[Senate Hearing 118-184]
[From the U.S. Government Publishing Office]
S. Hrg. 118-184
A REVIEW OF THE DEPARTMENT OF DEFENSE HEALTH PROGRAM
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BRIEFING
BEFORE A
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
SPECIAL BRIEFING
MARCH 7, 2023--WASHINGTON, DC
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Printed for the use of the Committee on Appropriations
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.gpo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
54-414 PDF WASHINGTON : 2024
COMMITTEE ON APPROPRIATIONS
PATTY MURRAY, Washington, Chair
DIANNE FEINSTEIN, California SUSAN M. COLLINS, Maine,Vice Chair
RICHARD J. DURBIN, Illinois
JACK REED, Rhode Island MITCH McCONNELL, Kentucky
JON TESTER, Montana LISA MURKOWSKI, Alaska
JEANNE SHAHEEN, New Hampshire LINDSEY GRAHAM, South Carolina
JEFF MERKLEY, Oregon JERRY MORAN, Kansas
CHRISTOPHER A. COONS, Delaware JOHN HOEVEN, North Dakota
BRIAN SCHATZ, Hawaii JOHN BOOZMAN, Arkansas
TAMMY BALDWIN, Wisconsin SHELLEY MOORE CAPITO, West
CHRISTOPHER MURPHY, Connecticut Virginia
JOE MANCHIN, III, West Virginia JOHN KENNEDY, Louisiana
CHRIS VAN HOLLEN, Maryland CINDY HYDE-SMITH, Mississippi
MARTIN HEINRICH, New Mexico BILL HAGERTY, Tennessee
GARY PETERS, Michigan KATIE BRITT, Alabama
MARCO RUBIO, Florida
DEB FISCHER, Nebraska
Evan Schatz, Staff Director
Elizabeth McDonnell, Minority Staff Director
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Subcommittee on Department of Defense
JON TESTER, Montana, Chair
RICHARD J. DURBIN, Illinois SUSAN M. COLLINS, Maine
DIANNE FEINSTEIN, California MITCH McCONNELL, Kentucky
PATTY MURRAY, Washington LISA MURKOWSKI, Alaska
JACK REED, Rhode Island LINDSEY GRAHAM, South Carolina
BRIAN SCHATZ, Hawaii JERRY MORAN, Kansas
TAMMY BALDWIN, Wisconsin JOHN HOEVEN, North Dakota
JEANNE SHAHEEN, New Hampshire JOHN BOOZMAN, Arkansas
CHRISTOPHER MURPHY, Connecticut SHELLEY MOORE CAPITO, West
Virginia
Professional Staff
Kate Kaufer
Mike Clementi
Laura Forrest
Abigail Grace
Katy Hagan
Brigid Kolish
Rob Leonard
Ryan Pettit
Kimberly Segura
Ryan Kaldahl(Minority)
Todd Phillips (Minority)
Jason Potter (Minority)
Jesse Tolleson (Minority)
Mike Wakefield (Minority)
Administrative Support
Gabriella Armonda
Alex Shultz (Minority)
C O N T E N T S
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Page
Opening Statement of Senator Jon Tester.......................... 1
Statement of Senator Susan M. Collins............................ 2
Statement of Dr. Lester Martinez-Lopez, Assistant Secretary of
Defense for Health Affairs..................................... 3
Statement of Lieutenant General Telita Crosland, Director of the
Defense Health Agency.......................................... 4
Statement of Lieutenant General R. Scott Dingle, Surgeon General
of the Army.................................................... 5
Statement of Lieutenant General Robert I. Miller, Surgeon General
of the Air Force............................................... 6
Statement of Rear Admiral Bruce Gillingham, Surgeon General of
the Navy....................................................... 7
A REVIEW OF THE DEPARTMENT OF DEFENSE HEALTH PROGRAM
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TUESDAY, MARCH 7, 2023
U.S. Senate,
Subcommittee on Department of Defense,
Committee on Appropriations,
Washington, DC.
The subcommittee met at 10 a.m. in room SD-192, Dirksen
Senate Office Building, Hon. Jon Tester (chairman) presiding.
Present: Senators Tester, Durbin, Baldwin, Shaheen, Murphy,
Collins, Murkowski, Moran, and Hoeven.
opening statement of senator jon tester
Senator Tester. I want to call this hearing to order.
Good morning all. Welcome Dr. Martinez-Lopez, General
Crosland, General Dingle, General Miller, Admiral Gillingham,
thank you all for joining us today.
I want to especially welcome Dr. Martinez-Lopez, and
General Crosland, this is your first time briefing this
committee and we look forward to hearing your brief.
I also want to recognize Admiral Gillingham who is retiring
later this month. I think, thank you for your service, is not
quite adequate. We appreciate everything you have done over
your career to keep this country the greatest country on Earth.
And so we appreciate you. We wish you much luck in your next
phase of your life. And just know that Maine or Montana; are
great places to retire to.
Admiral Gillingham. Yes, sir. Thank you.
Senator Tester. Look, the Defense Health Program accounts
for roughly $39 billion, or 5 percent of the DoD (Department of
Defense) budget. The Defense Health Agency is charged with
providing Health Care Services to 9.6 million servicemembers or
families, and retirees through TRICARE. Its mission also
includes managing the DoD Medical Research Program. And I want
to acknowledge that the Defense Health Agency has not been
immune from challenging trends in the national healthcare
industry.
These include escalating costs and a shortfall of
providers. I hear this firsthand from servicemembers and
veterans in Montana who tell me that TRICARE is not working for
them in rural America.
So today, I want to have a candid discussion about the
Department's delivery of healthcare and medical readiness of
our Force. The Defense budget has enjoyed robust top line
increases in recent years; however, for this year we have
members proposing reduced and outdated funding levels, Congress
has repeatedly failed the Department in recent years by putting
you on automatic continuing resolutions, and getting you a
budget that is late.
It is my hope that in this new Congress we can break
through the vicious cycle of CRs (Continuing Resolution), and I
wholeheartedly support efforts to get back on track. And I know
Senator Collins does too.
So the committee needs to know exactly what reduced funding
levels and a CR would mean for the Defense Health Program,
including for our servicemembers and their families, medical
readiness, and medical research.
We have much to discuss. The Defense Health Agency is in
the midst of a significant restructure, we continue to hear
about challenges with TRICARE, and I believe mental health is
our biggest healthcare problem. There isn't a family in America
that doesn't have a mental healthcare problem somewhere in
their midst.
So I want to thank you for joining the subcommittee this
morning. I look forward to our discussion, before you----
Oh. Go ahead. Senator Collins.
statement of senator susan m. collins
Senator Collins. Thank you Mr. Chairman, I appreciate your
holding this hearing on the Pentagon's Defense Health Program.
To each of our witnesses, thank you for being here, and for
your service to our country. I would echo the Chairman's
special thank you to Admiral, for all of your years of service.
Providing for the healthcare of our troops and their
families is a no-fail mission. Unlike other healthcare
providers, the Military Health Care System must support and
save the lives of our warfighters in battlefield environments.
I look forward to hearing about the Department's investments,
both the ongoing and planned, to train and posture medical
units to be able to respond in contested environments far away
from the safety of large hospitals or military bases.In
addition, as the Chairman has indicated, the Military Health
System continues to undergo substantial changes intended to
improve healthcare. All military hospitals and clinics are now
managed by the Defense Health Agency, rather than the
individual Military Services. DoD's new electronic health
records system appears to be on track to be fully implemented
this year, yet problems remain with the interoperability with
the Veterans Affairs--Veterans Administration. And the long-
awaited awards for the next national TRICARE Managed Care
contracts were recently announced as well.
Will these transformations improve the quality and level of
healthcare for our troops and their families? That is the
bottom line. That depends on DHA (Defense Health Agency) having
enough staff, hospitals, clinics, and private sector providers
to provide ready access for the physical and mental healthcare
needs of the 9.6 million, servicemembers, their family members,
and retirees who rely upon the Military Health System.
On this committee, we are also interested if the cost
efficiencies promised by some of these changes have in fact,
been realized.
The Defense Health Program also conducts the innovative
research that benefits our warfighters and the American public.
For example, from 2007 to 2018, eleven FDA (Food & Drug
Administration)-approved drugs that benefited from
congressionally directed medical research funded programs were
prescribed to more than 139,000 times for cancer treatment. And
that only includes those prescriptions within the Military
Health System. DoD must continue to transform our Health Care
System through this impactful research.
It is unfortunate that here we are, in March, and the
President has yet to deliver his budget requests for fiscal
year 2024. It is a little more than a month overdue.
Nevertheless, I look forward to hearing from our witnesses
about how the Department is using the resources provided by
this committee for fiscal year 2023, and what resources will be
needed to care for our servicemembers, dependents, and retirees
in the future.
Again, my thank you to the witnesses and to the Chairman
for holding this hearing.
Senator Tester. Thank you Senator Collins.
The first briefer will be the Assistant Secretary of
Defense for Health Affairs, Dr. Martinez-Lopez. You have the
floor.
STATEMENT OF DR. LESTER MARTINEZ-LOPEZ, ASSISTANT
SECRETARY OF DEFENSE FOR HEALTH AFFAIRS
Dr. Martinez-Lopez. Chairman Tester, Ranking Member
Collins, and distinguished members of the subcommittee, I am
pleased to represent the Office of Secretary of Defense to
discuss the Defense Health Program and its contributions to the
health and medical readiness of the Department.
I am speaking today in advance of the formal release of the
President's Proposed fiscal year 2024 Budget. I will outline,
the major activities unfolding in the Military Health System
that will inform our soon-to-be released budget proposal.
The National Defense Authorization Act, NDAA, for fiscal
year 2017, enacted sweeping reforms to the organization and
management of Military Medicine, the expanded responsibility of
the Defense Health Agency are now largely completed. The DHA
exercises authority, direction, and control over all the MTFs
(Military Treatment Facilities) worldwide.
Lieutenant General Crosland, the Director of the Defense
Health Agency, will provide further details on specific
initiatives that the DHA is undertaking.
This same law directed DoD to restructure or realign the
MTFs to support the Department's readiness requirement,
however, in fiscal year 2023 NDAA, placed a 1 year moratorium
on any changes to the configurations of our MTFs. As requested,
we are preparing an update to Congress on our way ahead in the
coming month.
The NDAA also included a 5-year moratorium on further
Military Medical personnel reductions. Together with the Joint
Staff we are updating our medical requirements, as COCOM
(Combatant Commands) operational plans are also updated. We are
conducting a comprehensive internal review with our OSD (Office
of the Secretary of Defense) colleagues and the Military
departments on the best configuration of medical infrastructure
and personnel for the long term.
We are resolute in our commitment to ensure combatant
commanders have the medical resources necessary to protect,
treat, and provide long-term care medical services to our men
and women in uniform. We are also committing resources and
attention to the ongoing challenge of suicide, both among
uniformed servicemembers and family members.
We recently received the recommendation from the Suicide
Prevention and Response Independent Review Committee and are
continuing to implement strategies that can help reverse the
heartbreaking trends that we have witnessed both in DoD and in
the Nation.
The Department remains grateful for the long-term support
from this committee for our Military Medical research in those
areas of most pressing needs, and relevance for today's
emerging threats. That includes: infectious diseases, combat
casualties, and other areas of importance to our warfighters
and to Congress.
For the current fiscal year, our mid-year review is
underway. As in past years, the MHS (Military Healthcare
System) continue a sustained track record in responsibly
managing healthcare costs, which remain below the national
health expenditure per capita rate. Our fiscal year 2024 budget
will present a balanced, comprehensive strategy that aligns the
Secretary's priorities.
We look forward to working with you over these coming
months to further refine and articulate our requirements. Thank
you for inviting me here today to speak with you about the
battle of Military Medicine in supporting our national
security.
I look forward to your questions.
Senator Tester. Thank you, Doctor.
Next up, we have Director of the Defense Health Agency,
General Crosland.
STATEMENT OF LIEUTENANT GENERAL TELITA CROSLAND,
DIRECTOR OF THE DEFENSE HEALTH AGENCY
General Crosland. Chairman Tester, Ranking Member Collins,
distinguished members of the subcommittee, thank you for
inviting me to join Dr. Martinez-Lopez, and the Service's
Surgeon Generals, to discuss the Defense Health Program.
I will add to Dr. Martinez-Lopez's remarks by briefly
focusing on some of the critical capabilities of the Defense
Health Agency in supporting the Military departments in the
combatant commands. As Dr. Martinez-Lopez also noted, my
comments assess the current state and do not speak to the
fiscal year 2024 budget, which is not yet released.
In 2022 and into 2023, the Defense Health Agency has been
able to focus its resources to supporting operational
requirements of the Department while continuing to manage
COVID-19 pandemic. There were a number of important milestones
achieved by the Defense Health Agency in the past year that
will continue to influence operations in 2023 and into 2024.
For my opening comments I will focus on just two. First,
more than 50 percent of our Military Medical treatment
facilities have migrated to our new electronic health record
known as MHS GENESIS. In a few weeks, we will deploy the system
here in the national capital region and that will take us to
approximately 75 percent. We remain on track to have the system
fully operational, worldwide, by 2024.
This modern electronic health record platform will provide
the Department a powerful tool to support our readiness
mission, improve interoperability, and record sharing, with
care delivered in the private sector, and allow our patients to
engage more directly with their providers in managing their
care.
The COVID-19 pandemic accelerated the Department's use of
virtual health. For the coming year I will build on what we
have learned, and how our providers and patients effectively
use this technology throughout this public health emergency; I
am creating a new digital Health strategy that will expand our
use of technology in ways that improve our training, our
preparedness, access, and quality of care. I intend to work
with the Military Medical leaders and industry partners to
focus on what we can achieve now and build on our successes
over time.
In late 2022, after a multi-year process, the Defense
Health Agency awarded the next generation of TRICARE contracts
at a value of over $135 billion over the next 8 years. These
contracts will deliver high value, patient-centric care that
integrates the military and the private sector care.
In January, protests were filed that will slightly delay
this transition. We are closely working with GAO (Government
Accountability Office) and we will ensure that the process is
carried out in a fair and timely manner.
Dr. Martinez-Lopez noted our current budgetary status and
future plans. We appreciate that Congress continues to grant
the Department carryover authority, allowing DoD to maintain a
better flow of funds to minimize disruption in healthcare
services, and our beneficiaries.
I am grateful for the opportunity to represent the men and
women of the Defense Health Agency. And I thank you for
inviting me here today. I look forward to your questions.
Senator Tester. Thank you, General.
Next up, we have Surgeon General of the Army, General Scott
Dingle.
STATEMENT OF LIEUTENANT GENERAL R. SCOTT DINGLE,
SURGEON GENERAL OF THE ARMY
General Dingle. Chairman Tester, Vice Chairman Collins, and
distinguished members of the subcommittee, thank you for the
opportunity to speak to you on behalf of the 111,000 that
comprise the total Army Medicine Force.
I am privileged to serve as the 45th Army Surgeon General
and Commanding General of the United States Army Medical
Command. The U.S. Army is the most lethal and capable ground
combat force in history. As the Army continues to modernize for
multi-domain operations, it is imperative that our Medical
Force remains ready, responsive, and relevant to conserve the
fighting strength.
The Chief of Staff of the Army, General McConville says
that winning matters. I agree. There is no second place in war.
From foxhole to the fixed facility, Army Medicine has achieved
a high survivability rate for soldiers wounded on and off the
battlefield in recent decades. We did this by remaining agile
and adaptive. We applied the lessons from operations and
developed a holistic system for future operations in austere
locations.
My vision for going forward remains consistent with the
Army Medical Modernization Strategy and nested with the Army
Modernization Strategy, ensuring our Medical Force is trained
and ready as an enabler of combat power. We will synchronize
and integrate the medical effort within the Army, the Defense
Health Agency Joint Staff, and combatant commands to be
responsive and steadfast to teammates of the Joint Force. This
will ensure that Army Medicine is responsive and relevant to
execute the National Defense Strategy.
We will also build readiness through our investments in
people, Army Medicine must be innovative and agile to remain
competitive with the healthcare industry on our recruiting and
retention practices while partnering with the DHA to deliver
high quality and safe care.
Army Medicine remains engaged at Echelon to confront the
challenges associated with Military Service and suicide. Each
life loss devastates the Force and Congress has spoken loudly.
As the medical integrator, we actively support the
modernization of the medical effort.
Timely funding this year will expand our expeditionary
medical capabilities and ensure that interoperability within
the Joint Force. Medical reform will allow us to update our
capability, design, and structure to optimize resources for
operating and generating forces.
Finally, we are strengthening our alliances and
partnerships in order to enhance interoperability with the
international community by providing institutional medical
training, collaboration on medical research, development,
innovation, and Force structure design. Across the globe, we
offer solutions to grow capability and capacity.
In closing, I thank the subcommittee for your long-standing
support to the Army and Army Medicine, our trained and ready
Medical Force depends on timely, adequate, predictable, and
sustained funding. Army Medicine is Army strong. I look forward
to your questions.
Senator Tester, Thank you, General.
Next up, we have Surgeon General of the Air Force, General
Miller.
STATEMENT OF LIEUTENANT GENERAL ROBERT I. MILLER,
SURGEON GENERAL OF THE AIR FORCE
General Miller. Chairman Tester, Vice Chair Collins, and
distinguished members of the subcommittee, it is my honor to
brief you today on behalf of 31,000 Medical Airmen.
We respond to our Nation's global needs during peacetime,
humanitarian crisis, and hostilities. Our cornerstones are
aerospace medicine and aeromedical evacuations, capabilities
that have saved thousands of lives and ensure our warfighters
come home with the best medical outcomes. Thank you for your
past and ongoing support to modernize key readiness
capabilities, and sustain our Force.
Last year, I charged my leaders to evaluate and reenvision
our readiness force and response structure. The objective is to
provide combatant commanders with a well-trained and equipped
medical force capable of adapting the rapidly evolving Joint
Force requirements. I expect a modular growth capability with a
smaller footprint than our Expeditionary Medical Support
System.
It will increase operational abilities in contested and
degraded environments, plus impact future capability
requirements, training, sustainment, recruitment needs and
changes to the AFMS (Air Force Medical Service) end-strength
mix. It will also improve our alignment to the Air Force's ACE
construct.
The initial concept was tested in war-gaming tabletop
exercises in January. Now, we are refining and moving forward
with a test at a joint exercise this summer. We must also focus
on the daily readiness care of our Airmen and Guardians to
address the challenges of their work environment. Occupational
and environmental exposure risk assessments are critical.
A current early-stage study on specific risks to the
missileer community is ongoing. We will be transparent during
this process as our responsibility is to protect the health and
safety of our Airmen and Guardians. We take that seriously. We
are moving forward with our operational support teams to
optimize performance and readiness using evidence-based
strategies.
Access to mental healthcare improve through our targeted
CARE Program, members are vectored to the appropriate place for
support based on individual needs whether that is a mental
healthcare provider or nonclinical support, like group therapy.
Family readiness also impacts member readiness. Those who
are part of our Exceptional Family Member Program may now have
access to expanded care and support through the Air Force
Developmental Behavioral Family Readiness Centers. The program
is rolling out as it uses a hub-and-spoke approach to support
our members' families. Air Force medics are uniquely ready and
capable to safeguard our interests both at home and abroad.
Thank you again for your support to the AFMS and our
medics. I look forward to your questions.
Senator Tester. Thank you, General.
Next, we have the Surgeon General of the Navy, Admiral
Gillingham.
STATEMENT OF REAR ADMIRAL BRUCE GILLINGHAM, SURGEON
GENERAL OF THE NAVY
Admiral Gillingham. Chairman Tester, Vice Chair Collins,
distinguished members of the committee; I am pleased to be with
you today to provide an update on Navy Medicine.
On behalf of our mission-ready, One Navy Medicine Team,
please know that we are grateful for the support you provide
us, as well as the trust and confidence that you place in us.
Navy Medicine is best described as well-trained people working
as expeditionary medical experts on optimized platforms,
demonstrating high reliability performance as highly cohesive
teams to project medical power in support of naval superiority.
These priorities guide our deliberate planning efforts,
resource allocation decisions, and strategic program
investments. We are at a critical and exciting juncture as we
pivot from operating military medical treatment facilities,
which are now completely under the authority, direction and
control of the Defense Health Agency, while our attention is on
the operational mission of delivering manned, trained,
equipped, and sustained medical units, who provide enduring
support to the Fleet, the Marine Corps and The Joint Force.
This operational focus maintains Navy Medicine's requirement to
provide health services at sea, and onshore, on our platforms,
and in DHA-MTFs.
As you know, the National Security and Defense Strategies
make it clear that China represents the pacing challenge
against which we must plan our warfighting strategies and
investments. For the first time in at least a generation, we
have a strategic competitor who possesses naval capabilities
that rival our own, and seeks to aggressively employ its Forces
to challenge U.S. principles, partnerships, and prosperity.
Similarly, Russia, Iran, and other authoritative states
continue to challenge the rules-based international order. Navy
Medicine is taking urgent action to support the Navy and Marine
Corps, and save lives in contested battle space that is quickly
growing in lethality, complexity, and scope.
Last month I released our 2023 Campaign Order, which
outlines our strategic direction for the next 5 years and
directs foundational changes to our entire enterprise,
operates, in order to meet combatant commander and combatant--
and component commander requirements for the warfighter.
To get us there we are working on several strategic
imperatives including new platforms in development, like the
Expeditionary Medical Ship, which will speed to assist
casualties, and have 3 operating rooms, and 60 medical beds.
Thank you for the program increase in the fiscal year 23
appropriations bill to procure two additional ships.
I was recently in Mobile, Alabama, representing the
Secretary of the Navy as we christened the USNS Cody, which is
our first Expeditionary Fast Transport Flight II, with enhanced
medical capabilities to augment the EMS.
These platforms truly represent a quantum leap forward for
Navy Medicine's ability to meet our mission in future complex
conflict on the water.
And another key priority in ensuring our sailors and
marines have access to the full continuum of mental health
resources, while aiming to utilize the right care, at the right
level, at the right time, Embedded Mental Health remains vital
for mental wellness by placing mental health as far forward as
possible.
Currently, 36.5 percent of active duty mental health
providers, and 31 percent of behavioral health technicians
serve in operational and training commands. Navy Medicine
supports readiness from accession to separation, prioritizing
resiliency efforts, suicide prevention, providing mental health
services within primary care and specialty clinics, embedded
within the fleet, and via virtual health platforms, and
deploying disaster mental health intervention.
Navy Medicine is most grateful to the committee for the
resources to support our research initiatives, particularly in
areas of dental technologies, and human performance. The Ads
that you provided will improve overall warfighter readiness in
the medical treatments we provide.
In summary, our center of gravity is the commitment to
provide expeditionary maritime medical care. Our ability to
quickly deploy and support a crisis response around the world
makes Military Medicine unique, but more importantly, demands
that we are both operationally relevant, and clinically
prepared.
Again, thank you for your leadership. And I look forward to
today's discussion.
Senator Tester. Thank you, Admiral. There will be 5-minute
rounds, and I will yield to Senator Durbin.
Senator Durbin. Thank you Senator Tester. Let me say at the
outset congratulations to you for leading this important
subcommittee, which I have been honored to serve on.
Let me respond to my friend, Senator Collins. It is true
that the administration is probably a few weeks late at
producing a budget request, but our hope for the budget process
this fiscal year lies in the capable hands of five people who
were featured in a color photograph on the front page of The
New York Times several weeks ago. It was an article that noted
that we have reached a historic milestone.
Both the Director of the OMB (Office of Management and
Budget), the Chair and Ranking Members of the House and Senate
Appropriations Committees are all women.
Senator Shaheen. Here, here.
Senator Durbin. I thought you would like to hear that. I am
hopeful. I believe that you are going to set out, as Senator
Murray has told me; I know that you are working closely
together to make history in that appointment. And I am
confident you will. So I wish you the very best, and I want to
help you reach that goal.
Senator Tester, I also want to say a word or two in praise,
I am sure you have given me an additional time if necessary, in
praise of your role as Chairman. I set out 8 years ago to
achieve 5 percent real growth in medical research by the
Department of Defense and the National Institutes of Health.
You were my partner in that effort, as was Senator Blunt of
Missouri, with the NIH (National Institutes of Health). And I
note that in the fiscal year 2023 Omnibus you have appropriated
$3.107 billion for medical research, 5 percent real growth.
Congratulations, Chairman. I hope we can maintain that
going forward.
Let me address the issue that we Rear Admiral Gillingham
raised at the end, which I think relates to a number of our
witnesses in my general question.
I will start with Dr. Martinez-Lopez.
Mental health, mental health counseling is so important for
all of us, all of us, and especially important in the Military
where they are under stress situations, and face trauma
incidents on a regular basis. In the past, let us be honest
about it, in virtually every aspect of medicine there was a
stigma attached to mental health counseling, and there was a
belief that if you conceded that you needed counseling, it was
a black mark on your record, which would hold you back come
time for promotion and advancement.
Has that changed? Are you changing it?
Dr. Martinez-Lopez. Sir, I think, you know, there is
movement in the bullpen to really change that. Culture takes a
while but the Department has been very entrenched, and I can
speak for Secretary on down, that mental health is health, it
is like anything else we need. So we need to really lower that
stigma, and people make it very available, close, so everybody,
it will be very easy to get just like a sick call for an
ingrown toenail, or something like.
But I will tell you, there still is an ongoing challenge
that we are really making headways, but we are not done yet.
Senator Durbin. I can see that point very easily in my own
family circumstance. A member of our family served in Vietnam
and came back from that Military Service, a changed person. We
never could quite understand what happened to him. He did some
things, which were not good for his family, for himself, it
took him many years to come to grips with his experience in
Vietnam.
We used to, euphemistically; refer to them as the Vietnam
generation. And I won't go into detail, but you know what I am
speaking of. Contrast that with those who served in Iraq. I
noticed, many times these young military veterans would come
home and be very open and honest about the need for help and
counseling. What a dramatic reversal that was over the Vietnam
generation. I hope that is the spirit that the military is
looking at this issue moving forward.
Dr. Martinez-Lopez. Senator, absolutely. I mean we are
committed for the overall wellbeing of all servicemembers, and
mental health is one of those issues that, thanks to God, now
we can talk and put it on top of the table and address it the
way it should be addressed.
In the Vietnam days, for whatever the reason we didn't talk
openly about these kind of issues that needed to be spoken
about. So stigma is one of the issues of mental health, but
obviously, it is very complex and we are taking the public
health approach to deal with the mental health crisis. And what
that really means is, it is not just a medical issue, it is an
issue that encompasses personal actions, it is an issue that
encompasses financial issues.
So anything that brings more stress, we need to figure out
how to level that load on the service member. So everybody has
to own, everybody, has to own on this exercise, on this issue.
Senator Durbin. Thank you, very much.
Thank you, Mr. Chairman.
Senator Tester. Senator Collins.
Senator Collins. Thank you, Mr. Chairman.
Dr. Martinez-Lopez, let me follow up on the mental health
issues that are of such concern to this subcommittee; you
mentioned the Department's Suicide Prevention Response
Independent Review Committee, which recently released a report
with the numerous recommendations aimed at reducing the number
of suicides.
I want to make a couple of observations about that report
before asking you a question. First, it is evident that the
Department needs to reduce the time that is required to recruit
behavioral health specialists. In one example cited in the
report, it took, on average, a-year-and-a-half to hire civilian
psychiatrists, and almost a year to hire psychologists at
Walter Reed. So it is not a big surprise that half of the
psychiatrists, ultimately, declined the position after that
long delay. Undoubtedly, they went elsewhere. And that is
unacceptable, that we are losing people because it takes so
long to bring them on board.
Second, TRICARE's policy guidance is that 98 percent of the
claims submitted by providers should be completed within 30
days. Yet, the report found that behavioral health providers
were reluctant to serve military beneficiaries because it took
so long for TRICARE to pay them. One provider cited in the
report said, ``It takes forever to get paid a pittance, if you
get paid at all.'' So obviously, our Military Force will be
stronger and healthier when more providers are available, and
more of them are willing and eager to accept TRICARE coverage.
So here is my question, will the upcoming budget requests
include funding to implement the committee's recommendations?
Dr. Martinez-Lopez. Senator Collins, first, the Secretary
and myself are very grateful to the members of the committee
for spending their time to come out with the recommendations,
you know study it out, and helping us out with this big issue.
Second, it is the Secretary right now has a team, and we
are looking, leaning forward each of the recommendations, and
we are looking at ways to, first, which one we are going to be
able to accommodate first, and which ones are going to come--
and in that process there will be issues of budgetary
requirements.
So I am not prepared to tell you what those look like right
now, but I am telling you, we, as a Department, we are looking
at all the--one by one, and addressing (a) are they viable to
how much--what it would take to implement those measures.
So as we are ready to do that, we will come back to you
with the specifics, ma'am.
Senator Collins. Thank you. General Crosland, just
yesterday, I met with a group of veterans from Maine who told
me that the rollout of the new electronic health records system
within the VA (Veterans Affairs) is still very problematic.
Obviously, even if DoD is going to have its new system in 75
percent of its hospitals, as you testified, by the end of the
year, if the VA is not in sync we are still going to have a
problem with transferring medical records once someone retires
from the active duty military. And the veterans were telling me
example after example of where they had difficulties in chasing
down records, getting them to the VA.
So how is DoD collaborating with the VA on the electronic
health records rollout, and ensuring that once it is fully
implemented that there is the interoperability that we have
been talking about for years, for years?
General Crosland. Senator Collins, thanks for the
opportunity to comment. First, ironically last week I spoke
with a senior leader within the VA and offered up the
opportunity for them to come and witness our rollouts and to
learn from our lessons on how we are able to execute our
rollout, and potentially, things we can offer for them by
sharing the lessons learned.
With respect to that value of the record, there is a lot of
value with the data, as I mentioned in my opening comments,
having the right information, being able to follow
servicemembers from the time they are assessed, all the way to
the time they transition. And obviously, if there is a further
delay in the VA's rollout we would have to work through how we
would--in our MHS GENESIS, the electronic record that we are
going to be on by the end of the year to the VA, we haven't
gotten that far yet.
Senator Collins. Thank you. I am sure the Chairman is going
to solve that problem in his dual role.
Senator Tester. No problem whatsoever. Moran is going to
help me do it too.
Senator, right?
Senator Moran. Yes, sir.
Senator Tester. Okay, good. Look, it is a very good
question, and I will just say that I don't know that there is
anybody that is not frustrated with the whole electronic health
record, the billions of dollars that are being spent, and it
doesn't appear that we are moving the ball. So we have got some
work to do.
I want to start my questioning on TRICARE. I just had a
town hall meeting in Montana, things were brought up that I
thought were solved, like providers that couldn't get into the
network. That offered up, but couldn't get Montana. I think you
see this about everywhere in the country. Providers are
something we need more of, not fewer of.
And then the payments for those providers were not being
done on time, so the providers that did sign up weren't getting
their checks when they should have.
So the question is, who has oversight of--it will be
TriWest--who has oversight to make sure, number one, that they
are bringing on the providers they need--and this is for you
General Crosland--they are bringing on the providers they need,
and that the providers are getting paid, and by the way, that
the money isn't--it is actually going out to provide services
and not being pocketed by somebody in one of these third-party
providers' pockets?
General Crosland. So Senator, the oversight of the TRICARE
Program is executed out of the Defense Health Agency, so that
that would be my responsibility.
Senator Tester. Okay
General Crosland. To engage with TriWest to make sure they
are honoring the aspects of the contract. We do have a pretty
aggressive auditing for the last part of the concern that it is
actually not going to the provider, but there is this potential
fraud. We do have a very robust program that looks in and
audits with timeliness, working harder with TRICARE West is
what I owe you, and the team in Montana, to make sure that they
are meeting their contractual obligations.
With respect to signing up providers, the Managed Care
contractors are given targets, they meet those targets. I
acknowledge that when they meet those targets, for the
beneficiaries that doesn't always translate that appointment is
available. So specifically, if you sign up it doesn't translate
that we have actually put appointments out. So in the T-5
contract we have added that as a criterion not just to sign up
providers, but to make sure that there are appointments
available for the patients to book with the providers.
Senator Tester. So this was a small sample size, but I had
providers there that had contracts with TRICARE, and I had ones
that would like to get contracts with TRICARE that couldn't,
these were mental health providers. So I don't know what the
contract says about the numbers of people you need. I don't
know if it is based on population, or geography, or what it is
based on, but I was shocked by what I heard. I was just
absolutely shocked.
At a time when mental health has been already brought up
here several times, when mental health is such a huge issue in
this country, and we are not bringing on as many folks as we
can, doesn't make a lot of sense to me.
I want to move on. I want to talk about China. It may
strike you as an odd discussion in DoD Healthcare, but we have
troops in Japan, and other places, where a number one readiness
concern we hear about is lack of healthcare for the dependents
and their families, and DoD civilians.
Apparently, the Defense Health Agency recently barred DoD
civilians from receiving care at hospitals--military hospitals,
forcing them to use local hospitals. Wow. I think it is a
disaster. And by the way, I think it is going to, if it hasn't
already, end up being an incredible recruitment challenge.
We have also heard concerns about a lack of mental health
care for dependents in Japan. This stops servicemembers from
deploying there, puts tremendous stress on military parents,
these reports are concerning and were repeatedly delivered with
a sense of urgency from senior Military leaders on the ground.
It has already been pointed out, China is our number one
pacing threat, so this impact on military readiness is
alarming. I understand the DoD is now going to make some
changes with this policy, but quite frankly, it should have
never happened to begin with.
General Crosland, was the impact on military readiness
taken into consideration when announcing this change?
General Crosland. So Senator, the change I believe you are
referencing was a policy put out on the 22nd of December, and
the policy limited the space available access to the system so
that we could preserve readiness for the Force, specifically
saying that Space-A would have to call in after 10 o'clock, and
they would only receive acute care.
I have since issued guidance, and the policy was released
last week that added clarity to that policy, which expanded
care to the Space-A. So the policy never targeted or short
access for dependents and their family members, it was meant to
make sure that they got the priority that they were supposed to
get, at the expense, potentially, of Space-A.
So we have removed the barrier for chronic conditions to
open up at the community level, access within our MTFs for our
beneficiaries to include the DoD civilians, and signed that out
last Thursday or Friday.
Senator Tester. Okay. And so do you believe this fully
addresses the concerns of the commanders in the field?
General Crosland. No. I do not believe this fully addresses
the commands--the field. I think the concerns are broader than
the care that the Defense Health Agency is resourced to
provide. So specifically, in Japan, if you have a hospital then
all beneficiaries, active duty, active-duty family members, in
partnership with TRICARE-ISOS, receives care from the host
nation. I believe that that is also part of the concerns that
are being raised.
Senator Tester. Okay. Senator Moran.
Senator Moran. Mr. Chairman, thank you. These discussions
don't seem to leave us, whether we are in the Veterans or in
Defense Appropriations. And the same challenges that have been
described, particularly with electronic health records, are
ones that we are facing in that arena as well.
I want to focus my few minutes on a challenge that I have
had in getting information from you going back to October.
There was a period of time, and it continues, in which just
military retiree after military retiree sought me, my staff, to
tell me about a significant change in their pharmacy benefit.
And they were now traveling much further or would have to
travel much further than previously.
Then, that was followed up by the pharmacists who have
struggled to keep their contracts with your agency. Or the
story of a number of major pharmacy chains who have declined to
continue dealing with the Defense Health Agency.
So in Kansas, a pretty darn rural state these--perhaps you
will tell me that the requirements are being met for the amount
of travel time or distance that you must meet; but the
inconvenience to veterans is significant, and the complaints
are real and continuing.
In October, I tried to get information from you. I was told
this morning that the letter is in the mail, not quite those
words, but in the phrase that we often use. But I and a handful
of my colleagues who were experiencing the same thing, have
sought the analysis that was done a long time ago that would
explain the decisions that you made. And 6 months later we
still don't have that information.
I have submitted requests for information through letters,
and through RFIs (Requests for Information) to the Department,
I went and visited with General Milley seeking his help to get
answers from the Defense Agency, Health Agency, but I am
disappointed by the lack of cooperation that has been extended
to me and to my constituents in an oversight responsibility
that I have.
I have heard the Department blaming pharmacists for leaving
the TRICARE network, but I also think that narrative is unfair
and not accurate. There were winners and losers in the initial
solicitation of contracts, some pharmacists were continued in
network and never received an amendment, while others received
rates lower than the cost to fill the prescription,
effectively, removing them from the network.
A question--perhaps to you General Crosland--how did the
contractor decide which pharmacies received an amended contract
at a much lower reimbursement rate, and which ones did not?
General Crosland. Senator, I will first acknowledge the
delay in getting back to you. And the letter is in the mail and
my apologies for that. I am not read on to what the contractors
process for negotiating rates are, what I am aware of is what
the decision process was, and how many to include into the
network.
I understand that some of the independent pharmacies,
specifically, in the initial bid, felt like they did not have
an opportunity to compete for the TRICARE. We released another
opportunity on 1 January, I believe, and received a response
from another round of independent, and grew those numbers of
the independent pharmacies. Specifically for Kansas, 55 percent
of the pharmacies are chain pharmacies, and 45 percent of the
pharmacies that----
Senator Moran. That are contracted with?
General Crosland [continuing]. Are contracted with ESI are
independent pharmacies. Acknowledge that in rural areas the
burden, or the field, when we say 98 percent of individuals are
15 minutes from a network contract, that will be in the letter
that we sent you, 98 percent. And so the change for drive time
for Kansas beneficiaries, is 95 percent of them are within 15
minutes of a pharmacy. And that leaves about 3,000 of your
constituents that have to travel a little bit beyond 15
minutes. 99 percent is the overall number once we go outside of
15 minutes, within 30 minutes.
Senator Moran. I would push back, or just make the case
that a pharmacy is not just a commodity, it is a relationship,
and our servicemen and women have had that relationship with
their pharmacists for a long time, and to be told that it is no
longer an option, and the pharmacists indicating they had no
option to continue, is still problematic to me.
The transition, apparently, was driven by a 2019
independent analysis that the Department seems to be unwilling
to provide to me. Is there a reason you cannot share that
analysis so that I and others can analyze the methodology by
which you reached these conclusions?
General Crosland. I actually don't have that answer.
Senator Moran. Okay.
General Crosland. But I will get back to you, for sure.
Senator Moran. All right. And Dr. Martinez, my time has
run, but I held your nomination, I put a hold on your
nomination because of lack of cooperation from the Defense
Health Agency. I lifted that hold with--it served its purpose.
Well, it presumably fulfilled its purpose. I lifted that hold
and voted for your confirmation. The commitment was that I
would have the answers that I have been seeking since October,
and often since then, by March the 1st. March the 1st has come
and gone. I would ask for your help in fulfilling that
commitment to me.
Dr. Martinez-Lopez. Sir, I thank you. And I thank all the
members of their supporting my confirmation process. And yeah,
hold me up to that. As Ms. Mullen said, that response will be
fairly soon.
Senator Moran. I may be satisfied, but let us see what the
response is.
Dr. Martinez-Lopez. Yes, sir.
Senator Moran. Thank you.
Senator Tester. I just want to touch on this. I am very
proud of this committee, because there are some really good
people in this committee. One of our jobs is oversight. I don't
need to tell you guys over half the money we appropriate goes
to the Military. If somebody on this committee wants an answer,
unless there is a classified reason for not having that answer,
we should get that answer, and we should get it in short order.
And so I don't think there should be any reason for a
Senator, and this goes for you guys, and anybody else
listening, on this committee, when we are appropriating the
money, not to get the answers we need, it is unacceptable.
Senator Baldwin.
Senator Baldwin. Thank you, Mr. Chair.
Dr. Martinez-Lopez, as the Department is well aware, the
National Guard has become an integral part of our Total Force,
one on which we have relied very heavily for the past 20 years
for the global war on terror, and a long list of other
missions. Increasingly, we have seen the National Guard
activated on short notice to support national priorities such
as pandemic response, domestic unrest, and securing our
southern border.
The increasing reliance on short notice deployments makes
readiness a very key concern, for both the National Guard, and
for this committee. According to the National Guard, over
66,000 Guard members do not have health insurance.
Would you agree that providing health coverage to all
National Guard members would be an important part of improving
readiness?
Dr. Martinez-Lopez. Senator Collins said the health of the
airmen or reservists are active duty, it is most important to
all of us in the Department. And the good news is, because of
you they haven't--the first option is the TRICARE Reserve
Select, so many of the members of the Guard and the Reserve who
have the option to enroll in that program. If we wanted to
expand that program, obviously, we are going to have to look
more in detail, so what does it imply----
Senator Baldwin. That brings me to my second question;
would you agree that if a Guard member cannot afford TRICARE
Reserve Select, and they lack access to other forms of
healthcare, that we should find a way to get them covered?
Dr. Martinez-Lopez. We need to figure out a way to make the
healthcare that they need, available.
Senator Baldwin. Okay.
Dr. Martinez-Lopez. So yes, I agree. I don't know how,
obviously, we are going to have to do studies.
Senator Baldwin. We have a bill for you. But additionally,
can you speak to any impact to or cost savings for the Reserve
Health Readiness Program if we were to achieve 100 percent
healthcare coverage for members of both the National Guard and
Reserve components?
Dr. Martinez-Lopez. Ma'am, I am not prepared to talk about
that. So I really would like to do a study and look at the
background, so I can make a formal statement.
Senator Baldwin. Dr. Martinez-Lopez, in recent years I have
sought and achieved increased funding for organizations within
the National Guard to hire additional mental health providers,
and to expand efforts to educate civilian providers on
intervention strategies. We have also worked to include suicide
prevention as a topic eligible for funding through the
Congressionally Directed Medical Research Program. But despite
these efforts, suicide rates have remained stagnant among the
Reserve and Guard populations since 2011.
Last month, the Department released its recommendations
from the Suicide Prevention and Response Independent Review
Committee. I particularly appreciate the report's holistic view
of mental health, and the inclusion of factors that, while not
directly related to clinical care, nevertheless, impact
prevention efforts.
For example, the report recommends properly funding morale,
welfare, and recreation programs, particularly on smaller and
remote installations, as well as recommending spousal
employment programs. What is your assessment of how we can
better apply resources to make progress in reducing the suicide
tragedy?
Dr. Martinez-Lopez. Ma'am, as I said before, the public
health approach is the way to go. Personally, I believe that,
as a physician. We need to look at three things: We need to
look at the risk factors that are affecting these
servicemembers, and figure out a way to relieve them from those
risk factors, right; if we are not paying them in time that may
increase their risk factor. So we should be able to figure out
how to give them payment on time.
If they, say, have family issues, we need to figure out how
to deal with those family issues. So we need to look at those
risk factors, and we need to look at from the preventive
standpoint, look at ways to decrease it, that is issue one.
Issue two, on the treatment side; we need to figure out new
ways to deliver the care. The first thing we need to figure out
is right care, with the right provider, at the right time. So
we have to make that right on target, because we don't have
that many, and the----
Senator Baldwin. And would you agree that zero-cost
healthcare to all members of our Armed Forces, regardless of
duty status, is an important component of accessing that
prevention care and treatment?
Dr. Martinez-Lopez. Ma'am, I will have to think and see
what are the repercussions of that before I make a statement
one way or the other.
Senator Baldwin. I yield back.
Senator Tester. Senator Murkowski.
Senator Murkowski. Thank you, Mr. Chairman. And thank you;
to all those that are part of the panel here this morning.
I know that there has been discussion about the Suicide
Prevention Response Independent Review Committee report on the
impact of suicide within the military. This is something that
we have been very keenly focused on in Alaska. Our Focus really
has been on Fort Wainwright, along with Eielson Air Force Base,
both of these were identified for site visits in Secretary
Austin's Independent Committee to review the suicide prevention
reports. I am sure that you are well aware of that.
I guess this would be a question for you, Dr. Martinez-
Lopez, and I am curious to know what level you all will be
involved in, in Secretary Austin's Implementation Working
Group? And as you answer that, I would ask for your commitment
to visit some of our bases in Alaska as you look at that
Proposed Suicide Prevention Report.
And I would suggest that starting at Fort Wainwright would
be a pretty good place to begin. And then, I don't know if you
are a walker, but encourage you to take the three-mile walk
from the furthest barrack, it was built back in the '50s, to
the outdated and two small dining facility there at Wainwright.
The sun is coming on, and it is getting warmer, but I would
challenge you to do it in the dark and at 30-below, as many of
our soldiers have to do. So if you can speak to that?
Dr. Martinez-Lopez. Ma'am, thank you for the invitation,
but I already accepted the distinguished Senator from Alaska
when I was doing my hearings, I have two places I need to go.
Senator Murkowski. Okay.
Dr. Martinez-Lopez. The same topic, Alaska and North
Dakota.
Senator Murkowski. All right.
Dr. Martinez-Lopez. I am working at, now in April, so I
hope to be able to--I have been there.
Senator Murkowski. Yes.
Dr. Martinez-Lopez. I did the Arctic Survival School a
couple years back.
Senator Murkowski. Good.
Dr. Martinez-Lopez. When I was doing Aerospace Medicine,
but also, for a Puerto Rican to be out there in Alaska during
those times, it was----
Senator Murkowski. You know we have significant Puerto
Rican population out at Fort Greely, and they love it there.
Dr. Martinez-Lopez. Yes, ma'am. And I survived, obviously.
Senator Murkowski. Yes.
Dr. Martinez-Lopez. Yes. I already told you. I mean, this
issue of suicide and mental health it is very important to me.
I will be working with the team, and I will be working with the
Secretary to address what we can do, short-term, midterm, long-
term. This is not done, and we are done, it is going to take us
a while. It is a journey. Every day we are going to learn,
every day we are going to deploy new ideas, but I am----
Senator Murkowski. So can I ask on that if I can just
interrupt there? Because we are going to be seeing the
President's budget laid down here in the next day or so, and I
don't know if you can speak to whether or not we are going to
see any of this outlined or projected in the President's
budget. Are we going to see certain military construction
projects prioritized, certain programs prioritized that can,
perhaps, help make a difference? Because we know we have got to
do something, and just doing the studies doesn't necessarily
save lives.
Dr. Martinez-Lopez. I am on my eighth day on the job. I
really don't know the answer to that one.
Senator Murkowski. Okay.
Dr. Martinez-Lopez. My assumption is yes, but can anyone
else help me? We owe you an answer on that one.
Senator Murkowski. Okay.
General Dingle. Senator, one thing I will add. Within the
Army we definitely have done that. And under General
McConville's leadership, we have what is called ``Quality of
Life'', in which the Commanding General, General Eifler, has
been able, through a holistic approach, you know, been giving
resources, and facilities that we are looking at adding for the
manning of the hospital. So we are taking a holistic approach
which prioritizes Alaska, and that is one of the Chief's top
concerns, priorities.
Senator Murkowski. Well, thank you for that. And we have
included in our Arctic Warrior Act Provisions two authorizing
provisions for troops stationed there in Alaska, one is for
cold-weather duty pay, the other one is a requirement that
servicemembers in Alaska be reimbursed for the cost of a flight
home. And when you think about financial stressors, the things
that just, people cannot handle anymore if they need to be
reconnected with family and they can't afford the $2,000,
$3,000 flight home. Or they don't have the cold-weather gear.
Or another issue that we hear is pay systems that the
servicemembers are literally victims of outdated technology,
they don't get paid on time.
We have heard from some young servicemen that it is taken
up to 7 months to get their paycheck situation squared out. I
don't know how that works, but you know, when you have that
kind of financial stress on our servicemembers, that is not
right to them. So I would like that, again, is where we are
looking for considerations to be factored in as well.
Mr. Chairman, thank you.
Senator Tester. Senator Shaheen.
Senator Shaheen. Thank you, Mr. Chairman. And thank you, to
each of you, for your testimony today, and your service to the
country.
Our office is still hearing, fortunately not as often, but
still hearing from people who have been affected by anomalous
health incidents. I don't know if this is for you, Dr.
Martinez-Lopez, but can you speak to how the Department's
understanding of those incidents has evolved, and to what
extent you believe people who have been affected, both military
members and their civilian family, are being treated now?
Dr. Martinez-Lopez. Overarches, ma'am, I mean, we need to
take care of these people, they are sick. So when they come to
our system, you know, we have the interagency agreement, and we
have processes to bring them, you helped us out with that, we
are going to take care of that. We are still doing research
trying to figure out the causality.
Senator Shaheen. Right.
Dr. Martinez-Lopez. That is going to take time. But the
overarching, like with anything, we need to take care of the
people first. And then with the best science we have,
development that science as we learn more, close that gap,
right, but it doesn't stop. So we are going to need the help
from you, from you to sustain that effort.
Senator Shaheen. And what I have heard from people who have
been affected is that they especially appreciate the care they
are able to get at Walter Reed Medical Center. Can you tell me
if Walter Reed is still open to those people who have been
affected by AHIs (Anomalous Health Incidents), not just within
the Department of Defense, but across the Federal Government?
Dr. Martinez-Lopez. Ma'am, we are very proud of that team.
And I think the General can speak about that.
General Crosland. Yes, Walter Reed is continuing to care
for AHI.
Senator Shaheen. Thank you. And it will continue to do
that, yes.
General Crosland. And it will continue to do that, yes.
Senator Shaheen. Thank you. So I maybe want to ask each of
you this question; what percentage of your Force are women,
Admiral Gillingham?
Admiral Gillingham. I would have to get back to you, ma'am,
but I believe it is approximately 30 percent.
Senator Shaheen. General Miller?
General Miller. Right now, Air Force, overall, is 21
percent, and within the AFMS it is 50 percent.
Senator Shaheen. Thank you.
General Dingle. Ma'am, I would have to get back to you with
the specific numbers.
Senator Shaheen. Dr. Martinez-Lopez, across the entire
military, can you tell me what it is?
Dr. Martinez-Lopez. I am told 18 percent.
Senator Shaheen. 18 percent, and that number is going up;
is that correct?
Dr. Martinez-Lopez. Yes, ma'am.
Senator Shaheen. So that women make up a very important
part of those who are serving on active duty.
Perhaps this is you, General Crosland; what contraceptives
are currently available to servicemembers?
General Crosland. All contraceptives are currently
available to our active-duty women. The Defense Health Agency
has rolled out a walk-in for contraception in all 133 of our
clinics that offer that capability, to include some of the
long-acting contraception, so they can walk in and be taken
care of without a referral or an appointment.
Senator Shaheen. And is that the case for people who are
deployed overseas as well?
General Crosland. It is a case for the people who are
deployed overseas when they have access to the capability
within the theater. So if the clinic provides long acting, then
they are able to walk in and get long acting.
Senator Shaheen. And can you tell me what percentage of
women are deployed in places where they can't get access to
those contraceptives?
General Crosland. I do not have that number, of what
locations do not have the capability to provide it.
Senator Shaheen. Is that something that someone within the
office is able to provide?
General Crosland. We will take that for action.
Senator Shaheen. Okay. We hear from women on a pretty
regular basis who tell us that they are in places where they
don't have access to contraceptives. Servicemembers and their
families are affected by eating disorders at elevated rates,
compared to their civilian counterparts, and the SERVE Act was
passed in fiscal year 2022, in the NDAA, and it was designed to
expand access to eating disorder treatments for servicemembers
and their families. Can you speak to the options that are now
available as the result of the passage of that, and has it been
fully implemented?
I guess this is for you, Dr. Martinez-Lopez.
Dr. Martinez-Lopez. Ma'am, I don't know the answer to that
one. I owe you a response.
Senator Shaheen. Okay.
Dr. Martinez-Lopez. Anyone else knows that? Okay.
Senator Shaheen. Well, thank you. I think it would be--I
would appreciate hearing that response, as I am sure the full
committee would--subcommittee would. And I think as part of
that it would be helpful to know if spouses and children of
servicemembers are provided the same level of care, as active-
duty servicemembers. Thank you.
Thank you, Mr. Chairman.
Senator Tester. I want to welcome the newest member to our
subcommittee. Senator Murphy.
Senator Murphy. Thank you very much, Mr. Chairman. It is as
honor, to join this prestigious subcommittee, and grateful for
the opportunity. Thank you all for being here today. I am
really grateful for the Chairman, and the Ranking Member's
focus on the suicide epidemic, and for all the work that you
have put into it.
I wanted to talk to you, Rear Admiral, about a very
specific case that I have become intimately and tragically
familiar with, and that is the death of seven sailors on the
USS George Washington just last year. One of them was a
Connecticut resident, seaman recruit, Xavier Sandor, took his
own life with a service-issued firearm.
And by now you know that the conditions on this ship, and
the conditions for these sailors was, you know, frankly just
unacceptable. This was, obviously, a ship that was going
through a major refueling, and complex overhaul the conditions
on board required a lot of these young men to be sleeping in
their cars, to be making long trips home to get away from the
chaotic scene, and the access to mental health was just
completely inadequate.
Sailors who were seeking routine care on a ship that had
significant conditions affecting mental health were facing
waits of up to 2 months for care, members of Seaman Recruit,
Sandor's Division reported that they were often hesitant to
seek mental health treatment through Navy channels because they
were under the impression that it would affect their future
career opportunities.
Obviously, this is exceptional that we had so many
individuals take their life in a short period of time. And I
know that there is still a final investigation that is
outstanding. But what can you tell me today about how were the
changing conditions for our seamen who are living under these
kinds of conditions, and how we are making sure they have
access to Mental Health Services?
Admiral Gillingham. Thank you, Senator Murphy.
From the Secretary of Navy, on down, we have taken this
issue very seriously, as we have taken the general issue of
mental health and suicide prevention seriously. I can tell you
that our immediate response was to send a special Psychiatric
Response Team; that was to counsel those who were directly
affected by these incidents, by these tragic incidents.
We have learned also that it is important, not only to
respond acutely, but to have a prolonged response. And so all
of the members of the George Washington are enrolled in what is
called ``ORION'', which is a periodic check-in to assess how
they are doing and to ask if they need help.
Historically, when we have done this, on five previous
occasions, we have about a 20 percent take rate, and we
directly do a warm handoff for those individuals. But the
larger issue, sir, is ensuring that we are creating a resilient
Force. GW, certainly, is an example of a challenging situation
to be in a shipyard like that, but our sailors and marines face
challenging situations worldwide, and so developing Force
resilience is key.
Toward that end, all of our recruits now go through warrior
toughness training; they learn stress reduction techniques, as
well as meditation. These are reinforced through their
training.
In addition, for the GW and for the greater Navy we have an
Expanded Operational Stress Control Program, this is a train-
the-trainer model, in addition as well our office of Navy
culture and Force resiliency just rolled out a mental health
playbook which provides tools for unit-level leaders and
beyond, ways to prevent suicide, ways to recognize an
individual in distress.
Senator Murphy. All right. Thank you very much. I will look
forward to follow up with you on that.
I just want to sneak in one more question, and that is to
you, Mr. Assistant Secretary. We talked a lot about this
Independent Review Committee Report; one of their urgent
recommendations was to address Section 1057 of the 2011 NDAA,
which prohibits the Secretary of Defense from collecting any
information regarding firearm ownership by active duty members.
Now, I think this was due to some concerns about overreach,
but I don't think that the drafters of that language
contemplated the fact that it is just good medical practice if
someone is in crisis, to inquire as to whether they have a
firearm at home, whether that firearm is properly stored, and
locked.
And so I am not going to ask you for your view on the law,
that is a question for us, but as a rule is it good medical
practice for there to be gag orders on physicians as to what
questions they can ask their patients, what information they
can try to solicit from their patients?
Dr. Martinez-Lopez. As a physician, you know the
relationship between my patient and I, it is kind of sacred, I
mean, because we talk. And I expect him to be truthful to me so
I can help him. So anything that interferes with that
interferes with good medical care. So that my position is that,
I mean, anything that interferes with a good open discussion
between the patient and the physician, or a provider, not
necessarily a physician, it is not good for either of the two
parties. If I don't know I cannot help you; and if you cannot
tell me, even worse. So we need your help to facilitate that
process.
Senator Murphy. Great. Thank you very much.
Thank you, Mr. Chairman.
Senator Tester. Senator Hoeven.
Senator Hoeven. Thanks, Mr. Chairman, appreciate it. Thanks
to all of our witnesses for being here, and for all you do to
keep us safe, and take care of our men and women in uniform.
I want to ask primarily about, well, first some mental
health issues, and making sure that those services are
available to our members of the Armed Services.
But first, I am going to ask Lieutenant General Miller
about the cancer study that is being done in regard to--
actually, the German State, the Malmstrom Air Force Base, there
were a number of cancer cases there, and in response the Air
Force has initiated a study on it to determine cause. And of
course, make sure that anyone that needs treatment is getting
it.
I did talk to General Bussiere. I met with General
Bussiere, the Commander of Global Strike Command, to ask him
about it. But my first question for you is; how do you
determine the cause of cancer, or a group of cases of cancer
are attributable to any particular cause?
General Miller. Thank you, Senator. And yes, there is an
ongoing study now based on General Bussiere's request, as he
has been offered the initial assessment from our team at
USAFSAM (U.S. Air Force School of Aerospace Medicine), and he
has elected to conduct a study that will be led by that team at
USAFSAM, in cooperation with other important agencies, the VA,
the cancer societies, and others.
But what is going on right now, is there is a ten-member
team on the ground, just left F.E. Warren, we are at Malmstrom,
they are headed to Minot, to assess what--each base is unique
and different--what the situation is like in each area. How
that study could best be done. Because to get to your question,
it is a complicated question especially when you are dealing
with multiple different Airman Guardians, different career
fields, different bases, different timeframes, and even
different cancer types, to determine what might be involved,
what the incidence is. And then, if possible, what might be a
causative reason that we would then take action on since our
priority is a safety for Airmen and Guardians.
So this is a process that will continue to play out over
the next 12 to 14 months, as we take this very seriously, and
try to get to the bottom of some of these concerns.
Senator Hoeven. Do you have any sense of time line, at this
point?
General Miller. 12 to 14 months is a reasonable estimate.
Now, the study we will plot in stages, and obviously as they
get information, if there is something actionable prior to that
that will happen. In the same regard it--certain paths may
result in more work being done that that could extend this out,
but the key is timeliness in trying to get this completed as
quickly as possible to best take care of all that might be
impacted, whether active, retired, and all beneficiaries.
And once again, partnering with others like the Veterans
Administration, understanding all that, potentially, could be
impacted.
Senator Hoeven. Thank you. The True North, Task Force True
North is something I have worked on with the Chairman of this
Committee, and also with Air Force leadership, Secretary of Air
Force, and so forth. In the initiative, the True North
Initiative, is there a concerted effort to make sure that you
are addressing mental healthcare adequately across the missile
bases?
General Miller. Yes, sir. It is a great question. And True
North is the initiative that the A1 community in the Air Force
is rolling out with the focus on mental health, in a mirror
framework, SG has something called Operational Support Teams
that will be at Minot, that will be at every one of our 76 Air
Force Bases, knowing that our Airmen and Guardians, the two
main reasons that they are often not deployable, or have
issues, it is mental health, and it is musculoskeletal.
So as a part of teams, five-member teams, that will be
embedded in the Med Group, will go out to units for short
periods of time, eight to nine weeks, develop trust, do
prevention, mental health will, absolutely, be a part of that
effort.
Senator Hoeven. And it is addressing family needs too, not
just the servicemember, right?
General Miller. And that is a great question, because
family is equally important. OST is based on the active duty
members. For the Air Force we have created something called
Developmental Behavioral Family Readiness Centers. So there are
eight hubs presently throughout the United States that will
address; we know that there is quite a few children that are
impacted by mental health issues, that these teams go out to
bases on a quarterly basis, and then support, virtually, from
afar, so that a Wright-Patterson, for example, is a hub that
could go out to a location like a Minot, and provide that type
of support.
Those teams right now are focused on children, but could be
expanded to include adult mental health providers that could
take care of dependent family members that have mental health
needs.
Senator Hoeven. Well, with the Indulgence of the Chairman,
one final question. And make it short please. I am past my
time. But both for Dr. Lester Martinez-Lopez, and also for
General Crosland; through TRICARE, are you providing enough
mental health services and providers for our service members?
Dr. Martinez-Lopez. I will defer to General Crosland.
General Crosland. So sir, there is not enough in our
country to meet the demand, to be honest with you.
Senator Hoeven. I will ask him the question.
General Crosland. Yes, sir. So we are doing our best with
the contract, and as some of our teammates have mentioned,
taken a much more holistic approach partnering with other
teammates to help folks with their mental health, not just
medical.
Senator Hoeven. And it is a focus?
General Crosland. It is absolutely a focus.
Senator Hoeven. Thank you. Again, thanks to all of you.
Thank you, Mr. Chairman.
Senator Tester. Just one quick follow-up on Senator
Hoeven's question.
This is for you General Miller. What role is the Defense
Health Agency playing in the assessment that is being--you
know, that the Air Force is doing under General Bussiere?
General Miller. There is a partnership there, and we are in
open communication so the Health Surveillance Division, part of
the DHA, is absolutely involved. So it is important to us that
this is--and all the key organizations are playing a role.
Like, as I mentioned, VA, American Cancer Society, and others,
with an interest that once the study is completed we may need
to have some civilian organizations to be involved to be
another set of eyes based upon the results that we receive.
Senator Tester. Thank you. We appreciate all of you, your
testimony, your opening statements, thank you for being here
today. This was a helpful conversation, covered a number of
topics. But our oversight responsibilities will not stop here.
Later this week the subcommittee will receive your budget
request, and we will conduct a thorough review. We ask that you
provide responses in a timely manner, and continue to keep us
apprised of the Department's health policy, decisions, and
implementations, similar to what I said earlier in this
meeting.
conclusion of briefing
The Defense Committee will reconvene on Tuesday, March 28,
at 10 a.m., for a hearing with the Department of Navy.
We stand in recess.
[Whereupon, at 11:19 a.m., Tuesday, March 7, the
subcommittee was recessed, to reconvene at 10 a.m., Tuesday,
March 28.]
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