[Senate Hearing 118-184]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 118-184

          A REVIEW OF THE DEPARTMENT OF DEFENSE HEALTH PROGRAM

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

                                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
                               __________

         Printed for the use of the Committee on Appropriations

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          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
                                 ------                                

                 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

                              ----------                              
                                                                   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

                              ----------                              


                         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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