare costs.
    The MHS is not unique in the variability associated with predicting 
health care costs as all health insurers face these same challenges 
when forecasting their health expenditures for a given year. Changes in 
medical practice, demand for services, and new procedures and drugs are 
hard to predict. COVID has only exacerbated these challenges.
    It is important to consider the FY22 budget request in the context 
of MHS cost control for the last ten years. Over the period of FY 2012 
to FY 2018, both private health insurance premiums and National Health 
Expenditures per capita rose 25% (or 3.7% annually). However, the 
Department, working with Congress, instituted a series of initiatives 
that reduced DoD costs well below the rate of civilian growth. A 
combination of benefit changes, payment savings initiatives, contract 
changes, and population reductions masked underlying increases in 
health care costs. Starting in FY 2019, cost patterns returned to 
normal growth until the COVID pandemic significantly reduced the 
utilization of health care services beginning in March 2020.
    The Department continues to pursue efforts focused on internal 
business process improvements and structural changes to find greater 
efficiencies, such as further integrating and standardizing the 
operation of hospitals and clinics; continuing the deployment of MHS 
GENESIS; modernizing clinical and business processes; and, streamlining 
internal operations. The Department is not requesting any additional 
changes to beneficiary cost-sharing in the FY22 budget.
    The Department remains vigilant about variation in year-to-year 
expenditures, and we are appreciative that Congress continues to grant 
the Department carryover authority each year. Carryover authority 
allows DoD to maintain better funding flows to minimize disruption of 
health care services to our beneficiaries. We are committed to making 
our health care cost projections even more transparent in the year of 
execution, providing regular updates to the committee, and providing 
full visibility to Congress on potential plans for reprogramming funds 
within the fiscal year should that possibility unfold. Furthermore, we 
will ensure that available funding is directed toward unfunded medical 
readiness and health care delivery requirements. Carryover authority is 
an invaluable tool that provides the Department with needed flexibility 
to manage issues that emerge during the year of budget execution.
    When released, our FY22 budget will present a balanced, 
comprehensive strategy that aligns with the Secretary's priorities, to 
include the ongoing response to the COVID-19 pandemic, and continues to 
fulfill our requirements associated with our congressionally directed 
transition. We look forward to working with you over the coming months 
to further refine and articulate our objectives in a manner that 
improves value for everyone--our warfighters, our combatant commanders, 
our patients, our medical force, and the American taxpayer.
    Thank you for inviting me here today to speak with you about 
military medicine and our response to the global pandemic, the 
essential integration between readiness and health, and about our plans 
to further improve our health system in support of the National Defense 
Strategy and for our beneficiary population.

    Senator Tester. Thank you, Dr. Adirim.
    General Dingle.
STATEMENT OF LIEUTENANT GENERAL R. SCOTT DINGLE, 
            SURGEON GENERAL, DEPARTMENT OF THE ARMY
    General Dingle. Chairman Tester, Vice Chair Shelby, and 
distinguished members of the subcommittee. Thank you for your 
support and for the honor to speak to you on behalf of over 
83,000 active-duty Guard and Reserve Army soldier medics.
    COVID-19 and unexpected challenges to our national security 
attempted to attack the foundation of our Nation, but it did 
not disrupt the fabric of our Constitution and its Army's 
response to it.
    I honor the soldiers that I am privileged to lead. As 
General McConville, our 40th Chief of Staff of the Army, 
states, ``People first and winning matters.'' I am proud to say 
that our Army is ready to win. Within days of our Nation's 
call, we collaborated with Health and Human Services, the 
Department of Homeland Security, and our State governments. We 
expanded critical testing capacity, inculcated retiree recalls, 
deployed vaccine and medical teams in support of civilian 
entities, and partnered with medical research and development 
in support of the whole-of-government approach.
    Soldiers deployed to three countries, 19 States, and three 
territories, to include California, Illinois, North Dakota, 
Washington, and Wisconsin to support and to save American 
lives. You called, we were ready, we responded.
    My vision for Army Medicine is clear. We will be ready, 
reformed, reorganized, responsive, and relevant in this era of 
unprecedented global complexity whether in support of our 
National Defense Strategy and whenever our government calls. 
So, when the Army deploys today and fights tonight, Army 
Medicine will be right there to return our soldiers to duty 
tomorrow. From the foxhole to the fixed facility, we will 
conserve the health and fitness of the fighting force and 
reinforce our readiness requirements through healthcare acuity 
for our beneficiaries.
    I will ensure that integrated medical efforts occur with 
strong fiscal stewardship and partnership between Army 
Medicine, the Joint Force, and the Defense Health Agency 
ensuring the readiness of our soldiers. The vision and 
operational focus for Army Medicine remains at building 
readiness and properly manned and proficiently trained units 
and modernizing to remain ready and relevant for future 
conflicts and challenged. Medical reform directors will be 
implemented to maximize readiness in support of the Army 
mission.
    Finally, we are committed to sustaining and improving our 
partnerships, foreign and domestic, to elevate battlefield 
interoperability, and to support our National Defense Strategy.
    In closing, I thank the committee for your long-standing 
support to the Army and military medicine. I look forward to 
answering your questions.
    [The statement follows:]
        Prepared Statement of Lieutenant General R. Scott Dingle
    Chairman Tester, Ranking Member Shelby, and distinguished members 
of the subcommittee thank you for the opportunity to speak to you on 
behalf of our Army's health professionals--Soldiers, Civilians, and 
their Families, about the state of Army Medicine. As the 45th Army 
Surgeon General, I want to express my gratitude for your unwavering 
support.
    Today, in the 20th year since 9/11, over 190,000 Soldiers are 
engaged worldwide to support contingency operations, multiple 
exercises, and theater security cooperation activities. Before this 
novel coronavirus pandemic, Army Soldiers and Civilians had served 
throughout the world as part of the Joint Force. This last year, 
however, has made our work like no other in our Nation's history.
    Before I begin my comments, I would like to acknowledge those 
tragically taken by the virus and other violent acts. They were 
mothers, fathers, first responders, healthcare providers, the elder, 
and the young, too many lives sacrificed. May they rest in peace.
    I would also like to honor the Soldiers, civilians, contractors, 
and volunteers I am privileged to lead. As our 40th Chief of Staff of 
the Army states, ``People First, Winning Matters!'' I am proud to say 
that our People are ready to win. Within days of the Nation's call, 
Soldiers began building hospitals and testing centers where the Nation 
needed them most. Soldiers and the Federal Emergency Management Agency, 
state, and local partners converted the Javits Convention Center in New 
York City into an alternate care facility to meet the potential demand 
for hospital beds created by COVID-19. Our researchers, project 
managers, logisticians, public health officials, health facility and 
operational planners, and scientists were embedded with the interagency 
for the whole-of-government effort against COVID-19. Over 1,850 service 
members augmented civilian hospitals or community vaccination programs. 
You called. We were ready. We responded.
    We marshaled our best and very talented professionals from across 
the Army. Our scientists and public health officials developed 
therapeutics, pandemic surveillance modeling, and testing strategies 
that produced the relevant outcomes we see today. Medical research and 
public health, the Army's vital asset in fighting diseases, contributed 
to the national effort under the Military Infectious Diseases Research 
Program and partnered with civilian, academic, and federal agency 
counterparts at all echelons in the whole of government response. Army 
Medicine did this while sustaining the health of our Soldiers, family 
members, retirees, and civilians both at home and abroad.
    Since 2019, the Army and Army Medicine have been diligent in 
separating the resource requirements for the Services' readiness needs 
from benefit delivery. This deliberate effort has enabled the Army to 
expeditiously provide the foregoing actions to support operational and 
readiness requirements.
    As The Army Surgeon General, my top priority is the health, 
welfare, and readiness of our Soldiers, their Families, our Civilians, 
and our Soldiers-for-Life, especially after two decades of persistent 
conflict across the globe. The Army and Army Medicine must consider the 
policy and funding needs to keep us ready and relevant for future 
challenges. This is what we must discuss today.
                           army medicine 2028
    The Army Medicine 2028 vision operationalizes my plan to meet Army 
Medicine's strategic readiness priorities along with five key 
objectives--Ready, Reformed, Reorganized, Responsive, and Relevant.
  --Ready.--Taking care of people, our Soldiers, and our Families, is 
        paramount to readiness. Their physical, cognitive, and 
        emotional health are the cornerstones to personal readiness. We 
        will build and sustain strategic readiness to ensure the 
        operational force can win across all domains--land, air, sea, 
        space, and cyber, by embracing modernization efforts through 
        emerging technologies, synthetic training, and partnerships.
  --Reformed and Reorganized.--Our Army remains committed to medical 
        reform initiatives. Similarly, Army Medicine must effectively 
        reorganize in accordance with reform requirements and Army 
        Senior Leader directives to remain nested with the Army 
        Campaign Plan and the Army Modernization Strategy.
  --Responsive.--Army Medicine will tailor our expeditionary force to 
        support the new paradigm of multi-domain operations, 
        synchronized as part of the Joint Health Service Enterprise.
  --Relevant.--Army Medicine must change at the speed of relevance. 
        This includes the modernization of critical capabilities, 
        technical innovations, and expanded alliances and partnerships 
        to meet the shared challenges of our time.
                         army medicine strategy
    The strategic vision positions Army Medicine to achieve the 
objectives and priorities set forth by the Army. The vision of Army 
Medicine 2028 is clear: we are responsive and relevant with 
expeditionary, tailored, medically ready, and ready medical forces to 
support the Army mission to deploy, fight, and win in a joint, multi-
domain, high-intensity conflict.
    Nested with Army vision and priorities, I lay the foundation for 
evolving concepts, tactics, and requirements in five specific ways to 
achieve this vision. We must synchronize and integrate the medical 
effort. We must continue to build Army medicine readiness through 
proper manning, organizing, training, equipping, and leadership. We do 
this while continuing our modernization and medical reform efforts. We 
must do this while cultivating our international alliances and 
partnerships, force multipliers, and strategic assets to our national 
defense.
Synchronize and Integrate the Medical Effort.
    In line with the Secretary of Defense's and Army senior leaders' 
guidance, Army Medicine will remain responsible and reliable for our 
teammates and stakeholders. We do this through our teamwork as the 
Army's medical voice regarding COVID-19 response, conserving the 
force's health and fitness, and caring for our beneficiaries, active 
and retired, at our treatment facilities. Our integrated efforts occur 
within and across the Army, between the Army and Defense Health Agency, 
and through the Joint Staff and Combatant Commands.
    COVID-19 Response: The Nation called; the Army was there with the 
relevant expertise, equipment, and technology to respond to this 
unprecedented public health crisis. We will not rest until the virus no 
longer threatens our Nation. The greatest proximate challenge to our 
Nation's security is the threat of COVID-19. Army Medicine is 
decisively engaged in fighting COVID-19 at all levels, supporting the 
Department of Defense and interagency partners to eradicate COVID-19. I 
will participate in the statutorily mandated COVID-19 medical health 
system review panel in the coming months. Per fiscal year (FY) 2021 
National Defense Authorization Act (NDAA) Section 732, my team will 
contribute and support the Secretary of Defense's strategy for pandemic 
preparedness and response plan. They are studying our response to 
COVID-19 and modifications to a pilot program on civilian and military 
partnerships to enhance medical interoperability and surge capability 
and capacity of the National Disaster Medical System. I finally want to 
express my gratitude to our Soldiers-for-Life. Last year, the Army 
asked our retirees to assist the historic effort to defeat COVID-19, 
and they responded. All of these men and women volunteers are true 
patriots and exemplars of the unwavering dedication of the Army 
Medicine team.
    Research, Development, and Acquisition: Army Medicine is the Army's 
medical shield defending the force against COVID-19 in this whole-of-
government approach. We responded to the Severe Acute Respiratory 
Syndrome, Ebola, and Zika outbreaks in the recent past. The Army 
Medical research enterprise delivered therapeutics, including 
antibodies in convalescent plasma, collaborated on the study of 40 
million compounds, and managed approximately 80% of the Defense 
Department's investments dedicated to medical research and product 
development. To date in FY21, the Medical Research and Development 
Command dispersed $363 million for research, development, test, and 
evaluation; $280 million for operation and maintenance; and $59 million 
for procurement across myriad programs supporting the health of the 
Department and our Nation. In the year since COVID-19 became a 
household word, our research and development team used these needed 
funds to protect the Nation from deadly viruses.
    Health and Holistic Fitness (H2F): Holistic Health and Fitness, or 
H2F, is now part of our doctrine per Army Field Manual 7-22. As the 
Army Chief of Staff states, ``People are my #1 priority: Our Army's 
people are our greatest strength and our most important weapon 
system.'' To maintain our military strength, we will invest in 
understanding, assessing, and improving the American Soldier's holistic 
health. That means we have a comprehensive schema to enhance and 
maintain the Soldier's performance by making Army medical and health 
professionals part of building cohesive combat teams. In April 2020, 
3.75% of the Army is currently medically non-deployable, equating to 
38,400 Soldiers. Musculoskeletal injury contributed significantly to 
the Army's healthcare burden, negatively impacting Soldier health and 
Army readiness. To conserve the force, Army has 536 military 
authorizations in the future years' defense program (FYDP) between 2022 
and 2026 for physical therapists, occupational therapists, registered 
dietitians, and enlisted specialists to be forward arrayed within our 
combat formations to prevent or mitigate injuries and ensure faster 
recovery to maintain combat power.
    Army Recovery Care Program (ARCP): The Army maintains a robust 
Warrior Care program for managing recovery and complex care for 
wounded, ill, and injured Soldiers across all Army components. Our 
program, formerly the Warrior Care and Transition Program, is a 
critical enabler of Army readiness. Through the use of 14 Soldier 
Recovery Units, ARCP manages the recovery of wounded, ill, and injured 
Soldiers requiring complex care at Division/Corps installations and 
specialty medical centers. The program also provides resources and 
advocacy for Families and caregivers of Soldiers recovering in the 
program. Since the program's inception in 2007, more than 84,000 
Soldiers have entered the program. As of October 1, 2020, the program 
completed a two-year Army-directed restructure. Its current population 
of 1,752 reflects the single entry criteria for all three components 
and is in line with original restructure estimates of 1600-1800 as of 
December 31, 2020. The latest restructure has reduced 501 
authorizations and $35 million for Program Objective Memorandum (POM) 
2021, but will not decrement operations and support to the wounded 
warrior.
    Medical Military Construction: The construction of medical 
healthcare and research facilities supporting Army and Department of 
Defense personnel and missions continues. Army Medicine, the United 
States Army Corps of Engineers, and the Defense
    Health Agency provide collaborative leadership and management to 
multiple projects. I thank you for your enduring support of the medical 
military construction program. The Army will recapitalize over 78% (15 
of 19) of inpatient facilities between 2005 and 2026. The military 
health system continues to require future investments in military 
construction to support safe, quality care for our Soldiers, Family 
Members, and Soldiers for Life, as well as capital investments for 
medical research and public health activities. As of this submission, 
there are currently 14 active hospital, medical research, clinic, lab, 
and blood program projects supporting Army equities.
    Departments of Defense (DOD) and Veterans' Affair (VA) Partnership: 
Caring for our Soldiers-for-Life reflects our commitment to People and 
synchronizing the medical effort. In collaboration with the VA, the 
Army has an integrated joint effort for providing care to our retired 
population through robust healthcare resource sharing programs. Between 
2018 and 2019, Army Medicine provided $138.2 million in reimbursable 
care to veteran beneficiaries in our Army treatment facilities. All 
Army facilities with excess capacity to provide care to the veteran 
population under the healthcare resource sharing program. Our Soldiers-
for-Life are America's strategic reserve. We are obligated to care for 
them.
Build Readiness.
    Building and maintaining readiness is critical to my strategic 
goal. Army Medicine is pivoting to proficiently trained and manned 
units led by competent leaders, equipped with modern capabilities to 
provide expeditionary life/limb-saving to a multi-domain operations 
capable force by 2028. I acknowledge legislation regarding our force 
mix options and service models, as well as legislation regarding the 
military medical manning end strength. Readiness and deployability must 
remain a top priority of Commanders and Soldiers.
    Medical Readiness: To build combat readiness, we affirm the need to 
reduce the Army's non-deployable rate to 5%, even during the pandemic. 
This means that despite COVID-19, Soldiers continued to complete their 
annual health assessments and dental exams. Initially, COVID-19 
impacted our ability to conduct the screenings. To clear the backlog of 
Soldiers who fell out of compliance during the early phase of the 
pandemic, we began to use video or telephonic health assessments. At 
the end of calendar year 2020, only 3.75% of Soldiers were medically 
non-deployable.
    Individual and Collective Training: The Army is committed to the 
readiness for large-scale combat operations. I will provide the combat 
force high-quality medical care across the full continuum of combat 
casualty operations by reforming our medical training processes and 
seeking innovative partnerships and solutions to providing a ready 
medical force. Army Medicine is using various initiatives to build 
deployment readiness:
  --Army Graduate Medical Education.--Five to seven years of training 
        after medical school is required to produce a board-eligible 
        surgeon. The graduate program generates 96% of critical wartime 
        specialty surgeons.
  --Military-Civilian Partnerships.--Army Medicine has entered into 
        medical training agreements with civilian trauma centers and 
        medical centers around the country. Pursuant to recent 
        legislation, Army Medicine has placed doctors, nurses, and 
        medics into facilities across the Nation, where, for example, 
        members from forward surgical teams maximize their exposure to 
        a high volume of patients with critical injuries. This cost-
        efficient initiative provides skills sustainment opportunities 
        alongside our civilian counterparts in premier trauma centers 
        and hospitals.
Support Modernization of the Medical Force.
    Army Medicine's modernization efforts include developing medical 
concepts parallel with Army efforts. These expeditionary medical 
capabilities leverage emerging technologies, design the future medical 
force, ensure interoperability, and invest in synthetic training 
environments to provide the ``sets and reps'' required to be 
battlefield-ready. We must consider leveraging technology and updating 
our strategies to meet the realities of the landscape.
    Recruiting and Retention of Health Professional Officers (HPOs) 
(Talent Management): Our Army's philosophy is People First, and our 
attitude is Winning Matters. The Army is about People. I want to thank 
our legislators for acknowledging the need to increase special pay 
incentive programs and rate caps. The increase in health professional 
compensation assisted with medical accession bonuses, health 
professional scholarships, Financial Assistance Program, loan 
repayment, professional training and education programs and incentives, 
allows us to recruit and retain health professional officers as they 
make the tough decision to serve the Nation or answer the lucrative 
opportunities in the private sector. Per section 757 of the Fiscal Year 
2021 NDAA, at the direction of the Department of Defense, we will 
participate in the congressionally-mandated review of our force mix 
options and the service models to enhance our medical force's 
readiness.
    Virtual Health: As we sustain and modernize Army Medicine's talent 
management systems and organization, our hardware and software must 
match the dynamic threat landscape of the 21st century. In this regard, 
the legislation directs a review of our use of virtual health services 
across the Army. Leveraging this capability during the pandemic was 
critical in delivering medical treatment and timely access to care. 
During the year of COVID-19, when many dreaded entering medical 
treatment facilities, telehealth provided direct care to our patients. 
In FY15, there were over 40,000 virtual health encounters in Army 
Medicine. About 80% of these encounters were related to behavioral 
health. From March 2020 to January 2021, we had an extraordinary 4.2 
million virtual health encounters. Virtual health improves patient 
satisfaction, continuity of care, readiness, and access-all components 
for efficient and effective medical care.
    Medical Simulation/Synthetic Training: The Department of Simulation 
at the Medical Center of Excellence is the lead agency for Army medical 
modeling and simulation policy and strategy. Working with the Army's 
Program Executive Office Simulation, Training and Instrumentation, and 
in collaboration with Army Futures Command, our simulation efforts will 
improve medical skill training through synthetic cross-functional 
training. The artificial environment will provide the realistic 
repetitions necessary to train and sustain combat lifesavers and 
medical personnel for Multi-Domain Operations. Other examples of our 
technological needs include:
  --Integrated Visual Augmentation System (IVAS).--This system enhanced 
        casualty care through a combination of technologies and 
        augmented reality delivered in the form of a Head-Up Display 
        device. The system will include a casualty response function 
        enabling the Close Combat Force to exercise squad-level 
        response to taking casualties in tactical training scenarios.
  --Tactical Combat Casualty Care (TC3) Simulation.--A first-person 
        game that allows a Soldier to play a combat medic's role during 
        an infantry squad mission in an urban environment.
  --Vertical Lift.--The next-generation medical vertical lift, such as 
        the medical variant of the Future Long-Range Assault Aircraft, 
        will give Army Medicine an aircraft with increased speed, 
        range, survivability, and maneuverability to allow the Army to 
        evacuate the injured from the battlefield to the point of care.
    We must make investments to develop further and purchase the 
required hardware and software to create the Synthetic Training 
Environment Medical training platforms and next generation of vertical 
lift.
Medical Reform.
    The Medical Reform initiative aims to ensure the highest Soldier 
and provider medical readiness while reducing administrative 
requirements associated with military treatment facilities (MTFs) 
health and business processes, procedures, and practices to deliver 
more effective and efficient beneficiary care at less cost. The 
Department of the Army and Army Medicine are committed to this 
initiative as we diligently evaluate the Medial Department's structure, 
ensuring its coherence to the needs of Title 10 and our operational 
demands.
    Medical and Dental Treatment Facility Transition: Due to the novel 
coronavirus response, the military health systems reform efforts were 
paused in the last year. The Defense Health Agency will assume 
authority, direction, and control for all United States- based MTFs by 
September 30, 2021. The Army will transfer 126 Medical and 60 Dental 
Treatment Facilities to the Defense Health Agency. The Army retained 
statutory Title 10 responsibility for training, readiness, and 
oversight of Soldiers at the Medical Treatment Facilities, Dental 
Treatment Facilities, Public Health establishments, and Veterinary 
Treatment Facilities.
    Defense Health Program Funds Transfer: The FY21 appropriations 
drafted by this committee provided more than $1.1 billion from the 
Defense Health Program to the Army Operation and Maintenance account 
consisting of over 15 service-centric medical readiness programs--over 
$655 million within Army Medicine and over $445 million across Army 
Major Commands. We understand that we need to further evaluate our 
readiness requirements in subsequent years as the medical health 
systems reform and transition progress. We acknowledge this committee's 
recommendations on the need for precise details and justification for 
Army's Medical readiness programs. Finally, we are also working with 
the Defense Health Agency to ensure that those medical readiness 
services within the Defense Health Agency purview (about $895 million) 
are meeting the Army's requirement for comprehensive readiness for our 
Soldiers and their family members.
Strengthen Alliances and Partnerships.
    Finally, our allies and partners are collaborators and force 
multipliers with whom we engage through various multilateral and 
bilateral affiliations, security cooperation programs, and global 
health engagement opportunities. From the early 1800s, to today, and 
into the future, the Army has a long-standing history responding to 
international public global health issues as a result of our 
responsibility to protect the health of our forces and to ensure that 
they are ready to deploy for missions anywhere in the world at a 
moment's notice. One component of global health engagements involves 
building, sustaining, and improving partner capacity so that nations 
can mature into competent combat health service support providers for 
their forces and coalitions in which they will operate. Among other 
capabilities, my goal in the Army Medicine strategy is to create a 
global network of military medical capabilities that will provide niche 
and system medical services to ensure ready, relevant, responsive, and 
excellent health service support both in the field and in the 
institutional setting.
    Funding for global health activities, partnership activities, and 
global health engagements has always been a challenge. As we have seen 
in the last year, our scientists' international work is a crucial 
funding concern. Allocated appropriations from Defense Health Program 
funds provided by our partner nations do not yield impactful results. 
Partner nation, Combatant Command, and Army Service Component Command 
prioritization toward combat and combat support capabilities are 
frequently below the cut line, underfunding global health engagements 
and medical security cooperation.
    To achieve global health objectives, medical forces would benefit 
from funding investment to continue and capitalize on our critical 
relationships with international ministries of defense, health, 
interior, academia, non-governmental, and private sector organizations. 
As required by statute, we will work with the Department to assess the 
feasibility of establishing medical security partnership with Taiwan 
(FY21 NDAA, Section 1260B) and the grant program to collaborate with 
Israel on post-traumatic stress disorder research.
    Medical Research and Development Command laboratories in Thailand, 
Philippines, Nepal, Cambodia, Kenya, Nigeria, Tanzania, Uganda, and the 
Republic of Georgia conduct essential surveillance of biological 
threats and groundbreaking research on infectious diseases and diseases 
of military and public health significance. Through regional and 
functional health commands, the Army's global presence also serves as a 
force for good, offering humanitarian assistance and disaster relief 
when requested.
    The Army Medical Center of Excellence provides officer and enlisted 
medical leadership training to approximately 200 soldiers from partner 
nations. Of these, our relationship with the Israel Defense Force 
medical services, based on the 1978 United States-Israel Data Exchange 
Agreement on Military Medicine, or ``Shoresh,'' sustained our 
relationship through their International Medical Programs office and 
the Army's Medical Strategic Leadership Program. Similarly, our 
relationship with Taiwan (one which Army Medicine looks forward to 
expanding) was sustained through our educational programs, which had 25 
participants in recent years.
    Army Medicine will build on our experience from multinational staff 
hospitals in Iraq and Afghanistan as the opportunity affords. We do 
this while leveraging current experiences in Europe with our allies and 
partner nations to strengthen our many long-lasting international 
relationships with the North Atlantic Treaty Organization and the 
American-British-Canadian-Australian-and New Zealand alliances. When 
matured, these relationships will enhance the readiness of future US 
military operations in that region. The corporate and national response 
to the global pandemic, ongoing research and development of freeze-
dried plasma, advancements in prosthetics and rehabilitation, and more 
effective treatments for post-traumatic stress disorder and other 
combat stress-related injuries have made Army Medicine a proven and 
formidable partner in global health and military medicine.
                               conclusion
    In closing, I want to thank the committee for your long-standing 
support to the Army and Military Medicine. I remain committed to 
working with our defense, interagency, intergovernmental, 
multinational, and civilian partners to improve Army readiness. At the 
same time, our healthcare professionals continue to care for our 
Soldiers, Civilians, and their Families.
    From the foxhole to the fixed facility--Army Medicine will be 
ready, reformed, reorganized, responsive, and relevant. My vision will 
ensure that we sustain mutual trusted relationships within the Army, 
the Joint Force, and the Nation. When a Soldier calls for a medic, Army 
Medicine will be ready and responsive with expertly trained Soldiers 
capable of healing injuries to the body. Medical units should be 
adequately manned and equipped with the best equipment and technology. 
It is not about fighting the last war. We must have the People, 
cutting-edge tools, medical concepts, doctrine, capabilities, and the 
training for the next conflict. I appreciate the subcommittee's work 
and your continued support to our Soldiers, Army Medicine, and our 
Army.

    Senator Tester. Thank you, General Dingle.
    General Hogg.
STATEMENT OF LIEUTENANT GENERAL DOROTHY A. HOGG, 
            SURGEON GENERAL, DEPARTMENT OF THE AIR 
            FORCE
    General Hogg. Chairman Tester, Vice Chairman Shelby, and 
distinguished members of the subcommittee, thank you for the 
opportunity to testify on behalf of more than 55,900 total 
force airmen who comprise the Air Force Medical Service. Your 
sustained confidence and support enables us to remain mission-
focused, excellence-driven, and ready to fight tonight.
    Over the past year, our airmen have been involved in every 
aspect of the COVID-19 response. From the early days of initial 
public health emergency response to supporting the whole-of-
government vaccine administration efforts, Air Force medics 
showed their ability to innovate.
    When COVID-19 epicenters in New York, California, Texas, 
and North Dakota were facing critical staffing shortages, we 
acted quickly, embedding critical care strike teams directly 
into civilian facilities.
    Today we have 1,000 Air Force medics deployed to 11 FEMA 
vaccination sites in 10 States to administer COVID-19 vaccines, 
and we expect them to surpass the 1 million mark this week.
    A year before the first COVID-19 case hit the U.S., we 
established our newest C-STARS training program at the 
University of Nebraska in Omaha. This Center for the 
Sustainment of Trauma and Readiness Skills focuses on disease 
containment.
    Our infectious disease specialists worked alongside 
civilian counterparts to treat some of the very first COVID-19 
patients using the university's biocontainment unit.
    We took our air medical evacuation capabilities into new 
territory when we were tasked to transport COVID-19 patients. 
Early in the pandemic, the rapid rise of cases drove the need 
to move more patients at once while mitigating the spread of 
COVID-19 to our aircrew members.
    We partnered with teams across the Department of Defense 
and the civilian industry to develop a new infectious disease 
transport system called the Negatively Pressurized Conex. This 
Conex can safely transport up to three times as many patients 
as the previous isolation system, and as of 19 April, we have 
completed 96 missions and moved 366 COVID-19 patients safely.
    While battling the pandemic, we also remained dedicated to 
the MHS (Military Health System) transformation efforts. We 
have worked side by side with the Defense Health Agency to 
identify all necessary processes needed to mature their 
functional capabilities. We also implemented a new medical 
reform model to improve our airmen's and guardians' readiness 
and deployability.
    We reorganized our medical treatment facilities into two 
squadrons. The first squadron focuses on the health of our 
airmen and our guardians, and the second squadron focuses on 
the health of our beneficiaries. This new model has been 
implemented at 66 bases, and early analysis has already shown 
the model enhances force readiness and lethality.
    This pandemic brought unprecedented challenges, but it also 
provided opportunities to accelerate, change, or lose, to 
become more agile, resilient, and capable to face the unknown. 
This is what we train for. We remain ready for the right. This 
mentality must remain in focus as we evolve to face the next 
major threat.
    It has been an honor to serve as the Air and Space Force 
Surgeon General alongside extraordinary medical professionals 
on the joint team. This is my final time to appear before this 
subcommittee, as I will be retiring this summer.
    Thank you for your continued support and for the 
opportunity to address you today, and I look forward to 
answering your questions.
    [The statement follows:]
        Prepared Statement of Lieutenant General Dorothy A. Hogg
    Chairman Tester, Ranking Member Shelby, and distinguished members 
of the Subcommittee, thank you for the opportunity to testify on behalf 
of the 55,945 active duty, reserve, national guard, and civilian Airmen 
who comprise the Air Force Medical Service. It is an honor to serve 
with these Airmen who demonstrate their ongoing dedication to the 
mission resulting in the success of the Department of the Air Force. 
Your sustained confidence and support in our efforts enables us to 
remain mission-focused, excellence-driven and ready to fight tonight.
    The Air Force Medical Service supports the Department of the Air 
Force's mission to fly, fight and win, and defend American interests in 
air, space, and cyberspace. Our strength resides in our resilience and 
on our willingness to succeed in austere, dynamic, and challenging 
environments. Our readiness focuses on delivering lifesaving care, 
whether on the battlefield or within our own communities. We train to 
successfully operate in field hospitals with limited supplies, pushing 
the limits of our capabilities to stretch our problem solving 
abilities. The Air Force Medical Service can successfully function, in 
fact, excel, on any cargo aircraft available to move our service 
members to higher levels of care. Air Force medics ensure combatant 
commanders have a medically ready and fit force. With the launch of our 
newest military branch, the U.S. Space Force, Air Force medics are also 
responsible for maintaining the readiness for Guardians operating the 
nation's space capabilities. We embrace these unique physical and 
psychological demands of Space mission sets and are planning for the 
future demands of space medicine requirements.
    My responsibility to provide the best prepared medical force has 
not been dampened by the challenges of the ongoing pandemic, in fact, 
it has proved the resilience and flexibility of our Airmen. This 
pandemic tested our capabilities; we faced many challenges, but at the 
core of our success was our medics. Their training, commitment, and 
dedication to service provided a resource our nation depends upon.
              air force medical service covid-19 response
    Over this past year, our medics have been put on the front lines 
like never before, to combat a new enemy, one that struck in our own 
backyards and bases around the globe. The pandemic brought military 
medical capacity and capability to the tip of the spear in our nation's 
response in combating COVID. Our medical Airmen from nearly every 
specialty and position have been working tirelessly alongside our 
sister services and civilian partners to conquer this disease. We have 
deployed to the hardest hit areas of our country to support overrun 
civilian hospitals. In the midst of these challenges, our Airmen have 
continued to innovate and respond to my call for disruptive innovation. 
One example is the Negatively Pressurized Containment unit. During the 
2014 Ebola epidemic, it became clear the Department of Defense needed a 
way to safely transport multiple patients within the same airframe who 
were suffering from a highly infectious disease. Four months from when 
the need was identified, the transport isolation system was introduced 
and ready for patient movement. It is easily transported on existing 
cargo aircraft, including the C-130 and the C-17 and provides a 
contained area for medics to care for these patients. While we trained 
to execute this system, it never saw an operational mission until the 
COVID-19 pandemic. The first operational mission for this isolation 
system took place on April 10, 2020, when three COVID-19 positive 
patients were transported from Afghanistan to Ramstein Air Base, 
Germany.
    While the mission was a success, the rapid rise of COVID-19 case 
numbers required us to move larger numbers of patients at one time. 
This was a challenge, but our Airmen partnered with teams across the 
Air Force, Department of Defense, and civilian industry, under the 
direction of the Program Executive Office for Agile Combat Support, to 
develop and procure an innovative solution. In less than 100 days, a 
new isolation system, the Negatively Pressurized Conex, was launched. 
This innovation rapidly went from an idea to a solution, and on July 1, 
2020, Airmen successfully transported 12 COVID-19 patients on a C-17. 
As of February 25, 2021, we have completed 39 missions and moved 216 
COVID-19 patients in this system.
    Our Air Force medics also provided the nation with innovative 
solutions to solve bed space and personnel shortages. When COVID-19 
epicenters in New York, California, North Dakota, and Texas were 
experiencing bed space shortages, our team went to work developing 
solutions and designed four COVID Theater Hospitals, consisting of more 
than 200 beds, to provide the support the communities were desperately 
seeking. As cases surged, it soon became apparent that these solutions 
would not accomplish the immediate needs of our civilian partners, so 
we quickly tailored a better solution. We broke our theater hospitals 
into smaller critical care strike teams and embedded them directly into 
civilian facilities to augment their capabilities. Nearly 800 Air Force 
medics were deployed into civilian facilities to work alongside their 
civilian counterparts. Most recently, we deployed an additional 1,000 
Air Force medics to 11 vaccination sites in 10 states to administer 
COVID-19 vaccines. As of April 6, 2021, we have successfully 
administered more than 678,162 vaccines.
                   delivering care to our warfighters
    While the nation's attention shifted to combating COVID-19, the Air 
Force Medical Service never took the eye off of the ball in supporting 
the operational demands of the Air and Space Force missions. Our medics 
hold the sacred responsibility for treating service members so they can 
complete the mission and return home safely. We have continued to 
bolster our existing capabilities.
    Currently, we are halfway through a five-year rollout of a new 
initiative to embed base Operational Support Teams at all Department of 
the Air Force installations. The Operational Support Teams consist of a 
clinical psychologist, social worker, physical therapist, exercise 
physiologist, and a team leader who are all focused on improving 
operational performance of our Airmen. The team will provide direct 
unit-level medical engagement outside of Air Force military treatment 
facilities. This is accomplished by enhancing both physical and 
psychological resiliency, as well as employing military occupational 
injury prevention techniques. These teams will temporarily embed into 
high-risk squadrons and begin to build and foster trusting 
relationships, conduct unit-focused needs assessments, provide 
interventions, and conduct consultations. The overall goal of this 
initiative is to address unit-specific health concerns before they have 
a chance to negatively impact Airmen, Guardians, or the mission.
              keeping medical airmen ready to deliver care
    The readiness of my medics is my number one priority. The primary 
readiness platform for medical skills are our military treatment 
facilities. However, some of our treatment facilities do not have the 
patient volume, diversity, and acuity Air Force medics require to have 
a current skill set. To address this gap, I have developed several 
partnerships and training agreements with civilian organizations. In 
the past year, we continued to grow these opportunities with our most 
recent partnership--the University of Nebraska Medical Center. In 2019, 
we started our newest C-STARS-Omaha program with a primary focus on 
disease containment. This site focuses on the care of highly infectious 
disease patients. Our Air Force medics, working alongside their 
civilian counterparts, were able to treat some of the first COVID-19 
patients utilizing the university's biocontainment unit. On March 1st 
of this year, we launched the inaugural course on principles of 
biocontainment care, covering topics on recognition, diagnosis and 
management of highly-infectious disease, infection prevention and 
control principles, and safe donning and doffing personal protective 
equipment. This course will pay huge dividends for future pandemic 
events.
    In addition to establishing civilian partnerships to maintain 
currency, we are also developing an internal training program called 
Medic-X. This program is designed to expand medical support skills in 
mass casualty scenarios where patient load overwhelms medical 
capabilities. This approach fundamentally changes what defines an ``Air 
Force Medic,'' extending response capabilities to all Air Force Medical 
Service skillsets and ranks, including non-clinical careers such as, 
pharmacists, lab officers, medical administrators, and medical 
logisticians. We have identified 58 specific skills aimed at equipping 
non-clinical Airmen with the ability to respond in the event of a mass-
casualty event. A beta test of non-clinical personnel was conducted in 
May 2020 at 10 different locations with a 96.5% success rate of 
comprehension, retention and execution of these skills. We plan on 
rolling out the Medic-X program in phases with the goal of full 
integration into all of our bases by 2025.
   commitment to military health system transition and transformation
    Despite challenges posed by implementing the changes outlined in 
section 702 of the 2017 National Defense Authorization Act and COVID-
19, we remain dedicated to the smooth transition of the delivery of the 
health benefit, and associated functions and personnel to the Defense 
Health Agency, so I can focus on my responsibility of delivering 
medically-ready Airmen and Guardians and ready medical Airmen. The Air 
Force Medical Service has been engaged with the Defense Health Agency 
to help them formalize processes, mitigate risks, and address 
challenges. We have provided a detailed framework that identified all 
functions and personnel required to stand up DHA's functional 
capabilities. We also worked with DHA to identify ways to standardize 
these services across all military treatment facilities. Despite a 
temporary pause in transition activities due to COVID-19, the Air Force 
Medical Service continues to provide the necessary transition support, 
providing requested resources and manpower needed to maintain specific 
functional capabilities at military treatment facilities. This direct 
support is expected to end on October 1, 2021.
    As our Air Force Military Treatment Facilities continue to 
transition to the authority, direction, and control of the Defense 
Health Agency, we also implemented an Air Force Medical Reform Model to 
align with the Air Force's Strategic Plan to enhance readiness, 
increase lethality, and utilize cost-effective modernization. Resource-
neutral changes in structure were applied to focus and improve the 
deployability of the forces. Under this new model, we reconfigured and 
launched two new squadrons with distinct missions. The first squadron, 
the Operational Medical Readiness Squadron, focuses on the health of 
Airmen and Guardians, and the second squadron, the Healthcare 
Operations Squadron, focuses on delivering care to all other 
beneficiaries. Analysis to date, has shown a decrease in the duration 
of Mobility Restriction by 6.6 days, an increase in Individual Medical 
Readiness by 1.1% and a decrease in Non-Deployable, All Reasons status 
by 2.3%.
                     new frontiers and new domains
    Our readiness posture has equipped us to swiftly and effectively 
respond to COVID-19 while maintaining the demands of our mission. We 
now need to be ready for a more dynamic and demanding battlefield, 
forcing us to push the boundaries of our capabilities even further Our 
future ground medical forces and equipment must be more agile, lighter, 
leaner, and more autonomous when considering logistical support may be 
limited. Wherever our Airmen and Guardians go, Air Force medics must 
follow.
    As mentioned earlier, the U.S. Space Force is now a year old. Space 
Force medical support focuses on addressing the occupational challenges 
that emerge while operating unmanned satellites. As the demands of the 
Space Force increase, so will the necessary medical support to keep 
those members fit for duty.
    The Arctic region's increasingly strategic importance, along with 
the Department of Defense's significant regional investment, requires a 
deliberate and forward-thinking approach to ensuring the U.S. can 
compete and protect the nation's interests in the region. This means 
leading the development and establishment of the Air Force Medical 
Service's capability to provide medical care in this environment. In 
support of the Department of the Air Force Strategy, on my direction, 
the Air Combat Command Surgeon, in collaboration with the Air Force 
Medical Readiness Agency conducted a Capabilities-Based Assessment 
focused on identifying capability gaps and requirements necessary to 
operate and sustain medical operations in extreme cold environments, 
called Below Zero Medicine. We convened two Below Zero Medicine 
Summits, made up of diverse groups of subject matter experts, to 
support the establishment of a Medical Pilot Unit and a Cold Weather 
Region Center of Excellence (Medical) at Joint Base Elmendorf-
Richardson. This initiative is focused on identifying and implementing 
innovative ways to bring the hospital to the patient in any 
environment.
    The ongoing COVID-19 pandemic has consumed much of the nation's 
attention, bringing with it unprecedented and unpredictable challenges. 
It forced our medics to adapt at breakneck speeds and face an unknown 
enemy, and they did just that. They worked to keep themselves safe, to 
protect the mission and continue to save lives. While many may see a 
group of military medics working against insurmountable odds, I see 
military medics putting their training into action. I see the 
deployment of agile, resilient and capable medics equipped with what 
they need to face the unknown. This is what we train for--we remain 
ready so we can fight tonight. This mentality must remain in focus as 
we evolve to face the next major threat.
    I am honored to serve as the Surgeon General for both the Air Force 
and Space Force and to work alongside the talented leadership in both 
Services, our Army and Navy partners, and the DHA as we continue to 
battle COVID-19 and transform the Military Health System. Most 
importantly, I am honored to work for our medics who are at the 
frontlines whenever and wherever they are needed. Thank you to the 
Subcommittee for your continued support of our remarkable Air Force 
medics and the health of our Airmen, Guardians, Soldiers, Sailors and 
Marines.

    Senator Tester. Thank you, General Hogg, and we appreciate 
your support to the services and wish you well in retirement 
when that time comes.
    Admiral Gillingham.
STATEMENT OF REAR ADMIRAL BRUCE L. GILLINGHAM, SURGEON 
            GENERAL, DEPARTMENT OF THE NAVY
    Admiral Gillingham. Chairman Tester, Vice Chairman Shelby, 
distinguished members of the subcommittee, it is my privilege 
to update you on Navy Medicine. I am grateful for your 
continued leadership and support as we execute our medical 
readiness mission in support of the United States Navy, United 
States Marine Corps, world's premier Naval Force.
    Last year has been like no other in our lifetimes as we 
confronted a deadly adversary, the SARS-CoV-2 virus and the 
disease it causes, COVID-19. The battle continues today.
    Navy Medicine's operational tempo remains high as we 
protect the readiness and health of our sailors, marines, and 
their families, along with making direct contributions to the 
whole-of-Nation pandemic response.
    To date, we have deployed over 6,000 active and reserve 
component medical personnel in support of operational COVID-19 
missions. I want to assure you that despite these unprecedented 
challenges, the One Navy Medicine team remains relevant, ready, 
and responsive.
    We continue to be guided by our strategic priorities: 
people, platforms, performance, and power. Well-trained people 
working as cohesive teams on optimized platforms, demonstrating 
high-value, high-velocity performance that will project medical 
power in support of naval superiority.
    With the earliest identification of the SARS-CoV-2 virus, 
it was evident that we were battling an adversary whose 
behavior is highly unpredictable, particularly with respect to 
its asymptomatic transmission. While all of us in military 
medicine are trained to respond to medical emergencies, we 
quickly recognized that protecting our personnel in this public 
health crisis along with maintaining operational effectiveness 
would be our primary mission.
    Actions and intervention by experts across Navy Medicine 
during early stages directly impacted our ability to better 
understand the virus, mitigate and contain its spread, 
effectively support ongoing fleet operations, and preserve Navy 
and Marine Corps readiness out forward.
    We rapidly applied lessons learned from the early outbreaks 
on board USS Theodore Roosevelt and USS Kidd and continually 
incorporated the latest critical information from the Centers 
for Disease Control and Prevention as well as Navy Medicine, 
public health, and R&D experts.
    Navy leadership quickly operationalized this guidance for 
the fleet in the form of standard operational guidance, and 
this is currently in its fourth update. This direction 
incorporates the most up-to-date scientific and public health 
information, to include testing, restriction of movement, 
isolation, quarantine, physical distancing, face coverings, 
contact tracing, and now vaccinations. Importantly, our sailors 
and marines have demonstrated tremendous personal 
responsibility, resilience, and adaptability in responding to 
the pandemic.
    Their work in concert with strong commitment from our 
operational leaders has been instrumental in allowing our ships 
and personnel to stay mission capable, despite the pandemic.
    Our highest priority remains ensuring that all Department 
of Navy personnel have access to the vaccine in order to 
protect themselves, their shipmates, their families, and their 
community. As the Navy Surgeon General, I have been clear in my 
guidance that these vaccines are for the most effective 
protection against this deadly virus.
    The bottom line is that we are getting shots in arms and 
providing our personnel with what I refer to as ``biological 
body armor.'' To date, Navy sites have administrated over 
three-quarters of a million vaccines, and over 50 percent of 
our sailors and marines have now received at least one vaccine 
dose.
    Navy Medicine continues to answer the call to help our 
Nation. Navy and Marine Corps personnel are now currently 
deployed around the country to assist with vaccine 
administration in community vaccination centers.
    I recently had an opportunity to see firsthand the 
significant impact they are making in the lives of our fellow 
citizens affected by the virus.
    Navy Medicine's COVID-19 response is marked by grit, 
resolve, and an unbreakable spirit. While battling the pandemic 
remains a primary line of effort, we remain fully engaged in 
all aspects of our mission of improving readiness and enhancing 
operational capabilities to increase warfighters' 
survivability.
    My written testimony provides you details on many of these 
important initiatives that directly support physical and mental 
well-being of our sailors, marines, and their families.
    In summary, the Nation depends upon our unique 
expeditionary medical expertise to support our Naval Forces. 
The Navy Medicine team, some 63,000-strong, is privileged to be 
entrusted with these responsibilities.
    Again, thank you for your leadership, and I look forward to 
your questions.
    [The statement follows:]
         Prepared Statement of Rear Admiral Bruce L. Gillingham
    Chairman Tester, Vice Chairman Shelby, distinguished Members of the 
Subcommittee, it is my privilege to update you on Navy Medicine. The 
last year has been like no other in our lifetimes as we confronted a 
deadly adversary, the SARS-CoV-2 virus and the disease it causes, 
COVID-19. The battle continues today. Throughout this global pandemic, 
the operational tempo of Navy Medicine remains high, as we protect the 
readiness and health of our Sailors, Marines and their families, along 
with making direct contributions to the whole of Nation response to 
help our fellow citizens in need. I want to assure you that despite 
these unprecedented challenges, the One Navy Medicine team remains 
relevant, ready and responsive. I am grateful for your continued 
leadership, support, and confidence as we execute our medical readiness 
mission in support of the United States Navy and United States Marine 
Corps, the world's premier Naval Force.
              aligning strategy, priorities and resources
    Foundational to Navy Medicine's mission effectiveness is full 
synchronization with the strategic direction articulated by the Chief 
of Naval Operations and Commandant of the Marine Corps in their seminal 
documents CNO Navigation Plan 2021 and the Commandant's Planning 
Guidance 2019, respectively. This guidance, along with the Tri-Service 
Maritime Strategy (2020), details the way forward in meeting current 
and future challenges posed by a dramatically changing international 
security environment. We in Navy Medicine recognize that our lines of 
effort must be vectored to support these strategic imperatives. Our 
four priorities--People, Platforms, Performance and Power--ensure 
important readiness linkages to our Marines and Sailors: Well-trained 
People, working as cohesive teams on optimized Platforms, demonstrating 
high value Performance that will project medical Power in support of 
Naval Superiority.
    To help ensure that we execute these critical priorities, I have 
added additional analytical rigor and alignment to our strategic 
planning process through a series of directive-type memoranda for our 
key program investments. Each must align with one or more of the Navy 
Medicine priorities. This process is critical as we shape our decision 
making; including, guiding our resource allocations, assessing 
organizational capacity and capability, and assessing performance. 
Overall, I am encouraged that these priorities are taking hold at all 
levels within Navy Medicine. Our personnel recognize that Navy Medicine 
is a team sport; and as such, everyone, collectively and individually, 
is performing an impactful role in contributing to mission success.
    In FY2021, additional Defense Health Program (DHP) resources were 
realigned to the Department of the Navy (DON) to support medical 
readiness activities which occur outside of military medical treatment 
facilities (MTFs). These resources are important to DON's efforts to 
execute non-MTF responsibilities in direct support of medical 
readiness. We are grateful for the financial resources provided in the 
FY2021 Defense Appropriations Act, as well as the supplemental funding 
that was provided last year in response to the COVID-19 pandemic. I 
want to assure you that inherent in our business practices is the 
application of sound fiscal stewardship of to the resources entrusted 
to us.
                  responding to the covid-19 pandemic
    With the earliest identification of the SARS-CoV-2 virus, it was 
evident that we were battling an adversary whose behavior was highly 
unpredictable. While all of us in military medicine are trained to 
respond to medical emergencies and crises, we quickly recognized that 
protecting our personnel in this public health emergency, along with 
maintaining operational effectiveness, would be our primary mission. 
Actions and interventions by experts from the Navy Medicine Public 
Health and Research and Development enterprises during the early 
stages, directly impacted Navy Medicine's ability to better understand 
the virus's behavior, mitigate/contain the virus spread, effectively 
support ongoing Fleet operations, and preserve Navy and Marine Corps 
readiness. To illustrate, using state-of-the-art technologies and 
research-use only assays for COVID-19, personnel from the Navy Medical 
Research Center deployed to USS THEODORE ROOSEVELT (CVN-71) providing 
the first COVID-19 detection onboard a Navy ship, and filling a 
critical gap in COVID-19 in the Fleet prior to the Food and Drug 
Administration (FDA) issuing Emergency Use Authorization (EUA) for 
COVID-19 diagnostic devices available onboard ships.
    This work continued as we learned how to deal with the virus from 
the early outbreaks on THEORDORE ROOSEVELT and USS KIDD (DD-661), 
particularly regarding its asymptomatic transmission. Rapidly applying 
lessons learned from these ships and continually incorporating the 
latest critical information from the Centers for Disease Control and 
Prevention (CDC) and Navy Medicine experts, Navy leadership quickly 
operationalized this guidance for the Fleet in the Standardized 
Operational Guidance (SOG), currently in its fourth update. SOG 
incorporates the most current scientific and public health information 
to include testing, restriction of movement, insolation/quarantine, 
physical distancing, face coverings, contact tracing, and vaccinations. 
This direction is critical for both individual and unit health 
protection and is impactful in preserving operational readiness while 
protecting shipmates, installation and communities from COVID-19 
transmission. Our Sailors have demonstrated tremendous personal 
responsibility, resilience and adaptability in responding to the 
pandemic. More than a year from the onset of the initial outbreak, the 
SOG, along with other key lines of efforts throughout the Navy, have 
been instrumental in allowing our ships and personnel to stay mission 
capable despite the pandemic.
    In an effort to gain more insight into SARS-CoV-2 virus, Navy 
Medicine conducted two important studies, both of which were published 
in the New England Journal of Medicine on November 11, 2020: (1) An 
Outbreak of COVID-19 on an Aircraft Carrier analyzed epidemiological 
data from the outbreak of SARS-Cov-2 onboard THEORDORE ROOSEVELT in 
order to understand the transmission and impact of SARS-CoV-2 on the 
crew. This work provides a better understanding of the behavior of the 
virus shipboard and supports the development of updated guidance for 
the Fleet to mitigate future outbreaks. (2) SARS-CoV-2 Transmission 
among Marine Recruits during Quarantine reports on the COVID-19 Health 
Action Response for Marines (CHARM) which took place at Marine Corps 
Recruit Depot Parris Island and examined asymptomatic and symptomatic 
transmission in a young adult population. A follow-on study with the 
initial Marine volunteers, CHARM 2.0, is currently underway. This 
research is important for Naval Forces but also reaffirms our 
commitment to widely contribute to further the understanding of the 
SARS-CoV-2 virus both nationally and internationally.
    An important epicenter for actionable information is our Navy 
Medicine Scientific Panel, comprised of Navy Medicine scientists, 
clinicians and public health experts. They advise leadership and work 
directly with operational medical personnel to facilitate rapid 
consultation and enable high velocity learning with respect to COVID-
19. In addition, their work is reflected in the widely disseminated 
Navy Medicine Weekly COVID-19 Public Health Report that provides 
current and timely scientific, clinical and surveillance updates.
    In addition to Navy Medicine's work efforts in support of Navy and 
Marine Corps unique requirements, collaboration with the DoD COVID-19 
Task Force, the Joint Staff, the Defense Logistics Agency, the DHA, the 
other Services, Uniformed Services University of the Health Sciences 
(USUHS), interagency partners, and many others have been important to 
the pandemic response. This work provides the needed coordination, 
standardization, and unity of effort in critical areas impacting all 
the Services including diagnostics and testing, therapeutics, contact 
tracing, personal protective equipment, COVID-19 convalescent plasma, 
vaccinations, logistics, technology and other key areas. Within the 
Military Health System (MHS), a compelling example of the synergy that 
comes from this collaboration across our clinical communities is 
reflected in the development and publication of the DoD COVID-19 
Practice Management Guide (version 7), an excellent resource that 
contains practice guidelines and studies for our providers.
    We also recognize the tremendous work by General Gustave Perna, 
United States Army, who led the federal response for accelerated 
development, manufacturing and distribution of vaccines. These efforts 
have resulted in the FDA issuing EUAs for three vaccines, and likely 
more to follow. Currently, our highest priority remains ensuring that 
all Sailors, Marines, and all DON personnel have access to the vaccine 
in order to protect themselves, their shipmates, their families and the 
community, consistent with the DoD prioritization schema. As the Navy 
Surgeon General, I have been clear in my guidance that inoculation with 
these vaccines, which is currently voluntary, is the most effective 
protection against this deadly virus.
    Navy Medicine continues to answer the call to help our fellow 
citizens through medical surge support and vaccination support. In the 
early stages of this public health emergency, at the request of the 
Federal Emergency Management Agency (FEMA), Navy deployed both hospital 
ships, USNS MERCY (TA-H 19) and USNS COMFORT (TA-H 20), as well as 
personnel assigned to our expeditionary medical facilities, to support 
overwhelmed civilian hospitals, clinics and skilled nursing facilities 
in several states. Applying lessons learned, Navy Medicine quickly 
developed new adaptive capabilities with smaller acute care teams and 
rapid rural response teams, which proved effective in augmenting staff 
at smaller hospitals in medically underserved locations including 
Texas, New Mexico, and Arizona. Navy and Marine Corps personnel are now 
currently deployed to assist with vaccinations as part of the DoD 
Community Vaccination support. These personnel are administering 
vaccinations to fellow citizens in state-run, federally-funded 
community vaccination centers around the country. I had an opportunity 
to visit several of these teams and see firsthand the impact they are 
making in the lives of our fellow citizens most affected by the virus. 
To date, Navy Medicine has deployed over 6,000 active and reserve 
component personnel in support of operational COVID-19 missions.
                        projecting medical power
    Navy Medicine's COVID-19 response continues to project medical 
power. It is marked by grit, resolve and an unbreakable spirit. While 
battling the pandemic remains our primary line of effort, we remain 
fully engaged in all aspects of our mission; directly focused on 
improving our readiness and enhancing capabilities to increase 
survivability. These efforts include leveraging all dimensions of 
people, platforms, performance, and, power.
    People: Recognizing that our dedicated and diverse workforce is our 
greatest strength, Navy Medicine published its Human Capital Strategy 
(2020--2025). This strategic framework provides a pathway to help 
ensure that our Force, active and reserve component personnel and Navy 
civilians, is structured to meet the requirements of evolving 
operational demands. It also requires us to optimize and align our 
talent management efforts placing right people in the right place with 
the right training at the right time.
    Overall manning in each of active and reserve component officer 
Corps (Medical, Dental, Medical Service and Nurse) remains good; 
however, we continue to focus on shortfalls in critical wartime and 
readiness specialties to ensure we can meet our operational 
requirements in support of the National Defense Strategy. This emphasis 
is important given the need to assess and realign our uniformed 
personnel requirements and platforms to better support medical 
capabilities of the Naval Forces with the transition to Distributed 
Maritime Operations (DMO) and Expeditionary Advanced Base Operations 
(EABO). We are also prioritizing the need to increase mental health 
specialists assigned to the Fleet and Fleet Marine Force, and to 
quickly provide full spectrum force health protection in response to 
public health emergencies.
    We must invest in recruiting, training and retaining our personnel. 
Continued accession and retention incentives are critical to the 
success of these efforts. Student accession programs are vital, 
considering Navy relies on USUHS and the Health Professions Scholarship 
Program for the vast majority of new Medical Corps accessions each 
year. Thank you for your continued assistance in this area, including 
the authorities contained in the FY2021 National Defense Authorization 
Act (NDAA) for increased special and incentive pays for officers in the 
health professionals.
    For the Hospital Corps, manning for active and reserve component is 
at 99 percent and 95 percent, respectively. Similarly, efforts are 
targeted to shortfalls in critical wartime specialty Navy Enlisted 
Classifications (NECs), including Independent Duty Corpsmen (surface, 
submarine, dive and Fleet Marine Force reconnaissance). These highly 
trained independent providers are vital to delivering expeditionary 
medical support to Naval Forces operating forward. To this end, we 
launched a campaign to highlight the professionally rewarding 
opportunities in these challenging NECs and expanded the eligibility 
pool for qualified candidates. We also increased retention bonuses. In 
addition, USUHS approved the Independent Duty Corpsmen curricula for 
incorporation in their College of Allied Health Sciences which will 
allow these Sailors to earn college credits.
    Navy Medicine civilians, a highly skilled workforce of 
approximately 11,500 professionals, are essential to our mission. They 
can be found throughout our world-wide enterprise delivering essential 
health care services--clinical care, research and development, public 
health and disease surveillance, logistics, and administration and much 
more. In addition to providing mentorship and training to our military 
personnel, they also provide much needed continuity in our facilities. 
We recognize that we face formidable competition with the private 
sector in attracting talented, highly qualified candidates, and we must 
work to recruit and expeditiously onboard these personnel. Expanded 
direct hire authorities provided in 2020 increased the number of 
specialties from nine to 27. Currently almost 55 percent of our 
civilian workforce is covered under these authorities which allows use 
of additional flexibilities for hard-to-fill health care positions. 
Again, we appreciate your support in helping us recruit the best and 
brightest. To date, Navy Medicine has transferred 40 Navy civilians to 
the DHA under transfer of function provision. We anticipate 150 
additional employees will transition later this year.
    Our priority is to have ready and confident personnel, with the 
knowledge, skills and abilities gained by experience and high velocity 
learning. The Navy Medicine Training and Education enterprise is 
critical to preparing our personnel for their warfighting mission. In 
spite of challenges posed by the SARS-CoV-2 virus, Navy Medicine 
maintained these capabilities and developed innovative solutions to 
mitigate interruptions, delays, and cancellations. Training commands, 
staff education and training departments, and operational training 
sites maximized use of virtual learning platforms, medical modeling and 
simulation, partnerships, cross-training, and blended learning to 
sustain ready medical forces. In 2020, we graduated 2,905 Hospital 
Corpsmen from basic ``A'' school and 1,235 students from advanced ``C'' 
schools, while 1,252 Hospital Corpsmen completed Field Medical 
Battalion Training. Directly supporting our maritime readiness, experts 
from the Navy Medical Modeling and Simulation Training program 
developed a mock shipboard training environment onboard the Medical 
Education Training Campus (METC). To date, over, 2,075 students have 
been trained in shipboard medical emergencies and mass casualty 
exercises utilizing this realistic operational training environment.
    In addition, our nationally recognized graduate medical and health 
education programs are critical to Navy Medicine. I refer to this 
robust training as Navy Medicine's ``industrial base'' since they are 
foundational to sustaining our pipelines to generate a proficient and 
combat credible medical force.
    Our partnerships with leading trauma and academic medical centers 
are essential in helping our providers get the trauma volume, 
complexity and experience to maintain competencies to save lives at sea 
and on the battlefield. We continue to leverage our existing 
collaborative agreements with the James H. Stroger Jr. Hospital in 
Chicago, Illinois; the University of Florida Health Shands Hospital in 
Jacksonville, Florida; and the University Hospital Cleveland in 
Cleveland, Ohio. Earlier this year, we established a new partnership 
with WakeMed Hospital, a Level I trauma center in Raleigh, North 
Carolina, while continuing to support a relationship with the Cleveland 
Clinic to provide skills sustainment specifically for Independent Duty 
Corpsmen. Pre-deployment training for our teams continues at the Navy 
Trauma Training Center at Los Angeles County + University of Southern 
California. In addition, we are working closely with the University of 
Pennsylvania Health System in establishing a military-civilian 
partnership for trauma skills sustainment.
    Inclusion and diversity are important components to a mission-ready 
Navy. Diverse, high performing teams provide us power, advantage and 
unity. We are a stronger Navy because of our differences as we draw on 
the diverse culture, skills and perspectives of our shipmates. All of 
us recognize that we have more to do. These efforts must be 
consistently demonstrated through our behaviors and a commitment to 
achieving a Culture of Excellence grounded in our Navy Core Values of 
Honor, Courage and Commitment.
    Platforms: Navy Medical personnel remain forward deployed with the 
Fleet and Fleet Marine Force. They are engaged in all warfare domains 
with the focus of keeping our Sailors and Marines ready and healthy to 
perform their demanding missions. To be effective, they must have 
optimized platforms and capabilities to deliver the full range of 
medical support, including combat casualty care at sea, rapid public 
health response, humanitarian assistance/disaster response, as well as 
Defense Support of Civilian Authorities missions.
    To meet the demands of sustained operations at sea, Navy continues 
to develop new medical capabilities as well as to re-shape current 
capabilities to operate throughout the range of military operations. We 
recognize that Naval Expeditionary Health Service Support in the DMO 
environment requires modular and scalable capabilities able to provide 
theater hospitalization and forward resuscitative care, ashore and 
afloat. Additionally, we are focused on improved patient movement and 
enroute care capabilities, along with more dispersed holding 
capabilities to maximize survivability. An important priority currently 
in development is fielding a Role 2 Enhanced medical payload for the 
Expeditionary Fast Transport (T-EPF) Flight II, hull 14 currently under 
construction. Progress continues in support of our overarching 
deployable medical systems strategy with the direction and resource 
sponsorship of the Navy's Medical Systems Integration and Combat 
Survivability Office and in close collaboration with the United States 
Marine Corps.
    It is also important to note that MTFs serve as important readiness 
training platforms. Within the MTFs, as well as through other 
partnerships, our providers get needed readiness-centric medical cases 
to keep their skills sharp and stay ready to deploy. Accordingly, our 
Navy Medicine Readiness and Training Commands (NMRTCs) provide the 
critical command and control for Navy Medicine personnel and ensure, 
through the Readiness Performance Plans, that our men and women have 
the clinical and operational currency and competency to support 
operational platforms such as hospital ships and expeditionary medical 
facilities. We work to ensure that we man, train and equip our 
personnel for current and future operations. These efforts continue to 
be impactful during the deployments of personnel from the MTFs in 
support of the COVID-19 medical and vaccine response. Furthermore, our 
overseas facilities function not only as vehicles for health care 
delivery, but more importantly as in-theatre pre-positioned medical 
capabilities that are critical components of Combatant Commanders' 
operational plans.
    Performance: Navy Medicine's success is measured by those we serve, 
our Sailors and Marines. All of us recognize that it is necessary to 
ensure we provide well-trained personnel serving on agile platforms 
with the proper equipment sets; however, we also recognize that it is 
not sufficient. We must complement these efforts with relentless 
pursuit of applying the principles of a high reliability organization 
in all our actions, particularly in the operational forces. High 
velocity learning, rapid cycle feedback, and applying lessons learned 
are the underpinnings of our collaborative work to improve clinical 
outcomes and patient safety. Drawing on our high reliability successes 
in MTFs, we are rapidly moving to fully operationalize these tenets to 
improve warfighter readiness and increase survivability including the 
establishment of six operationally-focused clinical communities: female 
force readiness; psychological health; neuromusculoskeletal; 
operational medicine; trauma; and, dental services. This priority is 
also clearly evident in the whole of Navy Medicine response to the 
pandemic as led by our network of chief medical officers and others to 
rapidly assimilate and disseminate relevant clinical and scientific 
information and best practices throughout the enterprise.
    It is critically important that our Sailors and Marines have access 
to mental health services, where and when they need them. Navy Medicine 
maintains a ``no wrong door'' approach to deliver prevention, early 
identification and evidence-based mental health treatment. Services are 
available world-wide in mental health specialty clinics, within primary 
care, at Navy and Marine Corps installation counseling centers, on the 
waterfront, and embedded within the Fleet and Fleet Marine Force to 
decrease stigma and ensure access to care for our Sailors, Marines, and 
their families. In 2020, embedded mental health (EMH) continued to 
expand with 35 percent active component mental health providers and 30 
percent of behavioral health technicians assigned to EMH billets. MH 
providers are permanently assigned to support aircraft carriers, 
submarine forces, amphibious assault and surface combatant ships, Naval 
Expeditionary Combat Command units, Marine Corps Ground Combat and 
Logistics Element units, and Navy and Marine Corps Special Operations.
    Navy Medicine supports operations and readiness, collaborating with 
stakeholders on enterprise-wide strategies to address EMH manning, 
laydown, and practices, Disaster Mental Health, resiliency, suicide 
prevention efforts, and expansion of Operational Virtual Mental Health. 
Navy Medicine adeptly responded to new challenges presented by the 
pandemic through proactive mental health guidance, surveillance, and 
outreach, as well as rapid transition to virtual mental health 
modalities in MTFs and EMH. Mental health assets deployed across the 
Fleet to support COVID-19 related missions and increased operational 
tempo. This support included deploying a Special Psychiatric Response 
Intervention Team (SPRINT) to THEODORE ROOSEVELT during the COVID-19 
outbreak. Navy Medicine continues to execute and expand the Caregiver 
Occupational Stress Control program to support psychological health and 
prevent burnout in Navy Medicine personnel, which may be particularly 
relevant during COVID-19.
    We remain acutely aware of the impact of traumatic brain injury 
(TBI) on our Sailors and Marines. Services are provided through a 
network of TBI clinics with a range of care levels, including Intrepid 
Spirit Centers at both Camp Lejeune and Camp Pendleton, and larger 
programs at Naval Medical Centers Portsmouth and San Diego providing 
scalable, multidisciplinary, evidenced-based TBI care with a high 
return to duty rate. Programs at Camp Lejeune and Naval Medical Center 
Portsmouth offer TBI evaluation and treatment tracks specifically 
targeted at tip-of-the-spear warfighters who are at greater risk for 
sustaining TBI.
    Supporting a medical ready force requires that we work diligently 
to improve the deployability of Sailors and Marines each and every day. 
Navy Medicine emphasizes the importance of completing a deployability 
assessment at every provider-based encounter. We also have made 
significant improvements to the management of our personnel on limited 
duty to include changing the assignment of limited duty from a fixed, 
prescriptive duration (180 days) to one that allows for the recommended 
recovery period to be determined by the specific medical condition for 
the service member. Navy Medicine is also refining algorithms within 
our information systems to better identify potential deployment 
limiting and temporary non-deployable conditions. All of us know that 
warfighting is inherently demanding and we need to do everything we can 
to support full recovery when a Sailor or Marine is injured or ill.
    Recognizing the unique health care needs of our female Sailors and 
Marines, we developed our comprehensive Navy Medicine Female Force 
Readiness Strategy. The focus is to organize and coordinate efforts to 
increase medical readiness, resiliency, and retention in the female 
force and to improve comprehensive care delivery. We are prioritizing 
efforts to increase patient education, improve access to care and 
striving to ensure front-line provider proficiencies specific to 
women's health. To this end, we launched a pilot program to embed a 
women's health provider within care settings closer to operational 
units to increase service women's ability to resolve health concerns 
and minimize time away from duty. The pilot is in place at two Fleet 
sites, Naval Station Norfolk and Naval Station Mayport, and both are 
yielding promising results. We also published the Deployment Readiness 
Education for Service Women Handbook, a digital women's health 
education resource for active duty Marines and Sailors.
    DON does not tolerate sexual assault. As part of Navy's Culture of 
Excellence, we continue to focus on developing and implementing 
prevention efforts while maintaining victim support and resiliency. 
Navy Medicine remains ready to respond to sexual assault by ensuring 
the availability of sexual assault medical forensic exams, ashore and 
afloat. We continue to provide responsive medical forensic care during 
the pandemic. Collaboratively, the Services sustained ongoing training 
by creating a virtual training platform for Sexual Assault Medical 
Forensic Examiner students to meet the requirements of the 80 hour 
multi-disciplinary course. These efforts helped ensure that we had the 
personnel trained to provide sexual assault care in both MTFs and 
operational settings. Despite COVID-19 restrictions, we trained 83 new 
medical forensic providers for total inventory of 167 serving across 
Navy Medicine platforms.
    Navy Medicine continues to support the fielding of MHS GENESIS, 
DoD's modernized electronic health record. This effort is essential to 
our work to drive standardization, improve patient safety and foster 
high reliability within the MHS. From 2017 through March 2021, MHS 
GENESIS has been deployed to nine Naval facilities in Washington and 
California. Lessons learned from the earlier MHS GENESIS deployments 
have been applied to current sites and we are seeing substantive 
improvements in both training and implementation. We are fully engaged 
in joint implementation and optimization efforts in the fielding of MHS 
GENESIS and will continue to work collaboratively with DHA and the 
other Services. Despite challenges due to the COVID-19 pandemic, 
significant progress has been made with implementation and the MHS 
remains on track to complete MHS GENESIS deployment by 2024.
    Power: Navy Medicine's capability to project medical power is 
critical to increasing the survivability of Naval Forces, at sea and on 
the battlefield. Our contributions include providing the best combat 
casualty care along with rapidly addressing the threats that contribute 
to disease non-battle injuries. The global pandemic has demonstrated 
that we must be prepared to employ the full strength of our One Navy 
Medicine capabilities to protect the health of Sailors and Marines.
    Our Navy Medicine Research and Development enterprise continues to 
demonstrate that it is responsive to operational requirements and is 
capable of providing rapid solutions for the warfighter. Collectively, 
their expertise in unique Naval environments provide high-value, high-
impact knowledge and materiel products as evidenced by the significant 
contributions in battling the SARS-CoV-2 virus, including diagnostic 
testing, genome sequencing of potential viral variants and 
countermeasures development.
    In addition, we conduct a range of research from basic research, 
applied research, advanced development, to testing and evaluation. Navy 
Medicine is engaged in work that directly supports Sailors and Marines, 
including advancing treatments of decompression sickness among diving 
and submarine personnel, providing research response to unexplained 
physiological events in tactical aircraft, and studying the impact of 
blast exposures on personnel. Due to the strategic location of labs, 
many projects involve infectious disease surveillance and international 
outbreak response enabling better understanding of global emerging 
health threats to military readiness.
    Our partnerships with nations on six continents, U.S. academia, 
non-profit organizations and the private sector, along with access to a 
global network of scientists, allow for research focused on keeping 
service members healthy and ready.
    Similarly, the Navy Marine Corps Public Health Center (NMCPHC) and 
its field activities continue to be on the vanguard of Navy's public 
health efforts in response to the COVID-19 pandemic. Their impactful 
contributions are reflected in all aspects of our strategy of 
prevention, mitigation, and recovery. Contributions include deploying 
public health and preventive medicine expertise on COVID-19-related 
missions to developing science-driven and evidence-based publications 
such as the ``Playbook for Managing Coronavirus Disease 2019 in a 
Shipboard Operational Setting'' which details management of SARS-CoV-2 
outbreak with platform specific recommendations for sanitation, 
prevention and treatment. Their portfolio is broad and includes 
laboratory operations, environmental health, population health as well 
as preventive medicine. NMCPHC brings the unique and vast expertise 
that is sought after, and, more importantly, is valued by Navy and 
Marine Corps operational leaders.
    Global Health Engagement (GHE) remains a critical element of global 
stability and national security, particularly in support of security 
cooperation by strengthening strategic partnership and alliances. Given 
its importance, GHE represents another important line of effort in 
support of projecting medical power. Our health security cooperation 
officers and global health specialists are working in support of 
Combatant Commanders, Navy Component Commanders as well as interagency 
and international partners. In addition, Navy GHE improves readiness, 
builds resiliency and provides competencies of our Navy Medicine 
personnel and prepares them to address an increasingly complex and 
interconnected world where health threats do not respect borders.
    Given that our Naval Forces are operating forward around the world, 
we must continue to leverage the inherent power of Naval Virtual 
Health, applying technology to provide care and clinical consultations, 
without the constraints of time and distance. Our response to the 
COVID-19 pandemic served to accelerate our efforts as Navy Medicine 
used virtual health services, both operationally and in-garrison, to 
continue to support the operational readiness of Sailors and Marines 
during a time when access to face-to-face care diminished, and movement 
limitations impacted our personnel. We saw significant increases in 
virtual health visits in many areas, but most notably in mental health. 
This trend is very encouraging and signals that we are able to maintain 
important access to care for our patients, particularly given the 
stressors brought about by the pandemic. We are also working to expand 
virtual health reach in important readiness areas including periodic 
health assessments, deployment-related assessments, suitability 
screening and others. A key complement to our virtual health priorities 
is Navy Medicine's enterprise-level efforts to advance and integrate 
data and data analytics throughout our decision making processes 
through capabilities such as machine learning, robotic process 
automation and metrics dashboards.
                             moving forward
    We continue the important work of MHS transformation. While the 
COVID-19 response necessitated an extended pause for many of these 
efforts, we have returned to planning and implementing the relevant 
Congressionally-directed reforms. Military Medicine's response to the 
pandemic provides us a meaningful organizational stress test to assess 
our capabilities and progress, essentially identifying what's working 
well, along with highlighting areas that need attention. Critical self-
assessment and applying lessons learned derived from rapid cycle 
feedback are important as we build a high reliability organization.
    Within the DON, our leadership recognizes the tremendous 
opportunity we have to refocus our efforts on medical readiness while 
transitioning health care benefit administration and management to the 
DHA, including direction and control of the MTFs. Properly executed, 
this construct will provide important opportunities to increase 
standardization, eliminate redundancies and favorably impact safety, 
quality and access within the MHS. In addition, it affords the DON 
capacity to focus exclusively on medical readiness and its unique 
responsibilities to provide a trained and ready medical force capable 
of operating in the maritime domain to meet their missions of Naval and 
Joint Forces.
    To this end, our work continues to address the smooth transition of 
MTFs to the DHA as well as the key mission and functions of our NMRTCs 
in providing critical command and control structures for Navy Medicine 
personnel to meet Navy and Marine Corps missions. NMRTCs, at the local 
MTF level, will facilitate and reinforce the mutually supportive 
relationship between Navy Medicine and the DHA. Our goal remains to 
build an integrated system of readiness and health. While there is much 
work ahead, I see tremendous potential for military medicine to be a 
national model for health care high reliability and integration.
    All of us in Navy Medicine understand the important 
responsibilities placed on us by the Nation to care for our Sailors and 
Marines who go in harm's way. Again, thank you for your support.

    Senator Tester. Thank you, Admiral, and thank you all for 
your testimony.
    We are going to start with 5-minute rounds of questions.
    Dr. Adirim, in your testimony, you talked about a $1.8 
billion shortfall, $1 billion with TRICARE, $800 million with 
military shortfall. Do these shortfalls impact the delivery of 
service of care to our servicemembers, retirees, or their 
families?
    Dr. Adirim. Senator, our first priority is our healthcare 
to our troops and to their family members. That will never 
suffer any decrement whatsoever. That is our first priority.
    And those numbers that I cited are projections that we are 
making. Currently, we have about $673 million in costs that 
were not expected due to the COVID response, but we project 
that it will be over $1.8 billion.
    Senator Tester. Okay. And so what are your plans to address 
these shortfalls? Does Congress need to step up?
    Dr. Adirim. The Department is not planning to ask for a 
supplemental. We are looking to other programs within the DHP 
(Defense Health Program), such as sustainment, modernization 
funding. We will have to postpone facilities maintenance. We 
are looking for things like that, and we will likely have to 
look to the Department as well to fill these shortfalls.
    Senator Tester. So you are going to fill these shortfalls 
with transfers within the Department of Defense?
    Dr. Adirim. We are currently now looking at how we can 
mitigate the shortfalls in any way that we can. It is a 
challenge.
    Senator Tester. Okay. I may come back to another question 
on that in a bit.
    I want to talk about TRICARE. I am going to stay with you, 
Dr. Adirim. Can you tell me what impact the recent 
implementation of enrollment fees for TRICARE Select is having 
on the number of beneficiaries enrolled?
    Dr. Adirim. Sure. I am not aware that there has been an 
impact due to any historical increase in fees. I can get you 
more precise information for the record if that is what you 
want, but I am not aware that there has been a decrement in our 
enrollment due to the fees.
    Senator Tester. So you are not seeing a decline in 
enrollment in TRICARE?
    Dr. Adirim. Senator, I think I would like to take that for 
the record so we can get you a more precise answer.
    [The information follows:]
         effect of new enrollment fees on tricare participation
    The overall decrease in TRICARE Select enrollments from December, 
2018 to April, 2021 for Retirees and their family members who are not 
Medicare eligible and the corresponding increase in the number not 
enrolled in a TRICARE plan may be attributable to the statutory 
requirement that most Group A Retirees and family members pay TRICARE 
Select enrollment fees beginning January 1, 2021 and the availability 
of other health insurance (OHI) options to some of these beneficiaries.
    There is certainly a correlation between implementation of 
enrollment fees and changes in the number of enrolled beneficiaries but 
an exact causation is more difficult to predict. If fees were not paid 
by early February, 2021, their existing TRICARE Select coverage was 
terminated for failure to pay enrollment fees, as required by statute. 
About 139,000 (15.9 percent) remaining Group A retirees and family 
members have until June 30, 2021 to request reinstatement of their 
TRICARE Select coverage if they desire to stay in TRICARE for the 2021 
calendar year.
  --Select Enrollment for Retiree & their family members who are not 
        Medicare eligible fell by about 160,000 (18 percent) between 
        December 2020 and March 2021, then went up by 10,000 in the 
        April 2021 data. It is inferred that the increase in the April 
        2021 data was a result of beneficiaries paying fees and 
        enrolling following the failure to pay notifications.
  --Aside from the differences between the Select and Prime 
        populations, one could conclude that other insurance options 
        are available and there may be other reasons for enrollments 
        (i.e. Medicare eligibility, change of address) to change over 
        time. As an example, Prime Enrollment for Retiree and their 
        family members who are not Medicare eligible dropped 18,000 (1 
        percent) between December 2020 and March 2021, then decreased 
        another 3,500 from March to April.

    Senator Tester. Okay. That would be good.
    In 2018, when the Military Health System was first 
beginning to implement reforms, we saw increases in TRICARE 
copays for specialty care, and this includes physical therapy 
and mental health, two treatments that are very common in 
military and veteran communities. Can you speak to the impact 
these increased copays have had on utilization of physical 
therapy and mental healthcare treatments under TRICARE?
    Dr. Adirim. Sure. And again, Senator, I am not aware that 
there has been an impact on utilization of those services due 
to the copays, and I am happy to take that back too and get you 
a more precise answer. We can compare years for you.
    [The information follows:]
 effect of higher copays on demand and accessibility of mental health 
                                services
    With our data, we cannot estimate the impact that copay 
modifications had on the utilization of these therapies, as there are 
many factors which modify utilization rates.
    For all behavioral health we saw increases in utilization in all 
years 2018-2020 for all beneficiary categories, though the rise in 
utilization was smaller for Retirees than Active Duty Family Members.
    For physical therapy, there were increases in utilization for ADFMs 
in 2018-2019. In 2020 we saw increases in Prime ADFMs, but a slight 
decrease in Select ADFMs. In 2018 there were decreases in Retiree 
utilization, a similar increase in 2019, and a small decrease in 2020.
    However, the data show that utilization of physical therapy for 
Prime Retirees fluctuated throughout 2011-2020, and not just the time 
period after implementation of NDAA 2017.

    Senator Tester. That would be good. I think it is 
critically important we know this. This is information that we 
need to know, and I will tell you why, because I am hearing 
about it on the ground in Montana. And if I am hearing about 
it, I am sure a lot of other Senators and Representatives are 
too.
    Dr. Adirim. Sure, Senator. I am happy to bring that back.
    Senator Tester. Okay. So considering the reforms that have 
taken place, not to beat this mule anymore, but considering all 
the reforms that have taken place for TRICARE beneficiaries 
over the last 3 years, do you believe this benefit has retained 
the same level of historical value?
    Dr. Adirim. Absolutely. I think it is a very rich benefit, 
especially when you compare it to the civilian sector. It is a 
uniform benefit. So all beneficiaries have access to the same 
benefit and menu of services that TRICARE offers.
    I believe that with the new T5 Request for Proposal coming 
out and that new contract, that we will see even more benefits 
for beneficiaries.
    Senator Tester. Okay. I want to go back to the shortfall, 
the $1.8 billion, and this is for the other folks who are here, 
the Surgeon Generals. Do you have any concerns about whether we 
are risking a shortfall? I mean, with this shortfall, that it 
is going to impact care to your troops?
    Go ahead, General Dingle. We will just go down the line 
here.
    General Dingle. I will start it off, Chairman Tester.
    So, as the Army looks at the operational force, what we do 
in conjunction with the Defense Health Agency and the Defense 
Health Agency and OCD (Office of Civilian Defense) Health 
Affairs, we identify our readiness requirements up front.
    Right now, we do not have a shortfall, as we have worked 
through our readiness requirements as we identify those, but we 
will have to assess that as the fiscal year continues on.
    Senator Tester. But the answer right now is no?
    General Dingle. Correct. Yes, sir.
    Senator Tester. Okay. General Hogg?
    General Hogg. Yes. So, along the same lines, Chairman, 
medical readiness of our force is paramount and number one, and 
so everything that we do will be directed toward that. At this 
point, yes, no shortfall.
    I do, however, have a concern that as we move forward, if 
there is a shortfall, how that is going to get covered.
    Senator Tester. Yep, I gotcha.
    Admiral Gillingham.
    Admiral Gillingham. Yes. Thank you, sir.
    Like my colleagues, I think this is something that we will 
watch carefully and continue to work internally. At present, I 
do not see a threat to our medical readiness, and as always, we 
will make sure that we provide most effective and high-quality 
care we can to our beneficiaries.
    Senator Tester. Appreciate that.
    Senator Shelby.
    Senator Shelby. Thank you, Mr. Chairman.
    Dr. Adirim and General Dingle, I will direct the first 
questions to you, both of you. As I noted in my statement, this 
committee continues to invest in medical research without 
regard to other similar Federal investments, it seems to me, at 
NIH, and maybe NIH is doing things you are doing better. I do 
not know that.
    Can you answer the question that I posed in my opening 
remarks, which is this?: What specifically are Defense medical 
research dollars doing that NIH funding cannot or is not doing? 
I think that is an important question.
    Dr. Adirim. Senator Shelby, I will start with this 
question, and I think that is a very good question.
    We focus our research priorities within the Department on 
the warfighter and on the needs of the Joint Force and on those 
conditions which may greatly impact our troops.
    We work very closely with the NIH and other agencies, 
coordinate very closely on research so that----
    Senator Shelby. What do you mean by working closely? Is 
that collaborative working together----
    Dr. Adirim. Yes. Yes, we do.
    Senator Shelby [continuing]. On specific things? Name some 
of them.
    Dr. Adirim. Sure. So, for example, for something like 
suicide and mental health, there is collaborative research that 
we work with NINDS (National Institute of Neurological 
Disorders and Stroke), have annual meetings on the research 
that comes out of both departments. The work groups work 
together to ensure that the research that is being done and 
sponsored by each department or together, because sometimes 
these research proposals come out of both departments are 
aligned to the requirements of our force.
    Senator Shelby. Ma'am, I realize, and I think we all do, 
that the military has certain needs that the general population 
does not need, but the military at the same time probably needs 
all of the needs and all the things that the general population 
in addition to the military specific things. Is that a fair 
statement?
    Dr. Adirim. Sure. Yes, sir.
    Senator Shelby. So name your top three research areas that 
you are doing through the military research.
    Dr. Adirim. Sure. I am going to turn it over to my 
colleague, General Dingle.
    Senator Shelby. Okay. General.
    General Dingle. Vice Chair Shelby, one of the things, to 
tag on to what Dr. Adirim was saying, the thing that the 
military also brings, as it takes the National Defense 
Strategy, the DOD guidance, and our service guidances, the 
focus is on the survivability of the soldiers.
    Senator Shelby. Absolutely.
    General Dingle. So prolonged real care in combat 
operations, trauma care, the latest technologies that we get 
from the civilian sector or in NIH, but taking those civilian 
technologies, medical technologies, it takes that military 
service research and development to incorporate it into 
tomorrow's battlefield on how it is going to be incorporated in 
a multidomain environment. And I think that is one of the key 
things that we bring from the military as we couple with the 
civilian sector, academia, and the industry.
    Senator Shelby. Okay. In the area that we all see a lot of, 
that is, improvised explosive devices dealing with our military 
that is a traumatic thing. We see it with our soldiers and 
everywhere. Is there any connection between our efforts to 
detect and prevent that and the treatment of the victims, our 
soldiers, after they have sustained huge blasts?
    General Dingle. Yes, sir. And that is one of the beauties 
of what the Chief of Staff of the Army set up with our Army 
Futures Command, because it takes that prevention mode and the 
detection to get ahead of that blast, but then even if that 
blast happens, occurs, that is when the medical research and 
development piece comes in and we are studying those blast 
injuries and how to conserve and save lives.
    So the short answer, yes, we are doing those preventive 
measures. It is all being done under Army Futures Command in 
which medical is incorporated across all of the cross-
functional teams.
    Senator Shelby. Is there any correlation in research 
dealing with, say, trauma medicine, emergency medicine, 
domestically, civilian, and what the soldiers--you know, the 
soldiers are shot at. They are shelled. They step on mines. 
They do this, a lot of the civilians are shot at too much in 
the country, but I guess, the treatment of wounds, is there 
correlated research there, Doctor?
    Dr. Adirim. Yes. And I am an emergency physician, and there 
is a number of research that has come out of the military that 
has----
    Senator Shelby. Absolutely.
    Dr. Adirim [continuing]. Greatly benefited the civilian 
sector. I mean, I can name the REBOA, which is a device that is 
used in trauma. There is fresh frozen plasma, which is 
currently being used for battlefield, which will have civilian 
applicability. So, yes, you are exactly right. A lot of what we 
do within the Department of Defense, especially around trauma 
research, is applicable to the civilian sector.
    Senator Shelby. In the area of warfighter, our soldiers, 
sailors, and marines, Air Force readiness and their health, is 
there research going on between the military research and the 
NIH research regarding with the health of our people, the 
health of our soldiers? Of course, the soldiers are probably--
not probably--are exposed to a lot different environments than 
the average American is.
    Dr. Adirim. Well, Senator, as you alluded to, there are 
multiple domains of research that we do in coordination and 
collaboration with the NIH and a lot of which has applicability 
to the civilian sector and to the American people at large.
    Senator Shelby. Admiral Gillingham, I want to shift to the 
ambulance ship, transport ship.
    The Navy recently issued a $235 million contract 
modification to construct a multipurpose Expeditionary Fast 
Transport ship. Can you talk about Navy Medicine adapting to 
Distributed Maritime Operations and specifically how the 
Expeditionary Fast Transport ship and ambulance ship will add 
value to those operations?
    Admiral Gillingham. Yes, sir. Thank you for this 
opportunity.
    We are enormously excited about what is known as the EPF 
Flight II, which is the vessel that was previously known as the 
Joint High Speed Vessel, designed initially as a logistics 
ship.
    In reviewing medical concept of operations for the 
Distributed Maritime Operations and Expeditionary Advanced Base 
Operations in support of the Marine Corps, recognized that we 
had a gap in the ability to respond quickly and much more 
quickly than we can with our Role 3 platform, the T-AH, or the 
hospital ship.
    So the ambulance ship, as envisioned, will allow us to 
respond to ships in distress, ships that may have been damaged 
in combat, be able to assist in personnel recovery.
    Senator Shelby. It also gives you a lot of mobility on the 
water, does it not?
    Admiral Gillingham. Yes, sir. The speed is--it is a 
catamaran, bi-hull catamaran. It moves very quickly. It will 
allow an Osprey aircraft to land for medevac purposes. It will 
allow us--as envisioned and as being built and adapted with 
that additional funding, it will have an operating room that 
will accommodating two operating room tables, a room for 18 ICU 
beds, a medical-enhanced Role 3 medical staff of about 100 
personnel.
    We see this as filling a critical gap in the DMO (Defense 
MilPay Office) environment.
    Senator Shelby. Would you say this--fairly say this is a 
high priority for Naval Medicine?
    Admiral Gillingham. Yes, sir. It very much is.
    Senator Shelby. Thank you.
    Thank you, Mr. Chairman.
    Senator Tester. Thank you, Senator Shelby.
    We have Senator Baldwin virtually.
    Senator Baldwin. Thank you. Thank you, Mr. Chairman.
    Dr. Adirim, how many cases of COVID-19 has the military 
seen this year and in 2020? And I also would like to hear the 
breakdown of the number of military personnel who have been 
hospitalized or who have passed away from COVID-19 since we 
first identified that threat.
    Dr. Adirim. Sure. Thank you for that question. I do not 
have the precise numbers, and we can get those to you. But what 
I can say is having looked at our percent positivity and 
following the hospitalizations, it is much less than in the 
civilian sector, which is what you would expect for a younger, 
healthier population.
    Currently, right now, we are seeing a test positivity rate 
of about 4.4 percent, and it is 6 percent out in--nationally. 
So we have a lower case rate than we see out in the civilian 
sector, and we have lower hospitalization rates as well.
    But I will get you those precise numbers for the record.
    [The information follows:]

 statistics on covid-19 infections/hospitalizations/deaths within the 
                           tricare population

----------------------------------------------------------------------------------------------------------------
                                              All beneficiaries                         Active duty
                                   -----------------------------------------------------------------------------
                                                   Private                                Private
                                    Direct Care  Sector Care     Total     Direct Care  Sector Care     Total
----------------------------------------------------------------------------------------------------------------
All COVID+........................      220,377      257,464      477,841      133,866       33,370      171,807
Hospital admissions...............        5,171       37,941       43,112          948          750        1,698
Deceased..........................          262       10,018       10,280            7           37           44
----------------------------------------------------------------------------------------------------------------


    Senator Baldwin. I will appreciate that.
    How many anthrax cases has the military seen over the same 
period of time?
    Dr. Adirim. Ma'am, I am not aware of anthrax cases.
    Senator Baldwin. Okay. Are you aware of potential anthrax 
exposure incidents that the military has experienced in the 
last year or the last 5 or 10 years?
    Dr. Adirim. Ma'am, I would not have that information. I can 
ask one of my Surgeon General colleagues if they might know the 
answer to that.
    Senator Baldwin. Does anyone have any information about 
anthrax exposure or cases in the last decade?
    General Dingle. Senator, This is Lieutenant General Dingle.
    We do not have that information on us. However, we do have 
a very detailed Environmental Health Surveillance Registry, 
which that information is documented in. We would have to take 
that for record to come back to you to provide you those 
details.
    [The information follows:]
  statistics on anthrax infections/hospitalizations/deaths within the 
                           tricare population
    The military has not had any cases of anthrax this year and in 
2020. There were a number of laboratory-based exposures in 2015 where 
individuals were treated with antibiotics and vaccinations. While there 
have been limited cases of potential anthrax exposure due to naturally 
occurring disease or laboratory incidents, the DoD maintains the 
requirement for anthrax vaccination in our personnel to counter the 
threat of the use of anthrax as warfare agent, to include use in 
bioterrorism. The advancement of biotechnology only increases this 
risk, and this is a validated threat for both DoD and the larger U.S. 
Government.

    Senator Baldwin. Okay. Does the Department of Defense plan 
to continue procuring anthrax vaccines moving forward, and if 
so, how many?
    Dr. Adirim. Senator, the anthrax is still considered a 
threat to our forces. Other governmental agencies as well has 
determined that anthrax is a threat. So to answer your 
question, it is yes. We do plan to protect our forces from 
those threats.
    Senator Baldwin. Okay. I think you can get a sense of the 
point that I am trying to make. There has been a lot of concern 
over vaccine declination rates for COVID-19 vaccines. There has 
also been a long history of concern over compulsory 
vaccinations, including for anthrax, beginning in the--towards 
the end of the 1990s. I would like to hear details on how the 
DOD has increased voluntary participation in vaccines in the 
past, and how does the Department approach making decisions 
about whether vaccinations should be compulsory for our 
servicemembers?
    Dr. Adirim. Right. Thank you for that question.
    And I can talk about COVID because we are doing a lot with 
regard to helping our servicemembers make their decisions about 
taking the vaccine.
    As you know, under EUA (Emergency Use Authorization), the 
vaccine is voluntary, and we are using every avenue possible to 
provide information, social media, and town halls. We have MTF 
physicians available to answer questions. We do Facebook live 
sessions. We put information on websites in order to provide 
accurate information about the vaccine, and as you alluded to, 
we do not have a perfect acceptance rate.
    We do not know what the declination rate is, really, 
because we only just yesterday opened up vaccination to all 
eligible beneficiaries. But we do track this, and we are very 
interested in helping our servicemembers and other 
beneficiaries make the decision to get vaccinated.
    Senator Baldwin. Dr. Adirim, you stated in your testimony 
that the greatest proximate challenge to our Nation's security 
is the threat of COVID-19, and I asked about anthrax because I 
am concerned that our spending priorities are not aligned with 
both current and emerging threats.
    We have known that a pandemic based on a novel virus, that 
it would attack the respiratory system, could cripple our 
country, and yet we did not purchase PPE (Personal Protective 
Equipment), and we did not reassure manufacturing of critical 
medical supplies or vaccines, yet 2020 saw one of the largest 
purchases of anthrax vaccines, a threat that to my knowledge 
has not been included in annual worldwide threat assessments or 
highlighted in testimony to the Congress in many years.
    And from 2015 through 2020, we spent about $1 billion on 
anthrax vaccines, even though many experts, including Dr. 
Fauci, have suggested that the best approach towards anthrax is 
antimicrobial therapy.
    I understand the continued need to monitor this thread, but 
it does seem to me like we have prioritized the requirement for 
this vaccine at the expense of preparing to protect our 
servicemembers and families against things like global 
pandemics. So I am looking forward to following up on my line 
of questioning.
    Thank you.
    Senator Tester. Thank you, Senator Baldwin.
    I only have one request, and then we will close this 
hearing out. And it is for Dr. Adirim. I would like to have you 
get to me and the committee, the research that is being done in 
respiratory ailments as it applies to burn pits, and I would 
ask that you be specific on the respiratory ailments that you 
are looking at. It is a big, big, big issue that has got some 
legs, this Congress, as far as providing benefits to our 
veterans.
    [The information follows:]
                health issues associated with burn pits
    The Department of Defense (DoD) and the Department of Veterans 
Affairs (VA) have funded many research studies related to the possible 
respiratory effects of airborne hazards in theater, including burn pit 
exposure. Many studies have been published on the relationship between 
exposure to airborne hazards and respiratory conditions, including: 
respiratory symptoms (chronic cough, dyspnea (shortness of breath), and 
wheezing); asthma; COPD (chronic obstructive pulmonary disease, that 
is, chronic bronchitis and emphysema); constrictive bronchiolitis; and 
several other lung diseases, such as sarcoidosis. DoD is currently 
funding human health studies on the relationship between burn pit 
exposure and the following conditions: respiratory symptoms; asthma; 
chronic bronchitis; constrictive bronchiolitis; and several other lung 
and cardiovascular diseases. VA is currently performing a long-term 
mortality study of veterans of Operation Iraqi Freedom (OIF) and 
Operation Enduring Freedom (OEF), which will evaluate the death rates 
due to several types of lung diseases and several types of cancer. The 
National Academy of Sciences (NAS) is a nationally recognized 
organization that is independent of the Federal Government. The NAS 
published a comprehensive 270 page report in September 2020, entitled 
``Respiratory Health Effects of Airborne Hazards Exposures in the 
Southwest Asia Theater of Military Operations.'' The NAS reviewed 
hundreds of health studies related to airborne hazards in theater, 
including studies funded by DoD, VA, and non-Federal sources. The NAS 
report evaluated the scientific evidence on 27 respiratory health 
outcomes, including all the diseases mentioned previously. The NAS 
report concluded there was limited evidence that there is an 
association (relationship) between exposure to airborne hazards in OIF/
OEF and respiratory symptoms of chronic persistent cough, shortness of 
breath, and wheezing. DoD and VA are continuing to fund multiple human 
health studies to develop more definitive evidence on the relationship 
of exposure to airborne hazards in theater and long-term health 
effects.

                     ADDITIONAL COMMITTEE QUESTIONS

    Senator Tester. I want to thank Senator Shelby and Senator 
Baldwin for their questions today. I want to thank you for your 
testimony today. The witnesses know that Senators may submit 
additional written questions, and we ask you to respond to them 
within a reasonable time.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
                Questions Submitted to Dr. Terry Adirim
            Questions Submitted by Senator Richard J. Durbin
    Question. This Subcommittee has long prioritized life-saving 
medical research--it improves our military edge, protects our service 
members and their families, and produces real, tangible benefits for 
all Americans.
    As the Defense Health Agency works toward a larger role in defense 
medical research, how do you plan to ensure that the effort continues 
to prove its value?
    Answer. DHA recognizes the long history of Research, Development 
and Acquisition (RDA) accomplishments made within DoD. DHA seeks to 
continue that history with support to the vital DoD research enterprise 
in advancing the delivery of capabilities to the warfighter and 
beneficiaries through support to elements such as the Congressionally 
Directed Medical Research Program that fosters synergy with academia, 
industry and other Federal agencies and continued support to CONUS and 
OCONUS DoD laboratories. As DHA takes on a larger role in the defense 
biomedical research enterprise, metrics will be captured that will 
demonstrate the value of a consolidated enterprise medical research 
organization.
    Question. Over the years, DoD has leveraged civilian partnerships 
to stretch limited dollars wisely and maximize research efforts, direct 
care, and military readiness. For example, DoD has successfully 
partnered with academic institutions on trauma training, through 
engagement on various programs as well as even assigning military 
medical personnel to civilian trauma centers. And in fiscal year 2019, 
Congress created a new pilot program to treat members of the Armed 
Forces for psychological conditions--such as PTSD--stemming from 
military sexual trauma, with the idea being that DoD should partner 
with civilian institutions for this effort. As we know, sexual assault 
can be a significant source of trauma stress for service members and 
their families. And while service members can and do receive adequate 
care within the Department, it is to DoD's advantage to have outside 
treatment options available to accommodate service members, where 
public stigma has too long been a barrier to care. However, I have been 
disappointed that in implementation of this new pilot, for which 
Congress has appropriated $9 million between fiscal year 2019 and 
fiscal year 2021, DoD has yet to choose a civilian academic medical 
center to participate.
    Please elaborate on the benefits of civilian partnerships within 
the defense health program and provide some examples.
    Answer. The defense health program (DHP) engages in civilian 
partnerships to address emerging needs that are not able to be met by 
existing government capacities. Civilian partnerships are most valuable 
when they provide expertise and/or programmatic capability that the 
government cannot feasibly or efficiently deliver in the timeline 
needed. Several examples are noteworthy. In 2010 the DHP funded and 
established the Military Suicide Research Consortium (MSRC). The MSRC 
leverages civilian scientific expertise as well as DoD capabilities to 
study the causes and prevention of suicide. Suicide etiology and 
prevention are complex scientific fields with substantial research gaps 
that cannot entirely be met by existing internal defense health program 
efforts. The military's Alcohol and Substance Abuse Disorder Research 
Program (ASADRP) expedites the identification of therapeutic compounds 
for the treatment of alcohol and substance use disorders through the 
multidisciplinary expertise of researchers from both the DoD and the 
civilian sector, most notably the University of California San 
Francisco and the Research Triangle Institute. The Study to Assess Risk 
& Resilience in Service members Longitudinal Study (STARRS-LS) benefits 
from a broad DoD/civilian partnership to address behavioral health 
issues in the military. The STARRS-LS collaboration taps the diverse 
skills of investigators at numerous research institutions including 
Uniformed Services University of the Health Sciences, the University of 
California at San Diego, Harvard Medical School, and the University of 
Michigan. In addressing treatment needs associated with military sexual 
assault and sexual harassment, the VA/DoD Women's Health Working group 
has also engaged with civilian partners with subject matter expertise 
from the School of Medicine at the University of Colorado-Denver and 
the University of Washington.
    DoD outreach campaigns to support transitions and reduce stigma 
also significantly benefit from collaborative partnerships with 
academic, industry, and civilian organizations. For example, the 
inTransition program and the Real Warriors Campaign make dedicated 
efforts to engage and foster collaborative partnerships with the 
Elizabeth Dole Foundation, Washington Nationals Baseball, Sesame 
Workshop, Give an Hour, Army Wife Network, Operation Homefront, Emory 
University Healthcare Veterans Program, General Electric, George Mason 
University, the University of Texas, and the American Red Cross.
    If the government has the capability and expertise to complete the 
mission, external partnerships may not be warranted. Internally 
conducted government projects ensure that incentives are aligned with 
internal needs and priorities, with minimal financial or scientific 
biases. Sometimes, however, contributions from civilian partners can 
add knowledge, resources, scope, and efficiencies that DoD alone cannot 
offer. Ultimately, the choice whether or not to work with external 
partners is determined by the availability of expertise, the maturity 
of the scientific and programmatic field, and the timeline for 
delivery.
    Question. How has DoD used the appropriated funds for the 
implementation of the MST pilot, and how do you intend to use the 
fiscal year 2021 funds?
    Answer:
  --Healthcare Cost Impact: Actual healthcare costs are not available 
        due to claims lag. Based on the current participation rate (43 
        participants as of 4/30/21), it is projected that DoD will 
        execute the full amount of $174,000. The pilot ends 8/31/21 
        with last admission to the pilot program on 7/31/21.
  --Administrative Cost Impact: The total administrative cost as 
        reflected in the definitization modifications of the contracts 
        is $200,059. The contractor's proposal costs came in lower than 
        the Independent Government Cost Estimate (IGCE), therefore, 
        lower costs were negotiated.
  --Related tasks/adjustments: Based on the current participation rate, 
        it is not expected that there will be higher enrollment as 
        projected. Therefore, DoD cannot execute $297,000 for related 
        tasks or adjustments as indicated in previous spend plans.
    Question. How does DoD plan to expand its civilian partnerships 
when it comes to the MST pilot, and will there be an opportunity for 
academic medical centers to participate?
    Answer. Section 702 of the NDAA for fiscal year 2019, authorized a 
pilot program to treat psychological sequelae associated with sexual 
assault to be accomplished through partnerships with public, private, 
and non-profit healthcare organizations and institutions. These 
partnership institutions must provide healthcare to TRICARE eligible 
members of the Armed Forces (including National Guard and Reserve). The 
pilot program is focused on treatment of Service members suffering from 
psychological health conditions associated with sexual assault 
including PTSD, substance misuse and depression. The pilot is designed 
to assess the feasibility and advisability of DoD-wide implementation 
of a DoD/civilian partnership model utilizing the IOP treatment format.
    All academic and private civilian intensive outpatient programs 
were eligible to participate in the pilot if they met TRICARE standards 
and were TRICARE certified (based on TRICARE Operations Manual chapter 
6010.59-M, Chapter 18, Section 8). Despite an open call for partners 
across civilian and academic medical centers, no academic medical 
centers applied for TRICARE certification.
    Civilian partner IOPs were selected in September 2020. To date, 
five TRICARE-certified intensive outpatient programs have enrolled in 
the pilot as well as two DoD intensive outpatient programs. All 
civilian partner IOPs have been engaged and are in active data 
collection.
    Enrollment numbers are in line with expectations overall, but the 
Humana sites have lower enrollment (Humana = 2, Healthnet = 41, DoD = 
133). PHCoE has engaged in several efforts to increase enrollment in 
civilian sites. PHCoE met with THP and Humana clinics to review 
implementation procedures and problem solve, DHA Communications was 
engaged to increase awareness of pilot among end users, and Humana has 
plans to pivot to 100 percent telehealth in an effort to mitigate 
travel concerns.
    Civilian Partner IOP programs include:
  --Oceans at Waco, TX
  --Oceans at Biloxi, MS
  --Help for Heroes at Denver Springs, CO
  --Strong Hope at Salt Lake Behavioral Health
  --Aurora Behavioral Health at San Diego
    Due to data collection being underway at all DoD sites and civilian 
partner sites, no additional sites are projected to be added to the 
pilot prior to its completion in August 2021.
    Question. I am pleased that the Defense Health Agency (DHA) chose 
the Army's Civilian Human Resources Agency (CHRA) as its provider of 
human resource support. I worked to ensure that CHRA, based at Rock 
Island Arsenal, was the primary office responsible for supporting DHA's 
human resource needs. I recognize that COVID placed a hold on hiring of 
many positions within the Department of Defense and, to date, only 
about 50 positions have been filled at Rock Island in support of the 
DHA contract.
     Can you detail for me when you expect the freeze on civilian 
hiring to be lifted?
    Answer. There has not been a freeze on civilian positions in the 
DHA. The DHA leverages all available human resource authorities to fill 
positions above the MTF level that include: Transfer of Functions, 
Management Directed Reassignments and competitive hiring since CHRA 
became the Human Resource Service Provider to the DHA.
    Question. Further, can you detail how many additional positions you 
expect CHRA to hire in order to support DHA requirements?
    Answer. The DHA has in excess of 450 civilian positions being 
actively recruited through CHRA. There are over 310 additional vacant 
positions available to the DHA for recruitment.
    Question. I understand the importance of the on-demand blood 
program and it's potential benefit to readiness and addressing critical 
supply challenges.
    Can you elaborate on the anticipated funding for the program this 
current fiscal year as well as into the FYDP?
    Answer. The total funding for this program is $110 million over 5 
years. To date the program has received $15 million (fiscal year 2019; 
Year 1) and another $12 million (fiscal year 2021, Year 2; pending 
award) this year for a total of $27 million.
    Question. Can we expect future budget requests to seek making this 
program a program of record within the Department of Defense? Why or 
why not?
    Answer. Currently the On-Demand Blood (ODB) program and its host, 
the USU-4D Bio3 Center for Biotechnology, are not Programs of Record 
and rely on annual budget funding prioritization. The ability to 
manufacture clean blood products near the point-of-need, even austere 
environments, could mitigate blood supply vulnerabilities not only for 
our warfighters deployed overseas but also for our Nation as reported 
in the 2020 HHS Report to Congress: Adequacy of the National Blood 
Supply (attachment). This report highlighted multiple challenges with 
sustaining the National Blood Supply that are particularly problematic 
during national emergencies such as the current COVID-19 Pandemic. With 
this program, we hope to mitigate the various National Blood Supply 
vulnerabilities by creating an alternate source of clean blood to 
traditional blood donation, not only for our Warfighters but also for 
the Nation and Global Health Community.
    Question. Has DoD done enough with interagency partners and the 
scientific community to address concerns? What type of interagency 
collaboration is occurring with this project?
    Answer. The USU-4D Bio3 ODB program consists of collaborations with 
the FDA, Harvard/Massachusetts General Hospital, as well as three 
industry partners. The program is also in partnership discussions with 
other Federal agencies, to include National Institutes of Health (NIH), 
Armed Service Blood Program (ASBP), Assistant Secretary for 
Preparedness Response (ASPR), Biomedical Advanced Research and 
Development Authority (BARDA), Federal Emergency Management Agency 
(FEMA), National Institute of Standards and Technology (NIST), National 
Aeronautics and Space Administration (NASA), and the UK Ministry of 
Defense and Innovate UK.
    Question. Does the Department of Defense have plans to develop a 
demonstration of on-demand blood in a real world training scenario like 
any of the major training exercises in the Pacific?
    Answer. Yes, in conjunction with USU-4D Bio3's Fabrication in 
Austere Military Environments (FAME) Program, it is our goal to conduct 
demonstrations of the On-Demand Blood program's capabilities to 
fabricate blood in austere environments. Currently, we are also 
exploring development of autonomous means to provide blood in theater. 
The team is in discussions with leadership of the ASBP and individual 
COCOMS to determine a transitional training scenario for fiscal year 
2022/2023 as the bioreactor technology that fabricates the blood 
products will be ready for in-field testing/deployment at that time.
    Question. I am concerned that there has been significant decrease 
in DHP core neurosensory research especially in vision-ocular trauma 
intramural funding that decreased from fiscal year 2019 $5.8 million 
under the JPC-8 Army Medical Material Research Command (MMRC) in the 
core vision research funding to $1,000,000 for fiscal year 2020 and 
fiscal year 2021 with no further funding fiscal year 2022 to fiscal 
year 2025. This leaves military trauma ophthalmologists with no 
internal trauma research funding, despite wounded warrior research 
remaining a priority at DoD.
    Please provide the amounts that DHP has funded for core trauma 
research funding for sensory injuries, including vision and hearing, 
TBI, orthopedic, and spinal cord injury research for fiscal year 2021. 
What is projected for fiscal year 2022 for each?
    Answer.

                Planned RDT&E Funding for Trauma Research
------------------------------------------------------------------------
                                                    Fiscal Year
              Research Area              -------------------------------
                                             2021 ($k)       2022 ($k)
------------------------------------------------------------------------
Vision..................................             $--             $--
Hearing.................................         $10,538          $7,587
TBI.....................................        $105,065         $47,272
Orthopedic..............................         $19,641         $19,511
Spinal Cord.............................          $4,272          $2,377
Other (non-specified)...................         $71,107         $59,686
    Total...............................        $210,623        $136,433
------------------------------------------------------------------------

                                 ______
                                 
              Questions Submitted by Senator Patty Murray
    Question. As you know, the Department of Defense has a long 
standing need for agents to prevent disease and death caused by plague 
and botulinum toxin, with the Department of Homeland Security issuing a 
Material Threat Determination in 2004 for both of these diseases. 
However, funding for these two vaccines under the Joint Vaccine 
Acquisition Program (JVAP) were zeroed-out as a result of the fiscal 
year 2021 Defense-Wide Review despite significant previous financial 
investment and completion of both Phase 1 & 2 clinical trials. Why are 
these programs being cancelled without alternatives in place? Will the 
Department propose other avenues to ensure servicemembers are not at 
risk?
    Answer. While OASD(HA) supports the Warfighter and all DoD 
personnel for all health aspects, we would have to defer questions on 
the development of countermeasures against manmade threats such a 
plague and botulinum toxin to the Office of the Assistant Secretary of 
Defense for Nuclear, Chemical and Biological Defense Programs. OASD(HA) 
is a stakeholder within the Chemical and Biological Enterprise, but we 
do not have control over the resourcing and developmental decisions in 
this space.
                                 ______
                                 
             Questions Submitted by Senator Jeanne Shaheen
    Question. The Biden Administration has reported that National 
Institute of Allergy and Infectious Diseases (NIAID) is examining the 
durability of the immune response and that the National Institutes of 
Health (NIH), Centers for Disease Control and Prevention (CDC), and 
Department of Defense (DoD) are assessing whether vaccine-induced 
immunity, or natural immunity from prior infection, can be effective in 
combating COVID 19 emerging variants. T cell testing has been 
integrated into the United Kingdom COVID immune response assessment.
    What are your views on the need to measure immune response?
    Answer. The Department believes it critical to understand the 
immune responses to COVID vaccination (and wild-type disease) to 
establish a known correlate of protection. This will help improve 
diagnostics and vaccines and help drive the future efforts to combat 
this disease.
    Question. What role do you see for T cell mediated response being 
integrated into vaccine efficacy assessments at DoD?
    Answer. The Department supports further study of the T cell 
compartment, as various studies have shown differing results between 
the B cell and T cell compartments, to include distinct kinetics.
    Although T cell tests are not routinely used clinically, they do 
provide extremely valuable insight to ultimately determine efficacy of 
some vaccines. We are committed to continued collaboration/partnership 
of DoD with national efforts. An Uniformed Services University/
Infectious Disease Clinical Research Program protocol proposal is just 
one example of that commitment.
                                 ______
                                 
            Questions Submitted by Senator Susan M. Collins
    Question. At the beginning of the COVID-19 pandemic last year, the 
nation saw a huge spike in demand for modular negative pressure room 
containment systems that can offer civilian hospitals or Military 
Treatment Facilities the capability to safely assess and treat patients 
with suspected COVID-19 symptoms. It is clear these commercial-off-the-
shelf systems can help ensure the readiness of the defense health 
system worldwide, especially in the case of future pandemics or 
biological attacks. Section 732 of the recently enacted fiscal year 
2021 National Defense Authorization Act (NDAA) requires a report of the 
Department's pandemic preparedness. I was pleased that the Department 
has committed to ensuring that these modular negative air pressure room 
containment systems are included as part of that Pandemic Preparedness 
Report directed by the NDAA. Provisions unanimously approved in the 
Senate's fiscal year 2021 NDAA bill also required a specific review of 
these systems.
    Given the use of these systems in the civilian sector and in VA 
hospitals, what does the DoD believe to be the potential benefits of 
these systems?
    Answer. Although there is limited published literature that 
provides a comparative analysis of modular negative air pressure room 
systems to traditional structures, such systems have demonstrated value 
in specific situations and environments. Specifically, these systems 
are believed to create a negative pressure environment designed to 
contain airborne infectious pathogens with minimal assembly time and 
disruption to permanent facility structures. One unique system with 
demonstrated success is the USTRANSCOM/Air Mobility Command developed 
Negatively Pressurized CONEX and CONEX Light (NPC, NPCL), which allows 
the transport of critically ill patients with highly contagious 
diseases aboard pressurized, military cargo aircraft. The CDC 
highlights the fact that inadvertent exposure to airborne pathogens can 
result in significant morbidity and/or mortality and the American 
Society of Heating, Refrigerating and Air Conditioning Engineers 
(ASHRAE) has emphasized that disease outbreaks (i.e., epidemics and 
pandemics) are increasing in frequency and reach.
    Question. How could these types of systems be used by DoD in the 
future to help mitigate the spread of future pandemics or biological 
agents in the future?
    Answer. Understanding that some facilities and environments may not 
be conducive to construction of permanent fixtures, modular negative 
air pressure room systems have the potential to serve as an alternative 
solution for pathogen containment. Integration of such systems is most 
applicable in situations where facilities are at risk for operating 
beyond surge capacity (e.g., uniquely positioned OCONUS facilities) and 
therefore emergency preparedness should be directly aligned to each 
facility's risk assessment. ASHRAE supports such statements and 
emphasizes that, Mitigation of infectious aerosol dissemination should 
be a consideration in the design of all facilities, and in those 
identified as high-risk facilities the appropriate mitigation design 
should be incorporated.
    Given the unique mission of the DoD, integration of innovative 
solutions such as the NPC/NPCL is critical for effective emergency 
preparedness with broad-scale applicability, including protection of 
personnel from pathogens during humanitarian relief operations. 
Decision-making regarding any emergency preparedness strategy must 
consider the evolving nature of biologic threats and therefore 
integrate a multi-layered systems approach in collaboration with 
bioenvironmental engineering.
                                 ______
                                 
             Questions Submitted by Senator Lisa Murkowski
    Question. A multitude of studies indicate that those who have 
served in the military are at a much greater risk of developing ALS 
(ALS, or amyotrophic lateral sclerosis, is a progressive 
neurodegenerative disease that affects nerve cells in the brain and the 
spinal cord) and dying from the disease than those who have no history 
of military service. I was pleased that $40 million in funding was 
provided to the Congressionally Directed Medical Research Program 
(CDMRP) for peer-reviewed ALS research for fiscal year 2021. Support 
for this research has been a long-time priority of mine, and an issue 
that is near and dear to my heart.
    Do you believe enough research on ALS is being done through the 
DoD's Peer Reviewed Medical Research Program (PRMRP)?
    Answer. The annual appropriation for the Peer Reviewed Amyotrophic 
Lateral Sclerosis (ALS) Research Program (ALSRP) has grown from $10 
million in fiscal year 2019 to $20 million in fiscal year 2020 to $40 
million in fiscal year 2021, totaling $149.4M since the program was 
established in 2007. With a focus of expediting the pipeline from bench 
science to new clinical therapeutics, historically, the ALSRP has 
offered awards in the areas of ``Therapeutic Development'' and 
``Therapeutic Ideas,'' with maximum awards up to $1 million and $500k 
in fiscal year 2020 respectively. This has resulted in 84 awards made 
through fiscal year 2019 and currently 19 awards made against the 
fiscal year 2020 appropriation.
    The Therapeutic Development award mechanism supports post-discover 
validation and development of candidate therapeutic agents through the 
steps required prior to FDA approval as an Investigational New Drug 
(IND). The Therapeutic Idea award mechanism supports high risk/high 
reward hypothesis-driven therapeutic ideas in an early stage of 
development. In fiscal year 2020, a third category, ``Clinical 
Development'' was introduced with a maximum award of $300k. This 
category of award is designed to support leveraging of patient-based 
ALS resources to define subtypes, predict therapeutic responses, 
improve the value of ongoing clinical trials, and/or optimize the 
components of current ALS clinical care.
    Question. Do you anticipate that an increase in funding will be 
needed to continue research under the new realities that the pandemic 
has imposed on us?
    Answer. The cost of research is always increasing due to inflation. 
The ALSRP adjusts the number of awards made in order to fund 
scientifically and technically appropriate research that provides the 
greatest impact in support of the programmatic vision established by 
the Programmatic Panel as part of the five-step process for soliciting, 
reviewing, and funding research. As an example and as described in the 
question above, the increase to $20 million in fiscal year 2020 enabled 
a new award mechanism to be established.
                                 ______
                                 
               Questions Submitted by Senator Jerry Moran
    Question. Dr. Adirim states in her written testimony that Joint VA/
DoD Clinical Practice Guidelines (CPGs) have been formulated for 
provider use for all major clinical conditions in mental health. 
However, there are not any current CPGs available that address serious 
mental illness (SMI) and conditions such as bipolar disorder and 
schizophrenia. In Public Law 116-171 Sec. 304, Congress directed DoD 
and the Department of Veterans Affairs to work together to develop 
current CPGs that address these SMI conditions.
    Can the Department please provide an update on the establishment of 
the work group directed by Congress in this Act in order to begin the 
development of the SMI CPGs?
    Answer. The VA and DoD are collaborating on two new VA/DoD CPGs 
that address serious mental disorders, one for schizophrenia and the 
other for bipolar disorder. Both VA and DoD teams have secured working 
group members and are awaiting on final arrangement with the VA 
contractor to start the work. A new CPG usually takes anywhere from 12-
18 months to complete.
    Question. Dr. Adirim, I continue to have concerns in regards to the 
high rate of suicide among our service members in the 1 year period 
post-transition. In your written statement, you mention that the 
Department and VA are currently working together to develop a 
Separation Health Assessment which will feature a Mental Health 
Assessment.
    Can you provide any more detail on what this Mental Health 
Assessment will include?
    Answer. The Mental Health Assessment (MHA) of the Separation Health 
Assessment (SHA) will have five components. These components are (1) 
The PC-PTSD-5, a screening instrument for PTSD; (2) The Patient Health 
Questionnaire (PHQ)-2, a screening instrument for depression; (3) The 
AUDIT-C, a screening instrument for alcohol use; (4) The Columbia 
Suicide Severity Rating Scale (C-SSRS) Screener, a screening instrument 
for suicide risk; and, (5), A 2 question screening instrument for 
violence risk.
    Question. Further, do you have an estimated timeline for when this 
assessment will be rolled out to service members?
    Answer. The Department anticipates that the SHA will be implemented 
in late 2022.
    Question. How will the DoD and VA share information to make certain 
recently-separated individuals receive the care they require?
    Answer. The DoD and VA will utilize the Electronic Health Record 
(EHR) to share information to make certain recently-separated 
individuals receive the care they require. Additionally the DoD's 
inTransition program and the VA's Military and Veterans Crisis line 
have integrated efforts to provide improved, comprehensive support for 
service members. The inTransition program works closely with the MVCL 
to connect callers with follow-up treatment after receiving crisis care 
at a military or civilian emergency department.
    Question. There is a somewhat long and complicated process for 
active duty service members in allied healthcare occupation specialties 
to receive approval and funding for professional credentialing 
opportunities. This leaves service members unable to translate their 
military training and experience into skills and qualifications 
required by private sector healthcare employers. As the COVID-19 
pandemic puts an increased burden on the healthcare workforce, 
improving the credentialing process seems like an easy way for DoD to 
assist in this space while helping thousands of service members 
transition to civilian life.
    Does the Department have a strategy to assist the service branches 
to fund and strengthen the credentialing process, such as through DHA's 
Education and Training Directorate?
    Answer. This question primarily concerns enlisted service members 
in the MHS, thus this answer focuses on the Medical Education and 
Training Campus (METC) and the work it does to both enhance the skills 
and education of our enlisted healthcare personnel while also assisting 
them in obtaining credentials that translate to the civilian sector 
upon separation or retirement. The METC offers 48 enlisted education 
and training programs and is accredited by the Council on Occupational 
Education (COE). METC's institutional accreditation qualifies 
individual programs to obtain specialized or programmatic 
accreditation. Both institutional and programmatic accreditation are 
prerequisite to students earning a certification, or a professional 
license.
    The METC has 14 accredited programs and five non-accredited 
programs that generate a student certification or license.
    In addition to maintaining institutional and programmatic 
accreditations, the METC is a branch campus of the College of Allied 
Health Sciences (CAHS) under the Uniformed Services University of 
Health Sciences (USU). The METC/CAHS branch campus is currently 
comprised of 15 enlisted training programs, all of which have Associate 
of Science in Health Sciences (ASHS) degree plans.
    Students attending programs that are part of the METC/CAHS branch 
campus receive a USU transcript with credit hours for successfully 
completed course work. Credit hours can be applied toward the programs' 
established degree plan, or transferred directly to the student's 
choice of school. All 48 enlisted medical education and training 
Programs have an avenue to receive college credit which can be 
transferred directly to colleges or universities, or applied to a 
bridge school program.
    The METC also partners with colleges and universities to offer 
Bridge Degree Programs. This program offers pathways to college degrees 
and certifications by giving credit for military education and 
articulating the credit into a career/college degree pathway. 
Currently, METC has 89 Bridge Degree Partners and over 1400 degree 
bridge pathways. This program saves both enlisted service members' and 
veterans' time and money, and makes the possibility of earning a 
college degree more attainable. Colleges and universities that wish to 
become a bridge partner express interest and then navigate a 
streamlined 8-step process that usually includes a campus tour, 
curriculum crosswalk, a question and answer session via email or other 
venues, a proposal of transfer credits, feedback from METC program 
directors, and acceptance of the proposal and bridge pathway that 
signifies an informal partnership. Degree bridge programs, plans, or 
pathways illustrate the courses military members must complete to earn 
a specific college degree after transfer credits have been authorized. 
Maintenance and expansion of these partnerships and pathways are vital 
to the well-being of veterans and their families and saves the DoD 
millions in education related costs. This program is at no-cost to the 
government and free to the service members receiving transferable 
credit. The only cost occurs when the service member attends the 
institution of choice to complete the remaining degree requirements as 
spelled out on the degree pathway.
                                 ______
                                 
               Questions Submitted by Senator John Hoeven
    Question. To immunize our service members as well as the general 
population, we need to produce enough vaccines. This includes having 
enough domestic manufacturing capacity to effectively produce the key 
components of the vaccines. As you may be aware, Aldevron is a company 
based out of Fargo, North Dakota, that manufactures advanced biological 
materials such as those used in the COVID-19 vaccines. They have a 
history of working with Federal partners, and are uniquely fitted to 
meet our future vaccine materials needs. Aldevron has been in 
communication with the Defense Production Title III Office at the 
Department of Defense as well as with the Biomedical Advanced Research 
and Development Authority (BARDA) to discuss their manufacturing 
capabilities.
    Will you work with my staff to ensure that American manufacturing 
companies like Aldevron, which supply key starting materials for the 
production of medical countermeasures and vaccines, can be part of the 
solution as we continue to respond to COVID-19 and prepare for future 
pandemics?
    Answer. OASD(HA) is happy to work with your staff to look at ways 
to improve the readiness of our Forces, including scale up and access 
to pandemic vaccines. We also have a robust relationship with Health 
and Human Services including BARDA, and are happy to explore 
partnerships that enable the Department to increase the protection of 
our force where it is most needed.
    Question. I note from your testimony the work that you are doing 
with the Veterans Administration to develop a single separation health 
assessment for those leaving service. You mentioned that this would 
include a mental health assessment, which is an important component. In 
the past, we have taken steps to support our active duty force but left 
out our service members in the reserve components.
    Can you confirm whether this assessment would be available to 
members of the reserve component who are separating from service?
    Answer. Currently this assessment would be available to members of 
the Reserve Component (RC) who are separating from Service if they meet 
the eligibility requirements as specified in Section 1145(d) Physical 
Examinations for Certain Members of a Reserve Component, of Title 10.
    Question. Would you support providing a single separation health 
assessment, including a mental health assessment, to all members of the 
Selected Reserve, regardless of whether or not they have served 30 days 
in support of a contingency operation?
    Answer. We support evidence-based screenings and examinations based 
on known and potential risks experienced during military service and 
the individual's medical needs. The single separation health assessment 
under development includes a physical examination. For many short non-
contingency operations a DD2697, ``Report of Medical Assessment'' or 
post-deployment health assessment and mental health assessment would be 
more appropriate and efficient for the Service member and DoD.
                                 ______
                                 
       Questions Submitted to Lieutenant General R. Scott Dingle
            Questions Submitted by Senator Richard J. Durbin
    Question. What are you doing on a regular basis to drive an anti-
tobacco message throughout your Service? Are we making progress?
    Answer. The Army Surgeon General's role in promoting tobacco-free 
living and directing tobacco-free campuses creates momentum to 
transform Army culture. By providing a healthier, tobacco product- free 
environment and readily accessible services to help users quit, the 
Army will cultivate a resilient, effective, and battle-ready force.
    Revisions to Army policy, such as AR600-63, AR40-5, AR 600-85, to 
name a few, highlight and emphasize the responsibility of 
installations, commanders and supervisors to create a culture that 
encourages and reinforces tobacco-free living.
    Tobacco use has decreased by nearly 7.0 percent since 2013. As of 
2017 Army has a lower rates than the general population.
    Question. What is the impact that we are seeing on service members 
with the rise of tobacco alternatives such as e-cigarettes and vapes?
    Answer. Tobacco product use, including e-cigarettes and vapes are a 
threat to the readiness and the resilience of our Army. 7.2 percent of 
Soldiers now self-report use of E-cigarettes or vape pens. Soldiers who 
use e-cigarettes realize decreased performance during physical 
evaluation tests compared to those who do not use. Soldiers that smoke 
and vape do the poorest.
    Some Soldiers view e-cigarettes and vapes as a safer alternative to 
cigarettes. Army Public Health is actively engaged with the DoD tobacco 
education campaign, and is continuing to educate Soldiers on the 
negative effects of e-cigarettes and resources to quit.
    Question. What are you doing about the impact of tobacco on 
military children and family members? Are you reviewing whether these 
products should be sold in military exchanges or commissaries?
    Answer. My team is working with Army Installation Management 
Command, in support of a great effort called Healthy Army Communities. 
Healthy Army Communities is an effort to create an environment where 
the healthy choice is the easy choice. The tobacco free-living part of 
this initiative is to work with installation commanders to expand 
tobacco free zones to where children live and play on installations, 
which is aimed at raising our Army youth as non-tobacco users.
    Cigarettes used to be cheaper to buy on post than off post. One 
important effort with the reduction of tobacco use in our military was 
the DoD Tobacco Pricing Policy. Now, tobacco products sold on post must 
be the same price as off post. This is a big change for our Soldiers 
and literature demonstrates that price increase discourages tobacco use 
and increases quit rates.
                                 ______
                                 
            Questions Submitted by Senator Susan M. Collins
    Question. At the beginning of the COVID-19 pandemic, the nation saw 
a huge spike in demand for modular negative pressure room containment 
systems that can offer civilian hospitals or Military Treatment 
Facilities the capability to safely assess and treat patients with 
suspected COVID-19 symptoms.
    It is clear these commercial-off-the-shelf systems can help ensure 
the readiness of the defense health system worldwide, especially in the 
case of future pandemics or biological attacks.
    Section 732 of the recently enacted fiscal year 2021 National 
Defense Authorization Act (NDAA) requires a report of the Department's 
pandemic preparedness. I was pleased that the Department has committed 
to ensuring that these modular negative air pressure room containment 
systems are included as part of that Pandemic Preparedness Report 
directed by the NDAA. Provisions unanimously approved in the Senate's 
fiscal year 2021 NDAA bill also required a specific review of these 
systems.
    Given the use of these systems in the civilian sector and in VA 
hospitals, what does the Army believe to be the potential benefits of 
these systems?
    Answer. In accordance with NDAA 2017 and 2019, the Defense Health 
Agency assumed authority, direction, and control of DoD's CONUS medical 
treatment facilities (MTF) on 25 OCT 19 with the transfer of all MTFs 
and Service direct support to be complete by 30 SEP 21.
    The Defense Health Agency implemented 14 modular COVID-19 screening 
facilities in CONUS and another eight OCONUS. The eight units in Europe 
include negative pressure rooms and HEPA filtration. The units in the 
U.S. do not include negative pressure rooms.
    These modular facilities are used to screen patients before they 
enter the medical treatment facility. Modular, negative pressure room 
containment systems were not used for the treatment of Army COVID-19 
positive patients.
    Hospitals used existing patient isolation capabilities and modified 
rooms and HVAC systems to create isolation within their existing 
footprints. Portable, self-contained HEPA filtration systems were 
employed in some cases to create negative pressure in treatment spaces.
    For dental clinics, DHA created Expeditionary Dental Air Infectious 
Isolation Rooms (EDAIIR) for two dental chairs per clinic using 
commercial-off-the-shelf HEPA whisper flow fan units and zip wall 
barrier sheathing.
    Question. How could these types of systems be used by Army in the 
future to help mitigate the spread of future pandemics or biological 
agents in the future?
    Answer. From Army perspective, Military Health System can implement 
a range of methods to help mitigate the spread of infectious diseases 
within MTFs.
    Patient isolation, personal protective equipment, frequent 
cleaning, and personal hygiene all play a part.
    Modular systems are one method for temporarily creating anterooms, 
treatment spaces, and support spaces. These systems can be used to 
physically separate visitors from patients and staff, contagious 
patients from non-contagious patients, and pre-admit patients from the 
admitted patient population.
    Future implementation would be in DHA's decision space.
                                 ______
                                 
             Questions Submitted by Senator Lisa Murkowski
    Question. Over the past year, the world has grappled with COVID, 
and mental health continues to be one of the least understood and most 
overlooked effects of the pandemic. Stress, fear, isolation, financial 
impacts and the loss of friends and family have contributed to the 
increase in anxiety and depressive disorder symptoms.
    Has the Department of Defense seen an increase in service member 
suicides over the past year?
    Answer. Army Medical Command vigorously supports Army G-1 efforts 
to assess the root cause of the Army suicide cluster.
    The Army is experiencing an increase of suicides coinciding with 
the COVID-19 pandemic.
    Preliminary analysis by Army Public Health Center indicates the 
suicide cluster among Regular Army is correlated with COVID's timeline, 
however causality is not currently known.
    Army Medicine provides Army Senior Leaders methods to mitigate 
clinical suicide risk through critical engagements with their troops 
and ensures critical information is provided to Commanders to support 
those with identified risk of suicide.
    Question. Have you seen an increase in the utilization of mental 
health and suicide prevention services that the Department offers?
    Answer. Early in the pandemic, BH service engagement by Army 
beneficiaries decreased.
    Army Medicine's adaption to pandemic healthcare environment 
beneficiaries re-engaged in virtual behavioral services with a peak 
utilization of 70 percent of services being conducted virtual 
environment in April of 2020.
    Social distancing policies are carefully lifted, the mix of in-
person and virtual appointments are exceeding pre-pandemic levels and 
roughly 10 percent more unique beneficiaries are engaging in behavioral 
health services when compared to this time in 2019.
    In March 2021, greater than 38K beneficiaries sought behavioral 
health services, which represents 33 percent increase from the same 
time in 2019.
    Innovations in the virtual space developed from necessity are 
affording Army Medicine increased flexibility to provide services to 
patients in their home.
    Army Medicine, in partnership with DHA, will continue to 
aggressively pursue and capitalize upon advancements in virtual 
behavioral health services as an enduring positive outcome of the 
global pandemic.
                                 ______
                                 
        Questions Submitted to Rear Admiral Bruce L. Gillingham
            Questions Submitted by Senator Richard J. Durbin
    Question. I remain a very concerned about curbing the use of 
tobacco in the military. We know that smoking makes it harder for 
individuals to perform the tasks we ask of them, lengthens medical 
recovery, and increases illness, increases healing times and accounts 
for greater health costs. In fact, the DoD indicates that tobacco use 
costs the department at least $1.6 billion annually. And it continues 
to trouble me that--amid all of the rigorous physical challenges and 
testing they perform--so many of our service-members pick up these 
habits after enlisting. We also know that there are continued concerns 
about military members using tobacco alternatives such as e-cigarettes 
and vapes. In addition, I was supportive of Congressional efforts to 
raise the Federal minimum age of sale of tobacco products from 18 to 
21. But I remain concerned that we are not adequately addressing the 
youth vaping epidemic
    What are you doing on a regular basis to drive an anti-tobacco 
message throughout your Service? Are we making progress?
    Answer. I share your concerns about tobacco use in the military. 
Navy Medicine is strongly committed to ensuring Sailors and Marines are 
healthy, resilient, and physically and mentally fit to perform their 
demanding duties. Tobacco use impairs readiness, performance and 
fitness. As the Navy Surgeon General, I continue to promote tobacco 
free living. Given the stress brought about by the COVID-19 pandemic, 
we have released messages highlighting the negative effects of tobacco 
use and encouraging those who use tobacco to quit. We want our 
personnel to know that Navy Medicine can and will assist them in these 
efforts.
    Our medical campuses are tobacco free compounds which reinforces 
our messages of healthy living and tobacco free living. During our 
medical and dental care, healthcare teams address tobacco use and 
provide evidence based treatment for nicotine dependence. Navy provides 
awareness and training on the dangers and harmful effects of tobacco 
and also provides education during the command orientation and 
indoctrination process. During recruit training and other schools, 
students are tobacco free. We use social media messages, developed by 
the Navy, Department of Defense (DoD) and Centers for Disease Control 
and Prevention (CDC), to promote tobacco free living along with 
extensive online resources to support our personnel and providers. We 
have also worked closely with the other Services and the CDC's Office 
of Smoking and Health to develop a 2020 media tobacco toolkit ``Tips 
From Former Smokers Military Service Members & Veterans Media Outreach 
Kit'' for use and to partner with local and state organizations to 
promote tobacco free military communities.
    We are making progress with reducing tobacco use in the Navy and 
Marine Corps. The encouraging news is that our tobacco use rates have 
declined over the past decade. Data from the Navy and Marine Corps 
Public Health Center's Health Risk Assessment show a reduction with 
smoking cigarettes and the use of smokeless tobacco in the Navy and 
Marine Corps within the past 2 years. These current trends as positive. 
We also anticipate that the Tobacco 21 law will contribute to a decline 
in tobacco use rates. It should be notes, however, vaping in the Marine 
Corps increased during this time period similar to the national trends 
of e-cigarette use.
    Question. What is the impact that we are seeing on soldiers with 
the rise of tobacco alternatives such as e-cigarettes and vapes?
    Answer. We are concerned about the use of e-cigarettes, vaping and 
other new and alternative tobacco products in the Navy and Marine 
Corps. Over the past few years, there has been increased use of e-
cigarette use and vaping in this country among youth and adults. We 
know that they are addicting, harmful and not a proven smoking 
cessation strategy. E-cigarettes also contain cancer causing chemicals 
and cause lung and cardiovascular disease. At this time we don't know 
the full extent of and all the negative long term effects of vaping 
which is being studied and researched.
    E-cigarette use is not safe. The use of these products have caused 
fires, explosions and injuries to our sailors and marines. As a result, 
Navy Fleet Forces Command and Pacific Fleet have suspended the use, 
storage and charging of any electronic nicotine delivery system device 
aboard all ships, submarines, aircraft, boats, crafts, vehicles and 
heavy equipment to ensure the safety of our forces. The new Secretary 
of the Navy instruction (SECNAVINST 5100.13F Navy and Marine Corps 
Tobacco Policy--2 December 2020) also bans e-cigarette, vaping and 
other alternative tobacco product use within military workspaces and 
facilities. We believe this approach helps protect the health and 
safety of our Naval Forces.
    Question. What are you doing about the impact of tobacco on 
military children and family members? Are you reviewing whether these 
products should be sold in military exchanges or commissaries?
    Answer. We want our military children, teenagers and families to be 
healthy and tobacco free. We address tobacco use during wellness and 
medical visits for children, adolescents and family members. Navy 
Medicine and the Defense Health Agency use the U.S. Public Health 
Service Treating Tobacco Use and Dependence Clinical Practice 
Guidelines to screen for and address tobacco use, encourage tobacco 
free living and provide resources, support and counseling. We encourage 
parents to quit using and not to use tobacco in their homes and around 
their children and families. Our medical team offers no cost, evidence-
based tobacco cessation treatment for all beneficiaries. The Secretary 
of the Navy instruction protects children and families by banning 
tobacco use where children live, play and learn--at playgrounds and 
athletic fields, pools and schools.
    Navy Medicine bans tobacco use on all medical property. Tobacco 
products are prohibited for sale in any exchanges and stores that are 
within hospitals, clinics or any other medical facilities. Sale of 
tobacco products at other exchanges are under the purview of the Navy 
Exchange and Marine Corps Exchange.
                                 ______
                                 
            Questions Submitted by Senator Susan M. Collins
    Question. At the beginning of the COVID-19 pandemic last year, the 
nation saw a huge spike in demand for modular negative pressure room 
containment systems that can offer civilian hospitals or Military 
Treatment Facilities the capability to safely assess and treat patients 
with suspected COVID-19 symptoms. It is clear these commercial-off-the-
shelf systems can help ensure the readiness of the defense health 
system worldwide, especially in the case of future pandemics or 
biological attacks. Section 732 of the recently enacted fiscal year 
2021 National Defense Authorization Act (NDAA) requires a report of the 
Department's pandemic preparedness. I was pleased that the Department 
has committed to ensuring that these modular negative air pressure room 
containment systems are included as part of that Pandemic Preparedness 
Report directed by the NDAA. Provisions unanimously approved in the 
Senate's fiscal year 2021 NDAA bill also required a specific review of 
these systems.
    Given the use of these systems in the civilian sector and in VA 
hospitals, what does the Navy believe to be the potential benefits of 
these systems? How could these types of systems be used by Navy in the 
future to help mitigate the spread of future pandemics or biological 
agents in the future?
    Answer. Senator Collins, thank you for your question. As reflected 
in my written testimony, Navy Medicine continues to work 
collaboratively with the DoD COVID-19 Task Force, the Joint Staff, the 
Defense Logistics Agency, the Defense Health Agency, the other 
Services, Uniformed Services University of the Health Sciences, 
interagency partners, and many others on the pandemic response.
    There has always been a need for negative pressure capabilities in 
our medical treatment facilities to meet the needs of our patients and 
staff. Negative pressure systems, whether built-in or modular, can 
assist patients and protect healthcare staff from certain diseases and 
agents.
    Navy Medicine has addressed these requirements on a permanent and 
temporary basis to meet the ongoing demands of the pandemic. In 
addition, both of Navy's hospital ships, USNS COMFORT and USNS MERCY, 
have negative pressure capabilities.
    As directed by the fiscal year 2017 National Defense Authorization 
Act, the Defense Health Agency (DHA) has assumed authority, direction 
and control of military medical treatment facilities. In this role, the 
DHA has primary responsibility for medical systems and their clinical 
application in these facilities. Given these responsibilities, the 
integration and value of portable negative pressure capabilities is 
most appropriately addressed by the DHA to ensure a coordinated and 
comprehensive response within the Military Health System.
                                 ______
                                 
       Questions Submitted to Lieutenant General Dorothy A. Hogg
            Questions Submitted by Senator Richard J. Durbin
    Question. I remain very concerned about curbing the use of tobacco 
in the military. We know that smoking makes it harder for individuals 
to perform the tasks we ask of them, lengthens medical recovery, and 
increases illness, increases healing times and accounts for greater 
health costs. In fact, DoD indicates that tobacco use costs the 
department at least $1.6 billion annually. And it continues to trouble 
me that--amid all of the rigorous physical challenges and testing they 
perform--so many of our service-members pick up these habits after 
enlisting. We also know that there are continued concerns about 
military members using tobacco alternatives such as e-cigarettes and 
vapes. In addition, I was supportive of Congressional efforts to raise 
the Federal minimum age of sale of tobacco products from 18 to 21. But 
I remain concerned that we are not adequately addressing the youth 
vaping epidemic.
    What are you doing on a regular basis to drive an anti-tobacco 
message throughout your Service? Are we making progress?
    Answer. The Department of the Air Force continues to discourage the 
use of all tobacco products. The DAF military treatment facilities 
support enrolled beneficiaries who require tobacco cessation support, 
which included access to medications, in-person counseling, and quit 
line counseling.
    Yes, we are making progress. Since early 2020, Active Duty 
cigarette and smokeless tobacco use continues to decline, and E-
cigarette use rates have remained steady.
    Question. What is the impact that we are seeing on service members 
with the rise of tobacco alternatives such as e-cigarettes and vapes?
    Answer. We have not seen a significant negative impact in reported 
cases of pulmonary distress due to use of tobacco alternatives. 
Retrospective study analysis illustrate individuals using vaping oils 
have the highest likelihood of experiencing pulmonary distress, 
particular because vaping oils are not regulated. Active military 
members who use tobacco and its alternatives are provided educational 
information about the dangers and available resources if they wish to 
quit.
    Reference: Rice SJ, Hyland V, Behera M, Ramalingam SS, Bunn P, 
Belani CP. Guidance on the Clinical Management of Electronic Cigarette 
or Vaping-Associated Lung Injury. J Thorac Oncol. 2020 Nov;15(11):1727-
1737. PMID: 32866653.
    Question. What are you doing about the impact of tobacco on 
military children and family members? Are you reviewing whether these 
products should be sold in military exchanges or commissaries?
    Answer. The sales of tobacco products is prohibited in all Air 
Force Services Activity (AFSVA) facilities (e.g., Clubs, Force Support 
Morale, Welfare, and Recreation facilities, golf course). Note: The 
military exchange and commissary are not AFSVA facilities and therefore 
cannot provide further comment about their anti-tobacco policies or 
initiatives.
                                 ______
                                 
            Questions Submitted by Senator Susan M. Collins
    Question. At the beginning of the COVID-19 pandemic last year, the 
nation saw a huge spike in demand for modular negative pressure room 
containment systems that can offer civilian hospitals or Military 
Treatment Facilities the capability to safely assess and treat patients 
with suspected COVID-19 symptoms. It is clear these commercial-off-the-
shelf systems can help ensure the readiness of the defense health 
system worldwide, especially in the case of future pandemics or 
biological attacks. Section 732 of the recently enacted fiscal year 
2021 National Defense Authorization Act (NDAA) requires a report of the 
Department's pandemic preparedness. I was pleased that the Department 
has committed to ensuring that these modular negative air pressure room 
containment systems are included as part of that Pandemic Preparedness 
Report directed by the NDAA. Provisions unanimously approved in the 
Senate's fiscal year 2021 NDAA bill also required a specific review of 
these systems.
    Given the use of these systems in the civilian sector and in VA 
hospitals, what does the Air Force believe to be the potential benefits 
of these systems?
    Answer. The primary benefit is the minimal assembly time required 
and subsequently, limiting the disruption of operations in the military 
treatment facilities (e.g., fixed facility operations).
    Question. How could these types of systems be used by Air Force in 
the future to help mitigate the spread of future pandemics or 
biological agents in the future?
    Answer. Modular containment systems can be used in the future to 
help mitigate the spread of future pandemics or biological agents by:
  --Providing a temporary, alternative solution when a permanent 
        facility is at risk of operating beyond its surge capacity
  --Mitigating the difficulties in establishing facilities in austere 
        environments
                                 ______
                                 
             Questions Submitted by Senator Lisa Murkowski
    Question. I appreciate Lt Gen Hogg's recognition of the ever 
growing importance of the Arctic. I would like to hear more about the 
Below Zero Medicine Program.
    What challenges does extreme cold place on medical service?
    Answer. The major challenges include, but not limited to, a lack of 
reliable extreme cold weather functioning medical and non-medical 
equipment, no suitable expeditionary medical facility, and the need to 
develop standard operating procedures/clinical practice guidelines.
    Question. What has the outcome been from the Below Zero Medicine 
summits?
    Answer. First, we developed the Cold Region Expeditionary Medical 
Operations concept. Second, we increased collaboration in extreme cold 
weather medicine research and facilitated joint service exercise 
participation. Finally, we are pursuing the development of recurring 
medical educational materials and a training curriculum proposal for 
military personnel.
    Question. Will the fiscal year 2022 request contain any Arctic-
centric medical requests?
    Answer. There are no budget requests planned for fiscal year 2022.
    Question. In October of 2018, administration and management of the 
Military Treatment Facilities (MTFs) began to transfer from each 
Military Department to the Defense Health Agency (DHA). This transition 
also came with significant cuts to active duty medical personnel, the 
fiscal year 2021 plan reduces the medical force by 9.6 percent (7,422 
personnel). Additionally, the transition includes restructuring the 
mission and scope of each MTF which must be completed by the end of 
fiscal year 2021.
    Given these significant changes and cuts to medical personnel, have 
medical readiness rates increased for our total force?
    Answer. No, the Military Health System changes have not 
significantly affected the medical readiness rates over the last 2 
years.
    Question. If so, have the standards for tracking medical readiness 
also changed?
    Answer. The standards for tracking medical readiness have not 
changed.
    Question. It was mentioned that COVID-19 has affected medical 
readiness within the military.
    Specifically Dental Readiness, how far behind has the DoD fallen 
with regard to providing dental care to service members and what is 
your plan to eliminate this backlog?
    Answer. AF/SG has worked closely with the military treatment 
facilities to develop a leveling strategy to expand scope and capacity 
of dental care and to target any backlog of pending dental readiness 
examinations. Pre-pandemic dental readiness in February 2020 was 93.8 
percent. Currently, dental readiness is 92.7 percent and continues to 
increase as we move past the pandemic. Overall, meeting dental 
readiness requirements has not slowed down the ability to support the 
warfighting mission.
                                 ______
                                 
               Questions Submitted by Senator John Hoeven
    Question. In your testimony, you mention the ongoing rollout of a 
new initiative that embeds Operational Support Teams (OSTs) at Air 
Force installations around the country. Minot Air Force Base was one of 
four locations to participate in the Task Force True North beta test, 
where the OST initiative began. In 2020, RAND Corporation evaluated the 
beta test and its initiatives. Four of five initiatives, including 
OSTs, were well received by leadership, providers, and airmen and the 
data supports a broad expansion of those initiatives across the Air 
Force. I want to express my support for new programs like Task Force 
True North and its initiatives that can improve the resilience and 
well-being of our airmen and their families.
    What were the key takeaways from the Task Force True North beta 
test?
    Answer. The key takeaways are:
  --Embedded medical programs are very popular with Airmen and 
        Guardians. In particular, they like the accessibility, and 
        ability to build a relationship with the assigned medic.
  --Embedded medical programs increase help-seeking, not only for their 
        services but for the military treatment facilities as well 
        (i.e. Mental Health Clinic increased 25 percent)
  --Training civilian embedded professionals takes significant time, to 
        ensure their cultural competence and ability to synchronize 
        with the military treatment facility.
    Question. How do you see these types of initiatives being rolled 
out across the entire Air Force?
    Answer. Embedded initiatives should be rolled out based on risk and 
need because of the practical limitations of how many providers/
specialists the Department of the Air Force can retain or recruit 
(i.e., impossible to embed personnel in every unit).
    Additionally, supporting these types of initiatives requires 
balancing the access demands placed on our military treatment 
facilities demands.

                          SUBCOMMITTEE RECESS

    Senator Tester. The Defense Subcommittee will reconvene on 
Tuesday, April 27, at 10:00 a.m. for a closed hearing on the 
Missile Defense Agency.
    This committee stands in recess.
    [Whereupon, at 10:13 a.m., Tuesday, April 20, the 
subcommittee was recessed, to reconvene at 10:00 a.m., Tuesday, 
April 27.]