[Senate Hearing 119-76]
[From the U.S. Government Publishing Office]
S. Hrg. 119-76
STABILIZING THE MILITARY HEALTH SYSTEM
TO PREPARE FOR LARGE-SCALE COMBAT
OPERATIONS
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HEARING
BEFORE THE
COMMITTEE ON ARMED SERVICES
UNITED STATES SENATE
ONE HUNDRED NINETEENTH CONGRESS
FIRST SESSION
__________
MARCH 11, 2025
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Printed for the use of the Committee on Armed Services
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via http: //www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
60-344 PDF WASHINGTON : 2025
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COMMITTEE ON ARMED SERVICES
ROGER F. WICKER, Mississippi, Chairman
DEB FISCHER, Nebraska JACK REED, Rhode Island
TOM COTTON, Arkansas JEANNE SHAHEEN, New Hampshire
MIKE ROUNDS, South Dakota KIRSTEN E. GILLIBRAND, New York
JONI ERNST, Iowa RICHARD BLUMENTHAL, Connecticut
DAN SULLIVAN, Alaska MAZIE K. HIRONO, Hawaii
KEVIN CRAMER, North Dakota TIM KAINE, Virginia
RICK SCOTT, Florida ANGUS S. KING, Jr., Maine
TOMMY TUBERVILLE, Alabama ELIZABETH WARREN, Massachusetts
MARKWAYNE MULLIN, Oklahoma GARY C. PETERS, Michigan
TED BUDD, North Carolina TAMMY DUCKWORTH, Illinois
ERIC SCHMITT, Missouri JACKY ROSEN, Nevada
JIM BANKS, INDIANA MARK KELLY, Arizona
TIM SHEEHY, MONTANA ELISSA SLOTKIN, MICHIGAN
John P. Keast, Staff Director
Elizabeth L. King, Minority Staff Director
(ii)
C O N T E N T S
_________________________________________________________________
March 11, 2025
Page
Stabilizing the Military Health System to Prepare for Large-Scale 1
Combat Operations.
Member Statements
Statement of Senator Roger Wicker................................ 1
Statement of Senator Jack Reed................................... 2
Witness Statements
Robb, Lieutenant General (Dr.) Douglas J., USAF (Ret.), Former 4
Director of the DefenseHealth Agency.
Friedrichs, Major General (Dr.) Paul A., USAF (Ret.), Former 6
Joint Staff Surgeon.
Cannon, Colonel (Dr.) Jeremy W., USAFR (Ret.), Professor of 19
Surgery, Perelman School of Medicine, University of
Pennsylvania.
(iii)
STABILIZING THE MILITARY HEALTH SYSTEM TO PREPARE FOR LARGE-SCALE
COMBAT OPERATIONS
----------
Tuesday, March 11, 2025
United States Senate,
Committee on Armed Services,
Washington, DC.
The Committee met, pursuant to notice, at 9:36 a.m., in
room SD-G50, Dirksen Senate Office Building, Senator Roger
Wicker (Chairman of the Committee) presiding.
Committee Members present: Senators Wicker, Fischer,
Cotton, Rounds, Ernst, Sullivan, Cramer, Scott, Tuberville,
Mullin, Budd, Schmitt, Banks, Sheehy, Reed, Shaheen,
Blumenthal, Kaine, King, Warren, Peters, Rosen, and Kelly.
OPENING STATEMENT OF SENATOR ROGER WICKER
Chairman Wicker. The hearing will come to order.
The Committee has convened this hearing to discuss the
State of the Military Health System (MHS). We hope to shine a
light on the challenges facing that system and begin working
toward solutions.
Our witnesses are experts in the field of military
medicine. Dr. Douglas Robb is a retired Air Force Lieutenant
General and the former director of the Defense Health Agency
(DHA). Dr. Paul Friedrichs is a retired Air Force Major General
and the former Joint Staff Surgeon. And Dr. Jeremy Cannon is a
retired Air Force Colonel and trauma surgeon who currently
serves on the faculty at the University of Pennsylvania School
of Medicine.
I look forward to their testimony. I want to hear their
recommendations about what Congress and the Department of
Defense should do to provide long-term stability to the
Military Health System.
Military medicine often follows a familiar but regrettable
cycle. During peacetime, medical teams focus on the treatment
of ordinary illnesses. When conflict erupts, military medicine
is frequently caught unprepared, resulting in unnecessary
casualties.
This interwar erosion of our unique military medical skills
is known as the ``peacetime effect.'' To disrupt the
``peacetime effect,'' Congress enacted sweeping reforms of the
Military Health System. These reforms, now nearly a decade old,
were designed to refocus military medicine on its primary
purpose: combat casualty care and medical readiness.
We elevated the Defense Health Agency to a combat support
agency and tasked it with administration of all military
hospitals and clinics, relieving the military departments of
that mission. The goal was to have the military services focus
exclusively on the medical readiness of their forces. These
ideas were recommended by an independent, bipartisan commission
embraced by Pentagon leadership, and signed into law in 2017.
Unfortunately, opponents of these reforms have delayed
implementation and undermined the effectiveness of the
legislation. For example, in 2019, the military departments
implemented drastic cuts to military medical personnel on the
faulty assumption that it would be easy for DHA to hire
civilians to take their places.
This assumption was misguided, which became evident during
the COVID pandemic. During that crisis, the existing national
physician shortage accelerated. To this day, private sector
health systems seek out and hire away doctors from the
military, not the other way around. We have all seen this in
our states.
In 2020, Congress ordered a halt to any additional military
medical reductions, but it was too late. A significant number
of reductions had already occurred, severely reducing the
capability of military hospitals. In many locations, the
private sector was unable to handle the additional patients,
sending more servicemembers to private sector care. This has
proven more expensive and has sapped the military doctors'
experiences that are vital to maintaining proficiency.
Even worse, the Department of Defense (DOD) has refused to
request adequate funding for DHA, which would allow DHA to
staff adequately and equip its hospitals and clinics. Since
2015, the budget for military hospitals has decreased by nearly
12 percent. The water damage at Walter Reed this January is an
example of the antiquated infrastructure that military medical
teams work with around the world.
In addition to the problems I have just explained, I would
like our witnesses to highlight how bureaucratic delays within
the Department of Defense have prevented the Military Health
System from preparing for the next potential conflict.
Combat casualty care is the primary purpose of the Military
Health System. When servicemembers are exposed to danger or are
injured, they need to know that they will receive the best care
possible. We know that troops in combat are more comfortable
taking the risks necessary to accomplish their mission if they
have confidence in military doctors.
We cannot go back to the way things were before 2017. We
must stop scapegoating the Defense Health Agency. The
Department of Defense must request adequate resources to ensure
the Department's hospitals and clinics are properly staffed and
equipped. This is the best way to ensure the Military Health
System is ready for the potential demands of large-scale combat
operations in the future.
I thank the witnesses for being willing to testify and now
recognize Ranking Member Reed for his remarks.
STATEMENT OF SENATOR JACK REED
Senator Reed. Thank you very much, Chairman Wicker, and
welcome to our witnesses. General Douglas Robb, General Paul
Friedrichs, and Colonel Jeremy Cannon each bring important
perspectives from their extensive careers in military medical
fields. We are fortunate to have such a distinguished panel
before us.
Throughout history, military medicine has often represented
the leading edge of modern health care. Many of the lifesaving
practices common in today's emergency rooms and clinics were
born out of necessity on the battlefield hospitals of the Civil
War, World Wars I and II, Vietnam, and the wars in Afghanistan
and Iraq.
Professional expert health care, both in combat and
peacetime, is a vital component of our military. Our service
men and women, and their families, deserve nothing but the best
in this regard.
I am concerned that our military health care system will be
challenged to meet the demands of a potential large-scale
future conflict, particularly in the Indo-Pacific. We have seen
the terrible challenges of health care in austere environments,
like the front lines of Ukraine, where supplies and medics are
often cutoff from the troops in contact. These risks would be
compounded in the Indo-Pacific where contested logistics and
the tyranny of distance would be major factors.
Congress has dedicated considerable attention to reforming
the Military Health System in recent years, with an eye toward
any potential future large-scale conflict. The primary
objective of these reforms has been to improve combat casualty
care, assume quality medical care for servicemembers and their
families, and ensure that military medical professionals are
able to deliver the world's best care on the battlefield, at
field hospitals, and at medical centers and clinics.
However, until relatively recently, the Military Health
System was inadequately designed to meet these missions. For
decades, the individual military branches managed their own
Military Treatment Facilities (MTFs) and the Defense Health
Agency, or DHA, was tasked with managing Defense Department
health care via civilian providers. This system was hampered by
unnecessary complexity, a lack of standardization, inefficiency
and redundancy in the system, and inflated costs. The Military
Health System was too focused on beneficiary care while
insufficient attention was paid to combat casualty care.
To address this, the fiscal year 2017 National Defense
Authorization Act (NDAA) included provisions restructuring much
of the system. This legislation transferred responsibility for
operating the Military Treatment Facilities entirely to DHA.
This change was intended to allow the military services and
surgeons general to focus on medical readiness for the force
and its health care providers.
Unfortunately, implementation of this legislation has been
difficult. The military services have not implemented the
changes readily, and they have failed to staff the treatment
facilities with the military personnel needed to provide timely
care. The Department of Defense made progress to break through
the inertia in 2023, when it issued a memorandum with specific
direction to save lives and improve the Military Health System,
to include adequate manning of Military Treatment Facilities,
and this effort marked a major milestone in modernizing the
system.
More work remains to be done, and I hope that the Trump
administration will continue the momentum in this area. During
today's hearing, I would ask for our witnesses' views on the
key challenges remaining for successfully reforming the
Military Health System and how Congress can help equip the
Department and our warfighters with the medical support needed
for any future conflicts.
Thank you again to our witnesses, and I look forward to
your testimonies. Thank you, Mr. Chairman.
Chairman Wicker. All right. We will begin with 5-minute
testimonies from each of our distinguished witnesses.
Lieutenant General Robb, you are recognized.
STATEMENT OF LIEUTENANT GENERAL (DR.) DOUGLAS J. ROBB, USAF
(RET.), FORMER DIRECTOR OF THE DEFENSE HEALTH AGENCY
Dr. Robb. Chairman Wicker, Ranking Member Reed, and
distinguished members of the Committee, thank you for this
opportunity to testify on the urgent need to restore and
sustain our military medical readiness in the face of large-
scale combat operations, and thank you both for what I would
believe is spot-on comments. So thank you very much.
Just a little background on where my perspective of the
Military Health System originates from, I started my military
career as a boots-on-the-tarmac operational flight doc, both
stateside and overseas. I have served at the Air Force Squadron
hospital, clinic, and medical centers in commander positions,
and at the headquarters level.
I have also had the honor and privilege to serve our joint
forces as the U.S. Central Command surgeon, joint staff
surgeon, and as the first Director of the Defense Health
Agency.
Moving forward, a refocus on our ability to support large-
scale combat operations, I believe, will require a
recalibration of current and future resources to support large-
scale casualty flow, from the battlefield or the sea battle to
definitive care, rehabilitation, and eventually reintegration.
All this in the face of incremental pressures from The Office
of the Secretary of Defense (OSD), The Office of Management and
Budget (OMB), and the military departments, resulting in a
decade-plus of flatline actually declining defense health
program budgets, personnel reductions, erosion of our mission-
critical Military Treatment Facilities, and intense competition
for quality health care professionals with the private sector.
One of the key Military Health System organizational
elements in support of the Military Health System strategy is
the evolving and maturing Defense Health Agency, designated as
a Combat Support Agency (CSA). It was established over a decade
ago. Recently, the DHA's justification, and specifically the
DHA's designation as a Combat Support Agency, has been
challenged and questioned.
In 2011, the Deputy Secretary of Defense issued a memo
titled ``Review of Governance of Model Options for the Military
Health System.'' That was driven by the Department's
significant growth in health care costs. Fast forward a decade
later--sound familiar?
The Task Force on Military Health System Governance Reform
was then established--and this is key--that included co-chairs
from the Joint Staff, OSD, and flag and senior executive
service (SES) representation from the Joint Staff, OSD
Personnel and Readiness, Cost Assess and Program Evaluation
(CAPE) and Comptroller, and the service surgeons general, for a
total of nine voting members. And I think it is also important
to recall the task force overwhelmingly recommended a Defense
Health Agency organizational model, with a final vote of seven
for the Defense Health Agency, one for a unified medical
command, and one for what then was called a single-service
model.
The recommendations were briefed through both Joint Staff
and actually through two Chairmen, and Office of Secretary of
Defense and actually through two Deputy Secretaries of Defense,
with the Defense Health Agency construct signed off by the
Deputy Secretary of Defense with the Chairman's support.
Another decision that has come into question in recent
years was the designation of the Defense Health Agency as a
Combat Support Agency. The designation was initiated by the
Director of the Joint Staff, with the Chairman's concurrence,
when reviewing the proposed DHA organizational structure and
the relationships with both the Chairman and the OSD. The CSA
designation was then codified.
Now, a decade later, do I still believe the original
analysis and the recommendation to stand up a Defense Health
Agency as a Combat Support Agency remain valid? And the short
answer is yes. But does a recalibration of the Defense Health
Agency supporting relationship with its Combat Support Agency
responsibilities to the supported entities of the military
departments and the Joint Forces need to be readdressed? And
again I would say yes.
I share with you several lines of effort that I believe are
essential as we strive to further achieve a more tightly
integrated Military Health System to support our national
military strategy and our national security strategy.
Number one, reemphasizing, with clear articulation and
execution, of the Assistant Secretary of Defense of Health
Affairs' authority, direction and control of the Defense Health
Agency.
Number two, I believe we need to establish a direct
organizational linkage at the Defense Health organizational
structure level, with the Chairman of the Joint Chiefs of Staff
and the combatant commands through the Joint Staff Surgeon, to
ensure that the responsibilities are prioritized with the DHA's
execution.
Finally, the Fiscal Year 2019 NDAA directed the Department
to establish joint force medical requirements process to
synchronize the Military Health System's already established
joint operational requirements governance process. And I think
that is key, that the medics need to play with the Joint
Staff's process for determining requirements.
In closing, I would like to thank you, and look forward to
support you in assisting the Military Health System's ability
to accomplish our mission of ensuring a medically ready and a
ready medical force in support of our military departments and
combatant commands through the provision of care to our 9.5
million beneficiaries. Thank you.
Chairman Wicker. Thank you very much, Dr. Robb.
Major General Friedrichs.
STATEMENT OF MAJOR GENERAL (DR.) PAUL A. FRIEDRICHS, USAF
(RET.), FORMER JOINT STAFF SURGEON
Dr. Friedrichs. Chairman Wicker, Ranking Member Reed, and
members of the Committee, thank you so much for the opportunity
to be here. I had the opportunity in my very last briefing to
some members of this Committee in May 2023 to give you a
classified assessment of MHS readiness, and I will start with a
recommendation that if you have not had an update since May
2023, I would implore you to schedule that so that the Joint
Staff Surgeon can give you the most current classified
assessment, because what we will provide today is an
unclassified assessment.
Second, I will give a disclaimer that the views that I
express are my own, not those of any organization with which I
have been affiliated.
I provided a detailed written statement to you, and I would
respectfully ask that that be entered into the record of this
hearing.
Chairman Wicker. All of the statements will be added to the
record at this point, without objection.
Dr. Friedrichs. Thank you very much, Chairman.
I have two disclaimers. The first, this is my family
business, so I will speak both from my experience and because
my dad served in the Navy--98, still alive--at the end of World
War II. Multiple other relatives in the Navy. My wife is a
former Army physician who now works for the Department of
Veterans Affairs (VA). We are very proud that one of our
children is a marine. I care about this not only because of all
of the others but because this is what my family has done for
generations.
My second disclaimer, like General Robb, is I have had the
privilege of serving our country now for 39 years, and the
majority of those years I have spent in joint roles. Congress
got it right in 1986, with the Goldwater-Nichols Act, but the
one thing I wish you would change is to include medics as part
of the military. As long as we preserve this false narrative
that the Military Health System is separate and not covered by
the same expectation of jointness as the rest of the military,
we are going to continue to have these fruitless, bureaucratic
buffoonery actions that distract us from taking care of
patients. I encourage you to treat the Military Health System
like a part of the military.
We have had tremendous accomplishments over the last 20
years, with the lowest rate of deaths among injured ever seen
in conflict, and we should be incredibly proud of that. When I
deployed, I had what I needed, when I needed it, air-evacuation
available. I flew air-evacuation missions. I operated on
casualties. I never lacked for what I needed. I cannot offer
you the assurance that my successors will have that same
environment in the next conflict, and I am grateful that you
are holding this hearing today.
I have several very specific recommendations. First, as I
touched on before, we must prioritize the patient over the
patch, put a nail in the heart of this discussion about
reorganizations and what the role of the Military Health System
actually is. We need to commit, and we need your help in the
next NDAA, to clearly articulate , just as both the Chairman
and the Ranking Member said, the Military Health System exists
as part of the military to ensure that we deter those who might
seek to harm our Nation and defeat them if they try to. The
military's role is to take care of the human weapon system. The
health care benefit delivery is part of how we do that, and
part of a commitment that we make. But I implore you to address
that in the next NDAA.
As I said before, I think that you got it right with the
Goldwater-Nichols Act, and I would encourage you in the next
NDAA to clearly articulate that you view the Military Health
System as part of the military and not exempt from the
requirements that the rest of the military faces. A joint
casualty stream requires a joint casualty care team. That seems
relatively straightforward, and yet that is still something
that we are arguing over, whether medical units should be
interoperable, whether they should have the same equipment or
the same training. The answer is yes.
Look at Israel. Look at almost every other country with a
large military. They have already made those changes, which you
rightfully began and appropriately began in 2017. We do not
need another reorganization. What we need is execution of the
vision that you laid out.
The next point that I bring up is resourcing, and both the
Chairman, the Ranking Member, and Dr. Robb touched on this.
Health care is not cheap. The mistaken belief that somehow
military medicine can be done at a lower cost than in the
civilian sector, and be ready for conflict, is just that. It is
a mistake and it is a discredit to those who State that they
care about our patients.
Finally, I am deeply concerned about our growing
vulnerability to biological threats. The decisions to take down
our overseas partnerships to build better biosurveillance, the
decisions to take down research in biological threats, the
decisions to take down multiple other programs that we had
built as a result of the 2018 National Defense Strategy, which
President Trump signed in the first administration and
President Biden updated, put us at greater risk. And we must
continue to address those risks of the evolving biological
threats, both naturally occurring and deliberate threats. The
confluence of Artificial Intelligence (AI), biotechnology, and
compute is dropping the bar dramatically for biological
threats. We should be working on mitigating that.
I thank you again for the opportunity to be here and for
your interest in this.
[The prepared statement of Dr. Friedrichs follows:]
Prepared Statement by The Honorable Paul Friedrichs, Maj Gen (ret).,
MD, FACS
Chairman Wicker, Ranking Member Reed and distinguished Members of
the Committee, thank you for the opportunity to testify on this topic.
My last congressional engagement as the Joint Staff Surgeon in 2023 was
with several of you to provide a detailed, classified update on the
gaps between Combatant Command requirements for medical support and the
readiness of the force elements which the Services organize, train and
equip, with support from the Defense Health Agency (DHA), in its role
as a Combat Support Agency. It is an honor to be back to share some
additional observations on this very timely topic on which Congress
needs to act, in order to address critical gaps in our readiness to
care for ill and injured Servicemembers.
The opinions and advice I share in this statement and in my
testimony are my own; I am not speaking on behalf of any organization
with which I am or have been affiliated.
I need to acknowledge several conflicts of interest related to this
hearing:
First, and foremost, this is my family's business. . .and I care
deeply about it. I am the proud son of Seaman Third Class Al
Friedrichs, who turned 98 this past January and who served in our Navy
at the end of WWII. Multiple other relatives served in the Navy. One of
the few really great decisions I have made in my life was to propose to
my wife more than thirty years ago, when she was serving as a doctor in
the Army. Our kids thought it was incredibly cool that their mom really
did wear combat boots. After separating from the Army so that our
family could stay together, she has worked for the Veterans Health
Administration for decades, continuing her commitment to care for those
who volunteer to serve their nation. And one of our children is now a
marine.
Second, I am deeply grateful to have had the opportunity to serve
our Nation in uniform for 37 years, including three tours as a
Commander, as well as service as the Command Surgeon for Alaskan
Command, Pacific Air Forces, Air Combat Command and United States
Transportation Command, where I oversaw the global aeromedical
evacuation system. My last assignment was for 4 years as the Joint
Staff Surgeon, attempting to integrate and synchronize medical support
to military operations and family members on every continent and in
multiple conflicts and disasters. These experiences have taught me that
the rest of the military deploys and fights as a Joint Force, not as
individual Service forces. I believe to my core that the military
health system is a part of the US military and should adopt the same
commitment to joint, integrated capabilities and readiness that the
rest of the military has embraced, and I commend Congress for the
actions they have taken to try to break down stovepipes and enable
greater standardization, interoperability, and integration.
Nearly 250 years ago, our Nation was born out of the American
Revolution. Historians estimate that between 25,000 and 75,000 members
of the Continental Army died during this conflict, with three deaths
from illness for every one death from injury. Roughly 1,400 medical
personnel served in the Continental Army, but only 10 percent had any
formal medical training. Since then, we have been on a journey to
continue improving the care we provide to America's sons and daughters
who serve their nation in uniform and this has resulted in a steady and
continuous decline in the percent of injured servicemembers who died of
their wounds. Numerous innovations in both pre-deployment care and the
care we provide to deployed personnel have enabled military medics to
successfully treat and return to duty more and more ill servicemembers,
enhancing combat capabilities. And for those who sustained injuries in
Operational Iraqi Freedom/Operation Enduring Freedom, fewer died than
in any conflict in history. This is an extraordinary testimony to the
work of countless military doctors, nurses, pharmacists, Corpsmen and
other military medics. And it was shaped by congressional direction in
the annual National Defense Authorization Acts (NDAA) and annual
appropriations which translated that guidance into reality. Thank you
for all that you and your predecessors have done to enable these
remarkable results.
As proud as we should be of these unparalleled accomplishments,
every organization committed to excellence knows the importance of
asking ``What could we have done better?'' High performing healthcare
systems know that ``Good enough'' is not acceptable, especially when it
comes to the health of America's sons and daughters who choose to
defend our Nation. Some of our military medical colleagues reviewed the
available data on every single servicemember who died in recent
conflicts and what they found is remarkable: even with nearly total air
superiority, unfettered communications, aeromedical evacuation on
demand, and largely unhindered supply chains, roughly 25 percent of
those who died prior to 2012 had injuries which should have been
survivable. This is an incredibly important--and painful--lesson: We
could have done even better.
Unfortunately, we have made insufficient progress toward minimizing
preventable battlefield injuries and death. In some cases, we have
mistakenly confused loyalty to the patch on our uniforms over our
commitment to our patients. We have confused efficiency with
effectiveness. We have argued for years about roles and
responsibilities and competing interpretations of congressional intent.
Thankfully, because the United States is not involved in large scale
combat operations at this time, we have the opportunity, with help from
the members of this Committee, to refocus efforts to ensure that, in
the next conflict, military members will be medically ready before they
deploy and military medics will be well-prepared to care for those
servicemembers who become ill, or who are injured.
The first priority of the military health system must always be our
commitment to provide the right care at the right place for every
American who volunteers to serve. We must continue to demonstrate to
Servicemembers and their families that the military health system will
be ready to provide the care they need before they deploy, while in
combat, and when they return, and that we will care for their families
and for those who have retired from the military. To do so, structural,
fiscal and policy changes are needed. After studying this for most of
my career, I urge the members of this Committee to reject any
recommendations to revert to stovepipes and siloes of care. There is no
data to support the premise that any one Service delivered better care
in garrison or down range and ample evidence from multiple conflicts
that the best outcomes for patients occur when medics work together
(like the rest of the military does when it deploys). I am dismayed
that some colleagues continue to assert that some Members of Congress
appear to question the merits of integrating medical capabilities as
directed in 2017; this perception has complicated efforts to focus as a
Joint medical team on improving care to Servicemembers who rely on
military medics to be ready when needed. I strongly oppose any
recommendations for another large-scale reorganization of the military
health system; these take years to implement and will continue to
distract my colleagues from the important job of improving care by
requiring them to instead focus on building new bureaucracies. I
believe the DOD has the capabilities it needs, although, as I will
address below, not the resources, to truly achieve the vision of great
care, anywhere for our those who go in harm's way in defense of our
Nation. Attachment One, National Defense Authorization Act
Recommendations, summarizes recommended language for the Committee's
consideration. (NOTE: For any recommendations which fall outside the
purview of this Committee, I respectfully request that Committee staff
share the recommendations with the appropriate Committee, and, if
possible, convey the intent of this Committee related to the
recommendation.)
1. Roles and Responsibilities: In 39 years of government service,
and especially in military health system ``governance'' meetings, I
have been dismayed at the amount of time and energy dedicated to this
topic at the expense of discussing how to improve the effectiveness and
efficiency of care. I remain deeply grateful for and supportive of the
changes directed in the 2017 National Defense Authorization Act (NDAA).
Congress wisely recognized that Servicemembers' anatomy and physiology
do not vary based on the patch they wear and that we can deliver better
care if we work as an integrated system, rather a system of competing
systems. Other than a few niche environments (e.g., care in low gravity
environments, undersea medicine, etc.), the Senate should direct
standardization of equipment and training for deployable medical force
elements, as recommended by the Joint Trauma System (JTS) and also that
medical force elements must be interoperable (i.e., a Role 2 medical
force element from one Service can combine with a Role III 3 medical
force element from another Service, when directed by the Combatant
Commander in order to provide the right combination of capabilities to
care for ill and injured servicemembers). Almost every other modern
military has already done so, and, as our Israeli and German and other
colleagues have repeatedly shown, military medics deliver more
effective care more efficiently if we standardize and integrate
capabilities. The only structural changes I recommend are:
a. Dual-hat the Joint Staff Surgeon as the Defense Health
Agency Deputy Director for Combat Support and align key operational
support capabilities under this two-star leader, as described below and
in Attachment 1.
b. Require the Combatant Commands to implement the Combatant
Command Trauma System staffing requirements to ensure readiness to
collect, analyze and share data on ill and injured in their Area of
Operations in order to continue to improve the care our Nation's
defenders receive.
c. Require the Defense Health Agency (DHA) to reinState Defense
Health Agency Procedural Instruction 6040.06, Combatant Command Trauma
Systems.
2. Evolving Threats: Care for ill and injured is challenging and
there are clearly opportunities to improve that care. And the range of
threats to which military medics must be prepared to respond is
growing.
a. Disease, Non-Battle Injury (DNBI): Military service is a
challenging calling, and many medical conditions impact the ability of
an individual to perform his or her duties. The military asks those
seeking to enlist or to become officers to voluntarily identify pre-
existing medical conditions and, based on that information, determines
whether the member is likely to be medically qualified to perform their
assigned duties. The introduction of electronic health records has made
it easier to validate the information provided by those seeking to
serve in the military and, in some cases, has identified medical
conditions which the applicant did not voluntarily report. Some have
claimed that this additional visibility into pre-existing medical
conditions is contributing to lower enlistment rates, although there
has been limited data to support this assertion. These pre-existing,
chronic medical conditions may degrade the member's readiness and
frequently increase the military health system costs once the member is
on active duty. Clarifying the impact of identifying pre-existing
medical conditions on both recruiting and on military health system
costs can help inform decisions about whether to continue to seek this
information. Furthermore, roughly 80 percent of deployed service
members who require medical care have medical conditions unrelated to
traumatic injuries. The most common medical conditions which cause a
servicemember to no longer be ``medically ready'' include dental,
musculoskeletal and mental health conditions. Across the Services, more
than 7 percent of the force is not medically ready prior to deployment,
immediately decreasing the effectiveness of combat units. To preserve
the fighting force, military medics must be able to rapidly diagnose
these conditions and safely and effectively treat them as close to the
front lines as possible. This committee should:
i. Require an annual report on actions taken to reduce the
number of uniformed personnel who are not medically ready to no more
than 5 percent of the force and the actions taken to improve the
ability to care for deployed Servicemembers with DNBI as close to their
deployed location as possible in order to sustain the operational
capabilities of their unit.
ii. Require the Services to provide an annual report to
Congress on the number and type of medical waivers granted to those
enlisting in the military (e.g., accession waivers), the number of
personnel who receive accession waivers and are later determined to be
medically unfit for duty, including the number and type of accession
waivers granted as a result of the use of the Military Health System
Genesis application (i.e., the military's electronic health record) and
any data on the impact of the use of GENESIS on accession rates.
b. Antimicrobial Resistance (AMR): One of the risks for
servicemembers with traumatic injuries is developing wound infections,
especially in austere environments. Bacteria or fungi which are
resistant to multiple antibiotics are growing domestically and globally
and this has become an increasing challenge for military casualties in
Europe, Asia and Africa. This Committee should require an annual report
on steps taken by the Miliary health system to detect and to mitigate
AMR in military personnel and should review the proposed Pasteur Act
language to enhance support to develop new antimicrobials to protect
our Servicemembers.
c. Emerging Weapons: Mankind has continued to seek new military
capabilities which will afford an asymmetric advantage over competitors
and potential adversaries. Recently develop new technologies like
hypersonic missiles and directed energy weapons do not appear to create
revolutionary changes in risk, but, overtime, may cause new patterns of
injury which military medical personnel must be prepared to treat.
Waiting until new patterns of injury are seen to begin planning for
appropriate care should be unacceptable. This Committee should:
i. Direct the Intelligence Community to prepare an annual
report on new and updated weapons which create risk to servicemembers;
ii. Direct DOD to ensure that the Joint Staff Surgeon and
select members of the Joint Trauma System and Service Surgeons' staffs
have sufficient clearances to receive these updates;
iii. Direct the Joint Staff Surgeon, in coordination with
the Services, the Joint Trauma Analysis and Prevention of Injury in
Combat program and the JTS, to provide Congress with a classified
annual assessment of changes needed to training and other military
medical capabilities to ensure military medical personnel are ready to
care for casualties from these new or upgraded weapons systems,
including actions taken by the Services to address findings from prior
years' assessments
d. Burden Shifting: In 2020, the National Academies of Science,
Engineering and Medicine published an analysis which highlighted the
lack of resilience and surge capacity in the US healthcare system. The
recent pandemic unfortunately validated that lack of resilience and, as
part of the mitigation efforts to protect the American public, as many
as 70,000 military medics deployed to augment the US healthcare system
through Defense Support to Civil Authorities (DSCA) taskings. The
National Disaster Medical System, which was designed to integrate DOD,
VA and civilian healthcare systems in case of a surge in military or
civilian patients has been allowed to atrophy. The Regional Emerging
Special Pathogen Treatment Centers, which are funded to care for
patients exposed to, or infected with highly contagious infectious
diseases (e.g., Ebola), have very limited bed capacity; and the ability
to move these patients depended on capabilities in other agencies which
apparently have been eliminated. In addition, only the DOD had the
contracting authorities needed to enable Operation Warp Speed to
achieve so much so quickly. And recent actions that reduce capabilities
in other Federal Departments, including the ability to respond to
disasters at home and abroad are typically mitigated by shifting those
responsibilities to the Department of Defense. Because of this, the
Military Health System is likely to see more taskings in the future to
compensate for these reduced capabilities in other parts of the Federal
Government. I recommend this Committee should:
i. Require an annual assessment by the Departments of
Defense, Health and Human Services and the Veterans Health
Administration of the resilience of the US healthcare system and the
readiness of the National Disaster Medical System to support DOD
operational requirements during Large Scale Combat Operations,
including the readiness to transport, receive and care for military
personnel, US government employees and US civilians who are exposed to
or infected with highly contagious infectious diseases.
ii. Require ASD(HA) to provide an annual summary of all
healthcare support provided to other Departments and Agencies which was
not funded in the DOD budget, as well as any reimbursements received
for that support.
iii. Authorize ASPR to execute the same contracting
authorities that DOD utilized during Operation Warp Speed.
iv. Sustain ASPR and CDC programs which help State and
local health authorities continue to improve the readiness of their
jurisdictions and make that support contingent on a commitment to
participate in NDMS and, for those hospitals with the appropriate
capabilities, RESPECT.
e. Biological weapons and other threats: The confluence of
artificial intelligence, increasing computational capacity and rapidly
evolving biotechnological advances offers incredible potential for new
treatments. And there will always be people who will seek to misuse
these new technologies for nefarious purposes; these rapid advances
significantly lower the bar for State and non-State actors to use good
technologies in ways that increase the risk to the American public and
to military members in future conflicts. The best deterrent to ensure
these weapons are never used is to demonstrate that we will rapidly
detect their use, attribute it appropriately, and hold those
responsible accountable, while demonstrating the ability of our health
system to rapidly mitigate the impact of acute biological threats. The
foundational research creating these advances was largely based on
research funded by the Federal Government through the National Science
Foundation, National Institutes of Health, and the Department of
Defense. It is critical that the military health system, in
collaboration with the Departments of Health and Human Services,
Energy, Homeland Security and the Veterans Health Administration
continue to invest in research to rapidly develop better tests,
treatments and vaccines for new and emerging biological threats, as
well as in enhanced domestic and global biosurveillance capabilities.
As noted above, the Centers for Disease Control and Prevention and the
Administration for Preparedness and Response should continue to help
fund State and local preparedness efforts to increase resilience to
future biological threats. The Department of State should reinState
funding for programs which enhance biopreparedness capabilities in
other countries to improve our ability to detect if a bioweapon or
other biological threat is occurring outside the US and to assist in
mitigating the impact of those threats. The 2018 National Biodefense
Strategy, which was updated in 2022, and the 2023 Biodefense Posture
Review outline multiple actions needed to enhance our ability to deter
nations and non-nation states from pursuing or considering employing
bioweapons. The Bipartisan Commission on Biodefense in 2024 released
its updated National Blueprint for Biodefense. The 2020 NDAA also
wisely tasked the Defense Science Board to ``carry out a study on the
emerging biotechnologies pertinent to national security,'' and that
report should be released this year. Similarly, the report from the
National Security Commission on Emerging Biotechnologies (NSCEB) is
scheduled for release next month and both these new reports will
provide valuable advice to DOD and to Congress to inform how we best
leverage these technologies to enhance our national, economic and
health security. Unfortunately, it appears that at least some of the
progress made during the past 8 years is being undone by sweeping
reductions in resourcing for scientific research, surveillance, medical
countermeasures and Federal, State and local all hazards response
programs. This Committee should:
i. Direct DOD to provide Congress with a classified and
unclassified update on implementation of the 2023 Biodefense Posture
Review (BPR) within 6 months, including any remaining gaps in
capabilities and mitigation plans to address those gaps.
ii. Direct DOD to publish an update BPR which addresses
all recommendations relevant to DOD from the 2024 National Blueprint
for Biodefense and the 2025 NSCEB and DSB reports by the end of Fiscal
Year 2025.
iii. Direct the DOD to ensure that all DOD hospitals and
operational labs, including those located overseas, provide the Centers
for Disease Control and Prevention the same data that is submitted by
other public health jurisdictions to enhance global and domestic
biosurveillance.
3. Manpower Constraints: Enhancing the readiness of the military
health system to care for ill and injured servicemembers relies, in
part, on having the right number and type of military medics. The
Health Resources and Services Administration (HRSA), in November, 2024,
updated the Health Workforce Projections for multiple career fields.
For nursing, they estimate that the current shortages in nursing cannot
be significantly mitigated until 2037, at the earliest and noted a
``significant geographic maldistribution'' of nurses. This appears to
be largely in rural areas where many military bases are located. For
physicians, the projections are even more dire, with 31 out of 35
physician specialties projected to have insufficient supply by 2037 and
an aggregate shortfall of 187,130 physicians across the US. Efficiency
advocates have asserted that the military health system can eliminate
military medical positions and either hire civilian replacements or
shift the care to the private sector. In reality, the military health
system is able to sustain the current level of care because it trains
many of its medical personnel internally. Given the congressionally
directed restrictions on increasing civilian physician training
programs, closing military training programs will exacerbate both
military and civilian medical workforces shortages and further degrade
readiness due to even greater shortages of uniformed medical personnel.
Efficiency advocates have also attempted to eliminate or substantially
reduce military medical billets for specialty codes which are not
required in Operational or Contingency plans; this seemingly logical
action ignores the reality that mission critical training programs for
critical care nurses, trauma surgeons and other specialties needed in
wartime cannot maintain their accreditation to continue training unless
they are in a hospital with pediatric, obstetrical and other ``non-
mission critical'' departments. And all these workforce challenges are
reportedly being exacerbated by decreasing retention of key medical
officer and enlisted specialists due a perception that they cannot
sustain their medical skills in the current system due to the low
volume of ill or injured patients in most military hospitals. I
recommend that this committee should:
a. Ensure that any proposed reductions in military medical
training pipelines are only implemented if Congress authorizes and
appropriates funding for additional civilian training capacity to
support military requirements.
b. Require the Services to provide updates to ASD(HA) and the
Joint Staff Surgeon on recruiting and retention of officer and enlisted
medical personnel by specialty code or equivalent designator and an
analysis of reasons for separation by specialty code.
c. Direct the ASD(HA) and the Veterans Administration
Undersecretary for Health to provide an assessment within 1 year of
opportunities to increase physician, nurse and other medical training
pipelines by integrating and expanding training programs.
d. Direct the ASD(HA) to develop a plan and cost estimate to
increase the number of officer and enlisted students trained at the
Uniformed Services University to address shortfalls in current training
pipelines and to assist the Services in improving recruiting and
retention of military medical personnel required to meet operational
requirements.
e. Require the Services to account for authorizations required
for military medical training as operational requirements, including
those for specialties which are required to maintain accreditation of
training programs for surgical, critical care, and other operational
capabilities.
4. Logistical Constraints: The military health system (MHS)
prepares and sustains the warfighter, while the defense logistics
enterprise (DLE) prepares and sustains the equipment and supplies used
by the warfighter. The two are inextricably linked. Almost all resupply
of medical units depends on non-medical logistical capabilities and
capacity. Almost all deploying medical personnel travel on non-medical
commercial or military logistical platforms. And almost all movement of
ill and injured servicemembers who cannot return to the fight is
conducted on non-medical logistical platforms. The Joint Staff
Logistics Director (J4) routinely performs a ``Logistic Feasibility
Assessment'' of Operational and Contingency Plans to determine if the
proposed military operation can be logistically supported. No similar
analysis has routinely been performed for medical support. In addition,
as part of previous efficiency efforts, the military health system
converted from a system which planned for combat to one which
prioritized the efficiencies garnered from ``just in time resupply.''
The United States has the highest number of medications in short supply
ever recorded; an analysis in 2024 by the Office of Pandemic
Preparedness and Response Policy found that these shortages were not
consistently found in other key partners (e.g., European countries,
Japan, Korea or India), suggesting that policy actions similar to those
taken by other countries could mitigate some of these shortfalls. In
addition to shortages of finished pharmaceuticals, assessments by the
Joint Staff have found that deployable assemblages which are expected
to be resupplied during large scale combat operations contain
medications and/or equipment from potential adversaries, or from a sole
source which may not continue provide these items during a conflict.
And recent analyses of generic pharmaceuticals have demonstrated
variability in the efficacy of some medications. I recommend that this
Committee should:
a. Direct the CJCS to include a Medical Feasibility Assessment
whenever a Logistics Feasibility Assessment is conducted or updated and
ensure the two are deconflicted as part of regular updates to
Operational and Contingency Plans and ensure the ASD(HA) and Services
review the results to identify gaps which can be mitigated through
changes to policy or Defense Health Program or Service Operations and
Maintenance funding.
b. Require the CJCS to provide an annual report on DOD
operational medical supply chain vulnerabilities and actions taken or
needed to reduce these vulnerabilities.
c. Direct the DOD to provide a report to Congress within 1 year
on options to mitigate gaps in patient movement capabilities and
capacity in the Continental United States during execution of the
Integrated Continental United States Medical Operations Plan, including
leveraging Civilian Reserve Air Fleet assets to execute this mission.
d. Codify that all future United States Transportation Command
Mobility Capability Requirements Studies include medical transportation
requirements for personnel, equipment and patient movement, as
validated by the Joint Staff Surgeon.
5. Partnerships: In the operating room, I was part of a team which
included nurses and anesthesiologists and other key contributors who
cared for the patient who trusted us to cure his or her cancer, or to
repair the damage from a traumatic injury. As a flight surgeon on
aeromedical evacuation missions, I was part of a team which included
medics and pilots and other key personnel who worked together to safely
move an ill or injured Servicemember to the care they needed. As a
medical leader in our Joint Force, I was part of teams which met
Combatant Command requirements by leveraging the best of each Service,
and by partnering with key industry and academic and international
stakeholders to ensure the next ill or injured servicemember was cared
for by a military medic who had the appropriate training and equipment
and supplies to provide the right care at the right place and time. The
American College of Surgeons has been an especially valuable partner
for many years, helping to improve care in both the military and
civilian healthcare systems by sharing information and research through
the Military Health System Strategic Partnership with the American
College of Surgeons (MHSSPACS), enabled by the Mission Zero Act. The
University of Nebraska and the University of Colorado are two examples
of the strong academic partners which have helped military medicine
continue to innovate and improve how we train, equip and sustain the
skills of military medics. In addition, because so many military bases
are located in rural areas, DOD relies heavily on community partners to
provide care for Servicemembers and other DOD beneficiaries. Finally,
our plans to provide necessary medical care in future conflicts and
contingencies are currently built on the assumption that we will be
joined by allies and partners, as we have been in every major conflict
for more than a century. I recommend this Committee:
a. Require the DOD to include medical industrial base partners
identified by the Services and DHA in future Defense Industrial Base
planning efforts and Joint and Service exercises involving other
industry partners.
b. Require ASD(HA) to provide an annual report on access to
care in rural communities impacted by changes in funding for Medicaid,
Medicare or other Federal health programs.
c. Direct the DOD to provide a classified report to Congress on
any assumptions regarding access to or reliance on allies and partner
nations for medical care for US military personnel during future large
scale combat operations and the impact on patient care if the United
States changes its relationship with these nations.
d. Reauthorize funding for the Mission Zero Act for military
civilian partnerships.
6. Research and Innovation: The United States has led the world in
investments in research which have enabled the United States to be the
leader in multiple industries which support military medical care.
Academic research centers which have long provided some of the most
innovative breakthroughs in medicine are facing significant challenges
due to the announced implementation of a standardized 15 percent
Indirect Cost Rate for research funded by the National Institutes of
Health, regardless of the complexity of the research performed, as well
as the planned 60 percent reduction in funding for the National Science
Foundation, and reductions in research funding from the Veterans
Administration and the United Stated Department of Agriculture and the
Department of Defense, compounded by the proposed tenfold increase in
taxes on university endowments which might have helped mitigate the
impact of some of these changes. Within the military health system,
research funding has been divided between the congressionally Directed
Research Program (CDRP), which funds research on topics identified by
Members of Congress, and the remaining research budget, which should
address gaps in knowledge and capabilities impacting care for ill and
injured Servicemembers. I recommend that this Committee:
a. Require the DOD to provide a report to Congress within 60
days of the impact of actual and proposed reductions in Federal
research funding on national security and on the ability to continue to
pursue innovations and treatments for ill and injured Servicemembers.
b. Direct CJCS to prepare an annual prioritized list of
military medical knowledge gaps requiring research, based on Combatant
Command and Service inputs, which will be provided to the ASD(HA) to
inform research funded by the Defense Health Program.
c. Require the Director of the Defense Health Agency to provide
an annual report to Congress showing how research oversight by the DHA
addresses the operational gaps identified by CJCS, as well as a summary
of any patents awarded and peer-reviewed publications in the past year
as a result of military health system-funded research.
d. Share the CJCS-identified priority gaps in knowledge
impacting care for ill and injured Servicemembers with Members of
Congress to help inform decisions about new CDRP projects.
7. Fiscal Realities: The United States Federal budget dramatically
exceeds revenues and is unsustainable. The United States healthcare
system is the most expensive system in the world on a per capita basis
and delivers some of the worst outcomes of any high income country.
With the current workforce, the annual US healthcare inflation rate has
averaged 5.11 percent. The Military Health System is a subset of the US
healthcare system; 70 percent of care for DOD beneficiaries is now
purchased in the private sector, but the MHS has seen effectively
almost no growth in funding for medical care over the past 10 years. In
addition, numerous new benefits have been authorized without additional
funding. Because our current Tricare contracts are ``must-pay'' bills
for the Department, the only way to cover these rising costs is to
divert resources from the direct care system and from accounts which
should be funding operational medical requirements. Assertions that
care can continue to be diverted to the private sector without
impacting readiness or access have not been supported by data and the
growing shortages of medical personnel nationally and the rapidly
rising cost of commercial care appear to make this unsustainable course
to enhance military medical readiness. Until this is addressed, we will
continue to see declining operational medical capabilities and rising
costs as more and more care is shifted to the private sector. Civilian
healthcare is expensive; military healthcare, because of its unique
additional requirements, is even more expensive. Like other military
capabilities, there are no direct analogues in the civilian or
commercial sector for all the capabilities needed by the military
health system to be able to care for ill and injured servicemembers
during a conflict. All of the Federal healthcare delivery systems (DOD,
Veterans Health Administration, Indian Health Services, etc.) face some
of the same challenges and all have very large, unfunded infrastructure
requirements to sustain their ability to deliver care (e.g., DOD
estimates an additional $10 billion is needed to update or replace
existing medical infrastructure). In many communities with aging
Federal medical infrastructure, there is an opportunity to develop
Joint Venture partnerships similar to the ones at Joint Base Elmendorf-
Richardson, or Travis Air Force Base. In addition, creative financing
mechanisms, like the Communities Helping Invest through Property and
Improvements Needed for Veterans ACT (CHIP-IN Act), which pools
Federal, State, local and philanthropic resources to fund
infrastructure requirements, should be reauthorized and expanded to
include the DOD. Finally, as authorized by Congress in the 2017 NDAA,
the DHA must ensure accurate tracking and billing for services provided
to non-DOD beneficiaries both within the direct care system and when
military medical personnel are working in partner facilities. The
mistaken belief that the military or other Federal health systems can
be funded at lower rates than the civilian sector while achieving
similar or better outcomes and be ready for future conflicts is a
remarkably optimistic triumph of hope over reality. To begin to address
this foundational problem, this Committee should:
a. Require that any implementation of new benefits which are
authorized in an NDAA cannot occur until there is an assessment by CJCS
of operational impacts, an independent government cost assessment of
the cost of mitigating the operational impacts and of the cost
implementing the benefit in both the direct and private care system,
and sufficient additional funding is appropriated in the Defense Health
Program to cover these costs.
b. Direct that any proposed reductions in services at a
military treatment facility can only proceed with an endorsement from
the CJCS that there is no impact on operational requirements, and an
endorsement from the Services that there is no impact on medical
officer and enlisted training pipelines, and an independent attestation
that there is sufficient excess capacity to absorb the workload to be
shifted to the community , as well as congressional notification at
least 180 days prior to implementation.
c. Direct the ASD(HA) to implement the necessary information
technology tools and to promulgate policy on accounting for work done
by uniformed medical personnel in civilian or Veterans Health
Administration facilities.
d. Reauthorize the CHIP-IN Act and amend it to include DOD
requirements.
e. Mandate that the DOD and VA provide a report to Congress in
6 months on how to consolidate inpatient care in communities where one
or both Departments are requesting funding for infrastructure
investments which exceed $100 million annually.
8. Uniformed Military Medical Leadership: Congress wisely
recognized that successful implementation of the reforms mandated by
the 1986 Goldwater-Nichols Act required a new type of leader who
understood the value of Jointness and who had personal experience in
that environment. For a variety of reasons, military medical leaders
have been exempted from this requirement, making them the outliers in
the Department of Defense, with limited understanding of the
opportunities and challenges implicit in the Joint Force. I recommend
that this Committee should:
a. Remove the Goldwater-Nichols Act exception for military
medical General and Flag Officers;
b. Require that any future Directors of the Defense Health
Agency must have previously served as either the Joint Staff Surgeon,
or as a Combatant Command Surgeon and must have commanded a hospital
which supported Graduate Medical Education programs.
ATTACHMENT 1
suggested national defense authorization act language
Clarify that the military health system is a part of the military
and, to the greatest extent possible, should use the same processes,
procedures and measures used by the rest of the military, including:
A. Civilian oversight of the MHS: As in the rest of the military,
the MHS is led by civilian leadership nominated by the President and
confirmed by the Senate, acting under the authority which the Congress
and the President have invested in the Secretary of Defense. The
Assistant Secretary of Defense for Health Affairs (ASD(HA):
1. Serves as the principal medical advisor to the Secretary of
Defense
2. Leads and provides oversight of the MHS and the Defense
Health Program (DHP), including developing and executing an MHS
Strategic Plan which will:
a. Require endorsement by the Chairman of the Joint Chiefs of
Staff (CJCS) and the Secretary of Defense prior to transmittal to
appropriate congressional Committees annually
b. Include measurable goals and objectives by quarter and
fiscal year, including:
i. Readiness metrics approved and monitored by the
Assistant Secretary of Defense for Readiness, in coordination with the
CJCS, through the process used by the rest of the military to assess
readiness of deployable and in-garrison capabilities, including
ii. All patient movement and Role 2 and above medical
force elements
iii. Any required equipment or other assemblages
iv. Surveillance for and response to bioweapons
v. The percent of servicemembers by unit who are not
medically ready.
vi. Quality metrics for assessing the effectiveness of
care provided to DOD beneficiaries both in the direct care and the
purchased care system, including access to care.
vii. Quality metrics developed by the Joint Trauma System,
in coordination with the Joint Staff, Combatant Commands and Services,
to assess the effectiveness of care provided in deployed locations and
in the patient movement system
viii. Fiscal metrics assessing the efficiency of the
direct care and purchased system against established targets, including
targets for beneficiary enrollment and leakage to the purchased care
system for each Military Treatment Facility
ix. Patient satisfaction metrics for both the direct care
and purchased care systems
x. Availability of uniformed medical personnel for
healthcare delivery, by location of assignment, when not deployed
xi. Metrics should be trended over time and, where
available, should be compared to US national benchmarks
c. Service input to this plan is necessary, but Service
concurrence is not required; the plan should clearly identify any goal
or objective with which one or more Services does not concur.
3. Establishes necessary policies to ensure the MHS provides
high quality care for all DOD beneficiaries; Joint Staff and Service
input to MHS policies is necessary; critical non-concurrence with a
proposed policy will be adjudicated as follows:
a. Policies affecting medical operational capabilities:
Services, Combatant Commands, with support from the Director of the
Joint Staff, will bring areas of disagreement to the Tank and then make
recommendations to the Secretary of Defense
b. All other policies will be adjudicated through governance
structures overseen by ASD(HA) or the Undersecretary of Defense for
Personnel and Readiness.
4. Ensures that research funded by the Defense Health Program
addresses the CJCS-identified gaps in knowledge impacting care for ill
and injured Servicemembers.
5. Serves as the immediate supervisor of the Director of the
Defense Health Agency (DHA).
6. Is the final approval authority for all fiscal decisions
related to the Defense Health Program (DHP) and communicates to
Department of Defense leadership and to Congress the fiscal
requirements for providing optimal in-garrison and purchased care, any
gaps between requirements and resources and plans to mitigate those
gaps.
7. Provides the Services with a template for reporting quarterly
on the location, availability for MTF utilization, and other
responsibilities of all uniformed and civilian personnel funded or
aligned in any way with each Service or sub-component.
B. Chairman of the Joint Chiefs of Staff Oversight of Military
Medical Operational Support
1. Operational and Contingency Plans. As defined by the
President and the Secretary Defense in the Unified Command Plan, CJCS
will ensure these plans clearly define:
a. Operational and training requirements for Role 2, 3, 4 and
5 deployed medical force elements and equipment with the goal of
preserving the fighting force in order to win future conflicts by
optimizing return to duty as quickly and safely as possible.
b. Operational requirements and resourcing for blood products
(e.g., whole blood, freeze dried plasma, etc.) as close to the point of
injury as possible using planning factors developed by the Joint Staff
Surgeon, in coordination with the Combatant Command, Services and with
concurrence from the ASD(HA).
c. Patient movement requirements for ill and injured
servicemembers and other combatants who cannot be returned to duty,
including those exposed to or infected with highly contagious
infectious diseases.
d. Explicit acknowledgement of any reliance on allies or
partners to provide medical care and attestation from Combatant Command
that the Ally or partner has affirmed they have the necessary
capabilities and capacity to provide this care to US personnel.
e. Ensure that the Integrated Continental United States
Medical Operations Plan (ICMOP) includes
i. Requirements for acute and rehabilitative care for ill
and injured returning to the US
ii. Requirements for patient movement from Aerial Ports of
Embarkation and Debarkation to appropriate levels of care.
iii. Planning factors from the Department of Health and
Human Services and the Veterans Health Administration for available
beds once the National Disaster Medical System is activated
iv. Planning factors from the Tricare Purchased Care
contractors for available beds within the purchased care system.
v. Supplemental funding estimates for sustaining care for
in-garrison DOD beneficiaries and any beneficiaries reliant on DOD
medical personnel who are tasked to deploy during a contingency
vi. Plans to expand blood collection, processing and
delivery to DOD to meet operational requirements.
2. CJCS oversight of medical readiness. In coordination with the
ASD(R), the Joint staff will monitor, report and address readiness of
all required medical capabilities listed above, using the same
processes used for the rest of the military.
3. CJCS oversight of Combat Support agencies: As with other
Combat Support Agencies, CJCS will conduct a Combat Support Agency
Review to assess the readiness and effectiveness of actions taken by
the Defense Health Agency (DHA) to support Combatant Command (CCMD) and
Service operational requirements and will provide an annual report to
Congress summarizing progress and shortfalls in DHA's performance.
4. CJCS will provide ASD(HA) with a prioritized list of
knowledge gaps impacting care for ill and injured Servicemembers
derived from input from the Combatant Commanders and Services.
C. The Service Secretaries (Army, Navy and Air Force) will:
1. Organize, train and equip medical force elements to meet
operational requirements defined by the Combatant Commanders through
established CJCS and OSD processes.
2. Organize, train and equip medical force elements to perform
Joint Trauma System-required activities during contingencies and ensure
data collection on all ill and injured personnel in accordance with
JTS-defined requirements.
3. Standardize all equipment in deployable assemblages across
Services in accordance with JTS recommendations; exceptions to this
requirement will require approval by the CJCS and Deputy Secretary of
Defense, as well as notification to the Senate and House Armed Services
Committees within 30 days of the exception being granted and before any
acquisitions for Service-specific equipment is executed.
4. Implement JTS-identified standardized training for deployable
force elements (e.g., Role Two ground medical force elements, patient
movement force elements, etc.)
5. Report the readiness of all deployable patient movement and
Role II and above medical force elements and equipment through
processes established by ASD(R) and the Joint Staff.
6. Fund operational medical requirements outside the scope of
the DHP and inform ASD(HA) of any unfunded operational medical
requirements and planned mitigation measures no later then the
beginning of the third quarter of each Fiscal Year.
7. Fund Service-specific research to enhance operational medical
readiness and inform ASD(HA) of any unfunded operational medical
requirements and planned mitigation measures no later then the
beginning of the third quarter of each Fiscal Year.
8. Provide DHA with quarterly updates on all uniformed and
civilian personnel as described above.
9. Ensure that Nominees to serve as the Director of the DHA must
have served as either the Joint Staff Surgeon, or as a Combatant
Command Surgeon and have commanded an MTF with inpatient capabilities
and graduate medical education programs.
D. Defense Health Agency as a Combat Support Agency:
1. The Joint Staff Surgeon will be dual-hatted as the DHA Deputy
Director for Combat Support and will:
a. Provide direct oversight of the Joint Trauma System
Director, in order to ensure the JTS:
i. Incorporates best practices and Clinical Practice
Guidelines into the MHS Genesis and medical education programs for both
officers and enlisted military medical personnel
ii. Provides requirements to the Services for data
collection as far forward as possible, with reporting to Combatant
Command Joint Trauma System offices.
iii. Identifies standardized, interoperable equipment for
Service-provided deployable medical force elements which support CCMD
operational requirements.
iv. Identifies and provides to the Services standardized,
training for Service-provided deployable medical force elements which
support CCMD operational requirements.
b. Provide direct oversight of the Director of the Armed
Services Blood Program, in order to ensure the ASBP:
i. Develops planning factors for operational blood component
utilization
ii. In coordination with USNORTHCOM, the Department of
Health and Human Services and other stakeholders, plans to expand US
blood collection, processing and distribution as needed to meet
validated operational requirements.
c. Provide direct oversight of the Director of the Armed
Forces Medical Examiner System (AFMES), in order to ensure the AFMES:
i. Reviews, in coordination with the Joint Trauma System,
any deaths of uniformed or civilian military personnel while training,
in-garrison or during contingency operations, including those for which
a civilian medical examiner performs the forensic pathology exam
ii .Prepares annual reports identifying opportunities to
reduce risks to servicemembers.
iii. Sustains accreditation by the National Association of
Medical Examiners
d. Provide requirements to update MHS Genesis and other MHS
systems to optimize data collection, analysis and reporting in order to
improve outcomes for ill and injured servicemembers.
e. Provide oversight of public health activities aligned under
the DHA as required by 10 U.S.C. Sec. 1073c, as amended.
i. Ensure all DOD hospitals and overseas labs are
transmitting the same standardized surveillance data to the Centers for
Disease Control and Prevention as do other Public Health Jurisdictions.
ii. Partner with Services to ensure waste water surveillance
is implemented at DOD installations.
iii. Implement biosurveillance programs to detect and
mitigate the risk of naturally occurring and deliberate biological
threats.
2. The Defense Health Agency will reinState Defense Health
Agency Procedural Instruction 6040.06, Combatant Command Trauma
Systems.
3. Defense Health Agency and Health Care Benefit Delivery-all
other functions of the DHA related to healthcare benefit delivery will
be executed in a manner which:
i. Enhances readiness of the military health system to care
for the ill and injured in future conflicts;
ii. Optimizes access to healthcare for DOD beneficiaries in
the direct care system and, when necessary, in the purchased care
system, with the objective of caring for those DOD beneficiaries with
the greatest medical needs (i.e., the ``highest acuity'') in the direct
care system, whenever possible;
iii. Optimizes health-related outcomes for DOD beneficiaries
as effectively and efficiently as possible.
E. Clarify the intent of Congress related to funding for the
Military Health System including:
1. Requiring that any new healthcare benefits are only enacted
following:
a. Assessment endorsed by the CJCS of any impact on
operational readiness of the proposed new benefit.
b. Completion of an Independent Cost Estimate endorsed by the
Managed Care Support contractors and the ASD(HA) which mitigates any
operational impacts and validates the cost of implementing the benefit
c. Appropriation of sufficient funding for the proposed new
benefit
2. Requiring notification to Congress of resource shortfalls
which preclude delivering care in the direct care system which enhances
the readiness of the military health system to care for ill and injured
during future conflicts, or the care to which DOD beneficiaries are
entitled.
Chairman Wicker. Thank you, Dr. Friedrichs.
Colonel Cannon.
STATEMENT OF COLONEL (DR.) JEREMY W. CANNON, USAFR (RET.),
PROFESSOR OF SURGERY, PERELMAN SCHOOL OF MEDICINE, UNIVERSITY
OF PENNSYLVANIA
Dr. Cannon. Chairman Wicker, Ranking Member Reed, and
distinguished members of the Committee, thank you for the
opportunity to testify. These comments are my own and do not
reflect an official position of my employer, Penn Medicine, or
of the Hoover Institution, where I current serve as a Veteran
Fellow.
As a practicing trauma surgeon, I have cared for injured
warfighters in both Iraq and Afghanistan. I have directed the
DOD's only Level I trauma center, and now I lead a Penn
Medicine Navy partnership for trauma training. I know firsthand
what it takes to save lives on the battlefield and what happens
when we fail to sustain medical readiness.
I want to start by sharing the story of the unexpected
combat casualty survivor that I took care of in 2010. Note, I
will use a pseudonym throughout my comments for patient
privacy.
U.S. Army Sergeant Erik Ramirez was on patrol in
Afghanistan when a sniper's bullet tore through his chest, just
above his body armor. His injuries were truly catastrophic. But
thanks to decades of investment and innovation in combat
casualty care, a military trauma team pulled him up out of his
certain death spiral by placing him on heart and lung bypass,
on the battlefield. Days later, I had the honor of caring for
Sergeant Ramirez in the United States, as he reunited with his
family.
This unequivocal display of medical supremacy was not
accidental. It was built on years of research, training, and
policy reforms. But I fear that if Sergeant Ramirez suffered
this same injury now, he would die a preventable death on the
battlefield.
Today, only 10 percent of military general surgeons get the
patient volume, acuity, and variety they need to remain combat
ready. We are actively falling into the trap of the peacetime
effect.
Meanwhile, as the MHS struggles, our enemies continue to
grow stronger. Projections estimate a peer conflict could
produce as many as 1,000 casualties per day, for 100 days
straight, or more, a scale not seen since World War II. Neither
the current MHS nor the civilian sector can absorb this impact.
What's more, many of these patients will have survivable
injuries, yet one in four will die at the hands of an
unprepared system.
How can we meet this living threat? First, we must clearly
articulate the root problem of our failed readiness efforts. No
one in DOD truly owns combat casualty care. In 2017, the Joint
Trauma System (JTS), was codified in law. This Committee must
now strengthen the statutory language to affirm that JTS owns
combat casualty care and to provide this precious resource with
both top-down authority and bottom-up support.
Then we must push the MHS to refocus on forward-deployed
care, the one thing that only military medicine can do. For
this I recommend three lines of effort.
First, clinical training. In order to train the way we
fight, we must establish five to six high-volume Military
Treatment Facility Centers of excellence for both trauma and
burn care. These centers must undergo civilian accreditation
and fully integrate into a national trauma and emergency
preparedness system.
We also need to strengthen and expand our military-civilian
partnership sites where military trauma teams manage critically
injured patients on a daily basis, like my partnership program
at the University of Pennsylvania. To do so, Congress must
reauthorize the Pandemic and All-Hazards Preparedness Act and
fully appropriate the Mission Zero Act.
Second, combat casualty research. To succeed on complex
future battlefields, DOD medical research must refocus on pre-
hospital care, team training, bleeding control, battlefield
blood transfusions, regenerative medicine, and long-term
outcomes. In order to fully understand the effects of
battlefield treatments we must link DOD Trauma Registry data
with VA records.
Finally, we need to unify military trauma system strategy.
We must urgently develop and implement a whole-of-society
roadmap, aligning military, VA, and civilian systems for both
peacetime readiness and large-scale combat operations.
The bottom line, if we maintain the status quo and enter a
peer conflict unprepared, we will condemn thousands of
warfighters to preventable death. Without urgent intervention,
the MHS will continue to slide into medical obsolescence. To
restore the medical supremacy that saved Sergeant Ramirez, we
must act now. Mr. Chairman, members of the Committee, our
warfighters and our Nation deserve medical supremacy.
Thank you for your time, and I look forward to the
comments.
[The prepared statement of Dr. Jeremy W. Cannon follows:]
Prepared Statement by Colonel (Dr.) Jeremy W. Cannon, USAFR (Ret.)
Professor of Surgery, Perelman School of Medicine University of
Pennsylvania
Chairman Wicker, Ranking Member Reed, and distinguished members of
the Committee, thank you for the opportunity to testify on the urgent
need to restore and sustain military medical readiness in the face of
large-scale combat operations (LSCO).
As a practicing trauma surgeon with multiple combat deployments, I
have seen the full gamut of combat casualty care from far forward in
Iraq and Afghanistan to Brooke Army Medical Center where I served as
Trauma Medical Director for the Department of Defense's (DOD) Level I
trauma center during the height of combat operations. I now serve in a
different capacity as Assistant Dean for Veteran Affairs for Penn
Medicine and as an attending in the Surgical Intensive Care Unit in our
Veterans Affairs (VA) Medical Center in Philadelphia.
At Penn Medicine, I am also proud to lead an embedded US Navy
trauma team as the civilian surgeon champion. This partnership enjoys
enthusiastic support from deeply invested Penn Medicine leaders
including our Chief Executive Officer, Mr. Kevin Mahoney. As a
reservist, I worked with RADM (Dr.) David J. Smith in Health Affairs
where I first appreciated the importance of good policy to mission
success, and now as a Veteran Fellow at the Hoover Institution, I have
the opportunity to study the effects of military health policy over
time. Finally, like many of you and my colleagues here today, I have
multi-generational family ties to the military with my oldest son now
training as a Naval Intelligence Officer.
I want to start by sharing a story of an unexpected combat casualty
survivor. In 2010, US Army Sergeant Erik Ramirez* suffered a
devastating chest injury while on patrol in Afghanistan. A sniper's
bullet passed just above his body armor, tearing through the airways
and vessels in his right lung. What happened next was nothing short of
a medical miracle. After damage control surgery to arrest the bleeding,
SGT Ramirez was placed on heart and lung bypass on the battlefield.
With this heroic intervention, he pulled up out of a spiral of certain
death, and a few short days later, I had the privilege of caring for
him as he was re-united with his family in San Antonio.
* Name changed for patient privacy
The survival of SGT Ramirez resulted from decades of investment in
combat casualty care. Through the efforts of many dedicated military
and civilian visionaries, we established a cutting-edge trauma system
in the heart of a combat zone. Through these intensive efforts and
close collaboration with line leaders, we achieved the best survival
rate on any battlefield in history. In sum, we achieved medical
overmatch and leveraged our medical supremacy into a strategic
advantage.
But I fear that if SGT Ramirez suffered the same injury in combat
today, he would not survive. Why? In short, combat casualty care
training and skills maintenance lose out in peacetime. Since the end of
combat operations in Iraq and Afghanistan, we have seen a systematic
erosion of military medical readiness. Today, fewer than 10 percent of
military general surgeons get the critical case volume and patient
acuity they need to be combat-ready.(1)
What is the cost of this erosion? It can be measured in lives lost:
one in four battlefield deaths are potentially survivable. This
reflects what I term the medical ``peacetime effect''--a recurrent
failure to sustain combat medical capabilities between wars. Although
this cycle has played out for centuries, today's peacetime effect is
driving us toward medical obsolescence precisely as our adversaries'
power is ascendant. Should a large-scale conflict materialize, we
anticipate casualty numbers as high as 1,000 per day for at least 100
days--casualty loads not seen since World War II, a scale far beyond
what our current system can handle.(3) True medical readiness could
mean the difference between winning and losing.
The challenge of maintaining a ready medical force during peacetime
represents a true ``wicked problem.'' Yet, one of the root causes of
this erosion in our medical readiness is clear: no single entity in the
DOD truly owns combat casualty care. COL (Dr.) Bob Mabry, a decorated
hero of the battle of Mogadishu, warned in his testimony to the House
Armed Services Committee nearly a decade ago, ``When everyone is
responsible, no one is responsible.'' To this day, combat casualty care
responsibility remains fragmented across military departments, the
Defense Health Agency, and individual service commands. With ongoing
diffusion of responsibility, we will fail, and our warriors will die
needlessly.
top priority: establish clear ownership of combat casualty care
Combat casualty care represents a critical warfighting capability--
the equivalent of a high-value weapon system, not just a cluster of
medical tents deployed in a contingency environment. To ensure the
optimal use of this valuable asset, the Armed Services Committee should
establish clear ownership of combat casualty care within the DOD. To
accomplish this objective, I strongly recommend both elevating and
streamlining the reporting structure for the MHS. Command and control
of the MHS should be commensurate with the importance of the mission.
The Joint Trauma System (JTS) must have direct responsibility for and
authority over all aspects of combat casualty care policy, training,
and readiness. The JTS Director should report directly to the Secretary
of Defense through the Joint Staff Surgeon. This organizational
construct will ensure combat casualty care is fully aligned with our
contingency operational strategy.
With a clear line of responsibility and authority for combat
casualty care, we can then restore and sustain military medical
readiness for LSCO by focusing on three key areas:
1) Clinical Training and Sustainment: Joint Military Trauma/Burn
Centers of Excellence, National Disaster Medical System, and
Civilian Trauma/Burn Partnerships
Combat trauma readiness requires military medical personnel to have
routine exposure to high-acuity trauma cases, something that most
military treatment facilities (MTFs) currently lack. To correct this,
we must consolidate military trauma training into a select group of
five to six joint MTFs verified and designated as trauma and burn
centers of excellence by civilian accrediting bodies. These trauma/burn
MTFs must fully participate in the civilian trauma system organized
around a series of Regional Medical Operations Coordinating Centers
(RMOCCs).
These trauma/burn MTFs must also align with the National Trauma and
Emergency Preparedness System (NTEPS), a concept developed by the
American College of Surgeons Committee on Trauma.(4) Utilizing RMOCCs
as its basic unit of action, NTEPS provides a framework to integrate
daily trauma care with mass casualty preparedness, ensuring that the US
trauma system--including military, VA, and civilian resources--can
seamlessly scale to handle mass population events including large-scale
combat operations, acts of terrorism, natural disasters, or pandemics.
At this critical moment, the Armed Services Committee should enact
statutory authority and identify a lead agency to effect this essential
alignment between these trauma/burn MTFs and NTEPS.
Military, VA, and select civilian patients should preferentially be
funneled to these regional trauma/burn MTFs. Legislative authority to
manage civilians in these centers already exists, although coding and
billing best practices represent opportunities for continued
improvement. By increasing the clinical volume and acuity in these five
to six large MTFs, we will also ensure that our military Graduate
Medical Education (GME) programs provide exceptional training aligned
with contemporary operational needs.
Beyond these five to six trauma/burn MTFs, the current small
network of military-civilian partnership programs (MCP) must be
expanded. To meet the scale of the readiness need, existing and future
MCP sites must be high-volume civilian trauma centers where military
trauma teams can be embedded as part of an integrated readiness
plan.(5) Access to burn training and opportunities to embed critical
wartime GME training slots within these programs should also rank as
preferred features of prospective sites.
Opportunities for the Committee to support MCPs include:
Mission Zero Act (MZA)--This initiative funded under the
Pandemic and All Hazards Preparedness Act (PAHPA) supports military
trauma teams embedded within high-volume civilian trauma centers,
including our center at Penn Medicine. To continue this high-yield
investment in clinical training, PAHPA needs immediate reauthorization
with full MZA appropriation. Future expansion of this program should
include DOD funding as well.
Military Health System Strategic Partnership with the
American College of Surgeons (MHSSPACS)--This joint military
partnership with an academic surgical society seeks to improve surgical
care for both military and civilian patients by fostering
collaboration, exchanging best practices, and advancing military
education, research, and quality initiatives. An expanded role for
MHSSPACS should include 1) verifying MCPs using accepted requirements
and quality standards and 2) advising the JTS on military-civilian
trauma system integration to optimize medical readiness for both the
MHS and civilian healthcare. MHSSPACS-type partnerships should expand
to other critical wartime specialties beyond surgery.
2) Research: Focus the DOD Medical Research Budget on Combat Casualty
Care
The Defense Health Program (DHP) funds a wide range of research,
but we must refocus efforts principally on combat casualty care--from
injury prevention to pre-hospital care and acute surgical care through
to rehabilitation and recovery. Research should prioritize pre-hospital
care (including prolonged field care), hemorrhage control, battlefield
resuscitation, rehabilitation, and regenerative medicine. These
research efforts must also consider potential peer-adversary threats
within a multidomain (land, air, sea, space, and cyber) battlefield
environment. I encourage you to work with your colleagues on Defense
Appropriations to prioritize research funding in these key areas of
direct relevance to the warfighter with applications to other domains
of public concern including emergency medical services, law enforcement
as medical first responders, civilian trauma, and disaster response.
We must also eliminate barriers to understanding long-term outcomes
following combat injuries by linking DOD Trauma Registry (DODTR)
records with current VA medical records at the individual patient
level. Further opportunities for improving battlefield survivability
and optimizing outcomes lie in fostering partnerships with trusted
academic research institutions with the wherewithal to innovate in
prehospital care, trauma and burn management, traumatic brain injury,
and the psychological and ethical aspects of LSCO. Such investments
will fill a need not addressed by the National Institutes of Health and
other agencies that fund medical research, and they will benefit both
warfighters as well as civilians impacted by acts of terrorism, acts of
war, and natural disasters.
3) Policy: Develop and Implement a Unified Joint Military Trauma System
Strategy
Decades of reports from the Government Accounting Office, RAND, the
National Academies, and past congressional hearings all point to the
same conclusion: we lack a coherent, unified strategy for military
medical readiness that will deliver expert trauma/burn care on future
battlefields while also benefiting civilian trauma care and public
health. In the words of Nadia Schadlow, a colleague at the Hoover
Institution and the primary author of the 2017 National Defense
Strategy, generating more reports or commissioning new studies will
only perpetuate the ``crisis of repetition.''
To break this cycle, I am currently working with Uniformed Services
University and other key stakeholders to develop a comprehensive
military trauma system policy roadmap that considers the direct care
component, civilian partnerships, the role of the National Guard and
reserves, synergy with the VA, involvement with NDMS and NTEPS,
research priorities, and training requirements. This roadmap will need
congressional support to succeed.
the bottom line: we must demonstrate medical excellence from day one
In Iraq and Afghanistan, it took us three to 4 years to develop a
trauma system in theater and another five to 6 years to achieve the
medical supremacy that allowed us to save SGT Ramirez. We will not have
10 years in the next war.
A near-peer conflict--whether in the Pacific, Europe, or beyond--
will generate massive casualty numbers from day one. If we enter that
fight unprepared, we will condemn thousands of our warfighters to
potentially preventable death. As General Peter Chiarelli painfully
noted in his testimony for the National Academies, ``You have just got
to pray your son or daughter or granddaughter is not the first casualty
of the next war.''
Will it take another Pearl Harbor or 9/11? Or do we have the will
to act now to re-establish and sustain our medical supremacy before the
first shot is fired? I submit that we cannot allow history to repeat
itself by sending the next generation of our warriors into combat
without a fully ready medical service supported by a highly functioning
JTS. Mr. Chairman, members of the Committee, our warfighters deserve
military medical supremacy.
references
1. Dalton MK, Remick KN, Mathias M, et al. Analysis of surgical
volume in military medical treatment facilities and clinical combat
readiness of US military surgeons. JAMA Surg 2022;157:43-50.
2. Cannon JW, Gross KR, Rasmussen TE. Combating the peacetime
effect in military medicine. JAMA Surg 2021;156:5-6.
3. Deussing EC, Post ER, Lee CJ, et al. Advancing systematic
change in the National Disaster Medical System (NDMS): Early
implementation of the US Department of Defense NDMS pilot program.
Health Secur. 2024; e-pub ahead of print.
4. Armstrong JH, Bulger E, Kerby JD. National Trauma and Emergency
Preparedness System (NTEPS). Available at: https://www.facs.org/media/
u1hpi2ce/nteps-blueprint.pdf. Accessed March 5, 2025.
5. Cannon JW, Holt DB, Potter BK, et al. Partnerships to overcome
the peacetime effect: Excelsior Surgical Society panel session. J Am
Coll Surg 2025; e-pub ahead of print.
Chairman Wicker. Thank you, Dr. Cannon, and I commend each
of you for your excellent testimony.
Let me just get quick answers here from all three of you. I
think what I am hearing from all three of you is that this is
going to require more than simply good management of what we
have on the books now. Each of you is recommending changes in
the statute that need to come in this coming NDAA. Is that
right, Dr. Robb?
Dr. Robb. Yes.
Chairman Wicker. And Dr. Friedrichs?
Dr. Friedrichs. Yes, sir.
Chairman Wicker. And Dr. Cannon?
Dr. Cannon. Yes, Mr. Chairman.
Chairman Wicker. All right. Let's talk about military
surgeon readiness for combat care. There was a study out in
2021. It found that the population of military general surgeons
meeting necessary readiness standards decreased from an already
low 17 percent in 2015 to about 10 percent in 2019.
We will let all three of you take a brief chance at answer
this. Why is this happening, and what specifically can DOD do
to reverse this trend? And we will just start with Dr. Robb and
go down the table.
Dr. Robb. We will try to share different perspectives here.
I think it comes back to the system to be able to resource the
requirements that we need. So, for example, if you want to look
at what Dr. Cannon referred to as the five to eight, what we
call critical Military Treatment Facilities, in order for us to
provide a higher volume, high acuity care, they need to be
resourced. And I think that is the challenge that we all face
right now, is what is that strategic reserve with our Military
Treatment Facilities, and then how you augment that with the VA
and the Department of Defense partnerships, and then how do you
augment that with the military----
Chairman Wicker. Is that what he called the centers of
excellence?
Dr. Robb. So I would call them--that is one way to call
them, but I, coming from the airlifter world--in fact, General
Friedrichs and I would both say follow the casualty flow. And
the casualty flow comes in from United States Indo-Pacific
Command (INDOPACOM) to primarily we will be coming to two or
three Military Treatment Facilities. From United States
Southern Command (SOUTHCOM) they will be coming into the
National Capitol region. And then from Europe, United States
Central Command (CENTCOM) and United States African Command
(AFRICOM), they will be coming into primarily National Capitol
region and then with a popoff at Portsmouth.
Chairman Wicker. Okay. Dr. Friedrichs, is this 10 percent
number a concern, and why do we have 10 percent of military
surgeon readiness?
Dr. Friedrichs. Mr. Chairman, it absolutely is a concern.
When I did my training in the military, I trained at the old
Wilford Hall, that was a Level I trauma center. I took care of
trauma patients because it was a 36 on, 12 off schedule every
other night. Or I took care of vascular surgery patients. Or I
took care of cardiothoracic patients. We de-scoped our
facilities to the point that they take care of low-acuity
community hospital patients, not trauma patients.
So I would reiterate the point that you have heard all
three of us make. We need our key hospitals to be Level I
trauma centers in partnership with the American College of
Surgeons in the communities in which they are located.
But to do that we must address the elephant in the room,
and that is resourcing. The medical inflation rate, on average,
since 1938, is 5.1 percent per year, and the military has seen
a net 12 percent reduction in funding. There is no way to fix
these problems if the Military Health System is viewed as a
bill payer and not something worth investing in.
The second point that I would make is we have got to
reiterate the intent that you and the Ranking Member mentioned.
I spent 4 years as the Joint Staff Surgeon. Almost every
meeting in which I participated in that role focused on roles
and responsibilities and patches, not on patients. Please,
again, I implore you, kill this narrative that somehow there is
a belief that we can unwind things and go back to the good old
days. We need to go forward toward a more integrated system
that focuses on patient care and, as you said, on readiness,
not continuing to focus on bureaucratic buffoonery.
Chairman Wicker. Dr. Cannon.
Dr. Cannon. Mr. Chairman, it is shocking, astonishing, and
awful, and it has to be reversed. That 10 percent number
results from inadequate, actually grossly inadequate, patient
numbers, volume. They are not doing the cases. They are not
doing the procedures. They are not doing what they were trained
to do, and that is because they do not have the patients in the
facilities. They are, in many cases, not designated or verified
trauma centers, so they are scrounging around, trying to get
cases, and it has been, frankly, an uphill climb. So we have
got to provide them the patients, the cases, the experience to
right that 10 percent number.
Chairman Wicker. Thank you very much, gentlemen. Senator
Reed, you are next.
Senator Reed. Thank you very much, Mr. Chairman, and
gentlemen, thank you for your excellent testimony.
In the 2023 memorandum by the Deputy Secretary of Defense,
one of the key points, I believe, is the direction to reattract
beneficiaries to the MTFs, which would increase the patient
flow, increase the demands on physicians, et cetera, and also
save money, they believe.
Dr. Friedrichs, your response to this approach.
Dr. Friedrichs. I strongly support the vision that Deputy
Secretary Hicks laid out, which is very similar to the vision
that Deputy Secretary Norquist laid out in the previous
administration, and almost every administration prior to that.
Again, to do that we must have resources.
I will offer one other option which I think you have heard
all three of us touch on briefly. Every single patient in the
Veteran Health Administration started in DOD. I had the great
privilege of commanding the DOD/VA joint venture facility in
Anchorage, and I can tell you that when the patient walked in
the door, they were taken care of by a joint team. It was far
more efficient than building duplicative adjacent facilities.
Instead, we built integrated adjacent facilities.
There is a $10 billion, unfunded recapitalization bill in
the DOD, $100 billion, unfunded recapitalization bill in the
VA. There are real opportunities to bring those higher acuity
patients from the VA into the DOD facilities, or bring DOD
medical personnel into the VA facilities, so that we are not
wasting money on duplicative buildings and instead focusing our
resources on the patients who need our care.
Senator Reed. Thank you. And General Robb, or Dr. Robb, or
both, do you think the Military Health System is adequately
focused on the combat-related medical capabilities? I have
heard comments by all the panel suggesting that they are
diverted into things that are not effective in a combat
situation.
Dr. Robb. Well, I think, in fact, I would kind of like to
challenge the misnomer that there is a separation between care
beneficiaries and medical readiness. And I would argue, the way
that we get our skills--primary care, specialty care, and just
as important, our allied health, pharmacy, x-ray techs,
logistics--we get that by taking care of our beneficiaries.
So what I think is so, so, important is that we use--not
use, but that we care for our patient population to best
achieve medically ready, in a ready medical force. And what I
think is really important is that, again, we have to create a
capability. It has to be an enterprise approach. And when we
talked about it, again, I will go back to the point of follow
the casualty flow, and you look at those critical hospitals
that we believe are important, we must staff those. And we must
staff those to the fullest extent possible.
You cannot reattract patient care into our MTFs unless you
staff them, and I think that is what is key. If I cannot get an
appointment, then I cannot get an appointment. So that is what
is key.
So if you talked with Walter Reed, for example, they may
have enough surgeons, but for various reasons the support staff
does not exist, so they do not have the throughput that they
need for surgical cases. The case load is there.
So what I think we need is an enterprise approach, and how
do we resource, okay, the full spectrum of support for our
critical care hospitals, and then make up the delta with our
military VA partners and with our military-civilian
partnerships.
Senator Reed. Thank you. Dr. Cannon, your comments, please.
Dr. Cannon. Senator, I think it is vitally important to
have highly functioning, premier medical centers that we can be
proud of, that our surgeons and other specialists and allied
health members want to be a part of. Right now, many of these
facilities are shells of what they used to be. You heard about
Wilford Hall. That was an amazing facility that did so much
good for so many decades.
The new incarnation, Brooke Army Medical Center, the San
Antonio Military Medical Center, is also amazing, but it is
sort of out on the vanguard by itself. We need other premier
flagship centers. And I think we can do it. We have got the
pieces in place, but we have got to commit to keeping the
combat casualty at the center of our focus, and make it happen.
Senator Reed. Thank you. My time has just about expired,
but a yes, no, or perhaps answer. I am concerned about the
ability to mobilize medical professionals for an all-out fight.
Is that a valid concern? Yes or no, please.
Dr. Robb. Yes.
Dr. Friedrichs. It is the billion-dollar concern. The
Israelis have proved that. And we have a shell game right now
with our Guard and Reserve and civilian facilities. We are
going to pull them out, deploy them, and assume that civilian
facilities, which during COVID required 70,000 military medics
to take care of the surge in demand, instead lower their staff
and then take care of a surge in demand. The math does not
work, even for a Louisiana Public School grad.
[Laughter.]
Chairman Wicker. Dr. Cannon, go ahead and answer the
question. Take the time.
Dr. Cannon. Yes, I agree. It is a concern.
Chairman Wicker. Thank you. Senator Fischer.
Senator Fischer. Thank you, Mr. Chairman. Thank you all for
being here today.
I really appreciate the information that you are giving us,
and also the concern you have with the direction that we are
not headed yet. In the Fiscal Year 2020 NDAA, a pilot program
was established to assess the National Disaster Medical System
(NDMS) and hopefully that it would increase not just capability
but also capacity within that. In a conflict, you know, we have
touched on that already. We have to be able to quickly disperse
and absorb casualties throughout the United States.
Dr. Friedrichs, why is it so important for the NDMS to
maintain this surge capacity?
Dr. Friedrichs. Senator Fischer, first, thank you for the
role that you and your colleagues from Nebraska played in
championing this and highlighting this. It is important because
the Military Health System does not have the capacity to care
for every casualty coming back. We do not have the capacity to
care for the people in peacetime right now. So to think that
somehow we can do this on our own is another mistaken belief.
During the cold war, we recognized that if our Nation went
to war, we would go to war together, and that we would do it
with an integrated system with DOD, the Veterans Health
Administration, and civilian partners. We must rejuvenate the
NDMS, not let it continue to atrophy.
Senator Fischer. So what is the next step in this pilot
program?
Dr. Friedrichs. So the next step is to make this not a
pilot program but to reiterate that this is, indeed, the intent
of Congress, that the NDMS is the framework in which we
integrate our ability to deal with either surges in military
patients or, in the event of a natural disaster, surges in
civilian patients. But that is the framework.
A subset of that are the Respect Centers, which you are
very familiar with, the regional Emerging Special Pathogen
Centers that are designed to take care of patients exposed or
infected with high-consequence infectious diseases. And another
subset of that is the trauma system that Dr. Cannon so nicely
described.
We need your help to articulate in law that we must work as
a nation and as a team. We are short 300,000 nurses nationally.
The projections are we will be short 130,000 doctors by 2035.
There is no way that we can do this individually. We must do it
together, and I urge you to codify the NDMS pilot and make that
the intent, moving forward.
Senator Fischer. Dr. Cannon, Dr. Robb, anything to add on
that?
Dr. Cannon. Senator, I would just advocate for what my
colleague, General Friedrichs, just said, but we need to put
our foot on the gas. We do not have 5 years, 10 years, 20
years. We need the solution really now.
Senator Fischer. Dr. Robb?
Dr. Robb. Yes, I concur with both their comments. And going
back, the fact that we dual-purpose these assets, these
expensive assets, to solve problems both in the military and
civilian sector, but they are mutually synergistic. So
absolutely, we need to press forward.
Senator Fischer. Thank you. Dr. Friedrichs, you mentioned
the University of Nebraska Medical Center and working with an
academic institution. Can you explain to the Committee the
benefits of those partnership with academic institutions in
particular, and what that can yield for the Military Health
System?
Dr. Friedrichs. Thank you very much, Senator Fischer. The
first benefit is we share and exchange information. University
of Nebraska has established, without a doubt, one of the
premier programs for treating casualties or patients who are
exposed to highly contagious infectious diseases, and they have
got remarkable onsite training, which they built in partnership
with the United States Air Force. This is a great example of a
military-civilian partnership in which the exchange of ideas
improves care, both for military and civilian patients.
But the other thing that we can learn from our civilian
partners is something that I offer to the Committee to
consider, the CHIP IN Act, which was originally passed to allow
for blending of funding to build new VA facilities. It should
be expanded to include the DOD. We cannot afford to keep
building duplicative facilities, and the CHIP In Act was a
great way to allow the blending of Federal, State, local, and
philanthropic funds so that we can most efficiently care for
this diverse patient population.
Again, I commend the University of Nebraska for the
pioneering work that they have done in showing what a good mil-
civ partnership looks like.
Senator Fischer. Thank you for the shout-out on the CHIP IN
Act. That bill was written in my office, so thank you very
much.
Dr. Cannon, as a professor of surgery, do you have anything
to add on that?
Dr. Cannon. I would just comment that these mil-civ
partnership sites can be incredible assets for force
generation, for building up that next generation of future
leaders in surgery and other combat-relevant specialties. And
these are epicenters of academic excellence where we can truly
inspire that next generation.
Senator Fischer. Thank you. Thank you, Mr. Chairman.
Chairman Wicker. Thank you, gentlemen. It seems to me that
the State of Nebraska must have excellent
representation in the U.S. Congress.
Senator Shaheen.
Senator Shaheen. Thank you all very much for being here
today.
Dr. Robb, you discussed the impact of declining budgets on
the Defense Health Agency. As a former director, can you talk
about how late budgets and operating under continuing
resolutions, continued budget uncertainty affects the readiness
of the Military Health System?
Dr. Robb. When I look back--in fact, I will go back in
history, because I was part of that. When we initially stood up
to the Defense Health Agency in response to the perception that
we had 10 percent of the DOD's overall budget, and then fast-
forward to 12 years later and now we are actually less than 10
percent. And we were meeting not quite but most of our demands
back then. But as I watch, we have had increasing combatant
command requirements with a decreasing defense health program.
And what that has forced us to do is we have seen a couple
of challenges, and there are multiple things going on. But the
military departments, their end strength has gone down, and the
way we man those hospitals is with a certain percentage of
military members. And as Dr. Friedrichs said, you just cannot
buy health care professionals off the streets.
So when we cut the end strength then we apportion this care
downtown, and then that increased TRICARE budget, but then we
have to pay with bag one money, which is direct care money, to
pay direct care. So now we actually have an internal shrinking
of our budget. So it has been challenging for the Defense
Health Agency to manage a set of Military Treatment Facilities
with that to be the current business process.
Senator Shaheen. And is it fair to say that budget
uncertainty exacerbates that problem----
Dr. Robb. Oh, absolutely.
Senator Shaheen.--that continuing resolution exacerbates
that problem?
Dr. Robb. Absolutely. Yes, ma'am. Yes, ma'am.
Senator Shaheen. Thank you. Dr. Friedrichs, you mentioned
the National Guard, and one of the things I know, the National
Guard, as we all know, is assuming a greater role in actual
deployments and picking up work for the regular military. I
could probably say that more eloquently, but they are taking on
a much bigger role than they did 30 years ago. Yet the National
Guard does not have the same coverage for health care that our
regular military does. Despite the challenges that you all have
identified, it is even a greater problem for the National
Guard.
Can you speak to what we ought to be thinking about as we
are thinking about how do we ensure that the Guard actually has
the health care they need so that they are ready to go if they
are called to deploy or called into combat?
Dr. Friedrichs. Thank you, Senator Shaheen, and I will
start, if I may, first with your premise that there is an
increasing demand signal. The decision to take down the United
States Agency for International Development (USAID) and most of
its capabilities is almost unquestionably going to drive more
demand on the Department of Defense. USAID provided countless
services for disaster response and for work with allies and
partners around the world.
Senator Shaheen. And for global health.
Dr. Friedrichs. And for global health, and for
biosurveillance, and many other roles. In the absence of USAID,
we either agree that when Americans are caught in a disaster
they are on their own, or we are going to turn to the only
other organization that has those kinds of capabilities, and
that is DOD. So we should, I am afraid, expect to see more
demand on DOD as a result of those changes.
To your point about health care preparedness, when we look
back at why people, shortly after deployment, have to be pulled
off the line, interestingly it is dental care primarily among
the Guard and Reserve, who do not have ready access to that. I
think if we are serious about a smaller force that must be
ready on a moment's notice, we are going to have to address how
to ensure that force is ready, when needed, to go forward, and
that is medically ready, as well as ready and proficient with
whatever their assigned task is.
Senator Shaheen. And we are learning a lot of lessons on
our industrial base side, from the war in Ukraine right now,
and a lot of lessons about the conduct of war today. Are we
learning anything about the health care system and what we
ought to be thinking about from what is happening in the war in
Ukraine? Anybody.
Dr. Friedrichs. If I may, I will just quickly say, having
just been with the Ukrainian Surgeon General, absolutely. What
they have found, first and foremost, is they are in the kind of
conflict we will likely be in, and in the absence of air
superiority, contested logistics, you must have a functioning
system that is integrated. And this gets back to Senator
Fischer's question about the National Disaster Medical System.
They are also learning the importance of supply chains.
When we looked at this at the Joint Staff, we found that a
significant percentage of the pharmaceuticals in our deployable
assemblages actually rely on ingredients from countries that
may or may not be willing to continue to provide those in the
next conflict. Same song, next verse, with medical equipment.
I urge you, as I said in my written statement, to require
the Department to give you an accounting for our
vulnerabilities in that area and a plan to address them. There
are ways to do that. We need a strong push, I would submit, to
actually accomplish that.
Senator Shaheen. Thank you very much. Thank you all.
Chairman Wicker. Thank you, Senator Shaheen.
Dr. Cannon and Dr. Robb, do you want to elaborate on what
Dr. Friedrichs said about USAID?
Dr. Cannon. Sure. That is out of my domain so I do not have
anything.
Chairman Wicker. Very well, then. Yes.
Dr. Robb. I would concur, one, with his comments, but
number two, again it is mostly out of my domain currently.
Chairman Wicker. All right. Thank you very much. Senator
Cotton.
Senator Cotton. General Friedrichs, I would like to
continue with the answer you just gave to Senator Shaheen about
our dependence on other countries for drugs and precursors,
specifically Communist China. The United States relies heavily
on Communist China for basic drugs and so-called Active
Pharmaceutical Ingredients (APIs). Providers obviously need
this, not just in the civilian world but in the military world,
especially to treat combat casualties. China, for instance, has
80 percent of the global supply chain of antibiotics.
How could Communist China use this dependence of ours to
its advantage if there were a major conflict in the Pacific?
Dr. Friedrichs. Thank you very much, Senator Cotton, and I
think we have seen examples of this with rare minerals and
other things that China largely controls the supply chain for,
in that they will choose to titrate that supply chain based on
their satisfaction or dissatisfaction with those trying to
purchase those items.
I had the great privilege in my last role of working with
India, the European Union (EU), Japan, and Korea on a
consortium in which we began to identify ways to leverage new
technologies to change and to broaden our supply chains. And I
encourage this Committee to direct the Department of Defense,
in partnership with the Department of Health and Human
Services, to continue exploring those options.
What we found was in many cases, as in the case of
antibiotics that are based on penicillin, the Japanese have
already made a tremendous investment in the ability to produce
those APIs within Japan. We should be partnering with them and
creating an environment in which at least the DOD and the VA
purchase from Japan to help sustain that production base and
ensure that we have the access that we need.
There are many more examples. I touched on some of them in
my written statement. But there are ways to mitigate this.
Senator Cotton. And your answer to Senator Shaheen said
that Congress should push the Department of Defense to catalog
all of these dependencies. It sounds like you are saying we
also need to push to eliminate, or at least significantly
curtail, these dependencies, as well. Is that right?
Dr. Friedrichs. Absolutely.
Senator Cotton. And you mentioned four different sourcing
options--South Korea, Japan, the EU, and India. Those first
three are advanced industrial democracies, just like ours. If
they can produce these items, like acetaminophen or ibuprofen
or penicillin, at a reasonable cost, surely the United States
could do so, as well, right?
Dr. Friedrichs. I believe that is the case. And what we
found is that particularly in these countries they have created
an environment in which it was financially possible for
companies to produce these items within their country. We have
not done that here in the United States. But a thoughtful
industrial policy that was focused on resilience and national
security, as well as economic security and health security,
could do that for us, as well.
Senator Cotton. It is fair to say that between the two of
them, the Department of Defense and the Department of Veterans
Affairs, sure does have a lot of purchasing power to create a
domestic market for the production of these fairly basic and
longstanding medicines, right?
Dr. Friedrichs. Absolutely. About 8 percent of the market--
and it get back to Senator Shaheen's point about continuing
resolutions and predictability. If companies know that they
have a predictable demand signal, they will build to it. If
they have an episodic or random demand signal, they will let
somebody else deal with that.
Senator Cotton. General Robb, I have noticed you nodding
your head vigorously, so please get off your chest everything
you wanted to add to General Friedrichs' answers.
Dr. Robb. Yes. Also, and I am sure you are aware, and this
has been the direction from questions asked by our Congress,
the Center for Health Services Research at the Uniformed
Services University has been tasked, along with the Defense
Logistics Agency, to catalog and specifically look at what, and
define the problem what is, the Department of Defense's
reliance on the medicines that we have talked about that are
primarily sourced from China and from India, which would then
help what I would call inform the decisions a way ahead of
whether you, what I call it, ally shore, or near-shore, or on-
shore, as Dr. Friedrichs discussed, in looking at a way
forward.
But they are creating that, you know, what is the data to
drive the decision and the investment. Thank you.
Senator Cotton. Thank you, gentlemen, both, for your
answers. It has long been the case that the Department of
Defense, acting at congressional direction, has mandated the
domestic purchase of many uniform items, so I think surely we
should make sure that our troops have the medicines they need
to stay healthy, or to recover, as needed.
Chairman Wicker. Thank you, Senator Cotton. Senator Kaine.
Senator Kaine. Thank you, Mr. Chairman. Thank you to the
witnesses. I want to particularly recognize Dr. Cannon. I know
you are very well-prepared for this hearing today because one
of the leaders that is with you, Kristin Malloy, used to be on
my staff, and she made sure I seemed a lot smarter than I was
at any hearing that I attended.
You know, I think I want to focus all of your attention on
the workforce issues, because I am on the Health, Education,
Labor, and Pension too, and if I go to my hospitals and health
care providers they are singing the blues about workforce,
tight labor market, difficulty hiring and retaining folks.
I went to the grand opening of the new VA clinic in the
Fredericksburg area two Fridays ago, and we built it to the
tune of about $350 million. And we built this state-of-the-art
clinic, with one step down from a hospital, because there were
multiple clinics in the area, and veterans were having to go
from pillar to post to get care rather than a single place.
But when we opened it, and I was there for the opening, I
had staff say, ``We are on a skeleton crew.'' The three VA
hospitals in Virginia--Salem, Richmond, and Hampton--are laying
people off. There are hiring freezes. There are plans for even
more layoffs. So the estimates I was getting at that grand
opening is they are probably 20 to 50 percent staffed. There is
another sizable clinic similar that is going to open in
Chesapeake, supposed to, on April 11th. If it does open on
time, I am suspecting that it will be a similar thing. And you
saw the announcements about more cuts coming in the VA.
You have talked a little bit about the need to be more
integrated between DOD facilities and VA facilities, but then
also on the civilian side, what is your vision for how we equip
our civilian system to provide a surge capacity or backup
capacity when we need it, to perform well in combat situations?
Please, Dr. Cannon.
Dr. Cannon. Senator, thank you for your very insightful
comments and questions. I am a veteran. I get my care at our VA
in Philadelphia. My wife is a primary care physician and takes
care of veterans. So I can speak to your comments about the VA
from that perspective.
I do have a role at Penn Medicine as the Assistant Dean for
Veteran Affairs for Penn Medicine, but I am quite new in that
role and still learning the ropes. So I will speak more from my
end user experience.
I would say that certainly there are opportunities for
synergy. The partnerships between VA facilities and academic
medical centers I think have been partially realized, but in
this sort of urgent situation we find ourselves in, we need
truly a whole-of-society approach, and where there can be
market synergy, where there can be economies of scale we should
aggressively pursue that.
I know that our Chief Executive Officer (CEO), Kevin
Mahoney, has made overtures to the VA, and there have been
agreements signed between the VA. I do not have detailed
knowledge about that and where that stands. But I think there
is an opportunity, and we should push for that. And as a
veteran who receives my care, I hope that we can continue to
deliver excellent care through better synergy.
Senator Kaine. How about Dr. Friedrichs and Dr. Robb?
Dr. Friedrichs. Thank you, Senator Kaine, and that is a
beautiful facility. It will be tragic if it sits there empty
while veterans are unable to access care because of shortages
of medical professionals in the VA, in the DOD, and in the
civilian sector.
We are in a less-than-zero-sum game right now, and that is
both a health security issue but also a national security
issue.
The first recommendation I would make to this Committee,
direct that the Department of Defense does not close any more
of our military training programs. For decades, the military
training programs have been one of the pipelines that, when
people eventually left the military, which all of us do, they
go to the civilian sector. We cannot afford to close any more
training programs when we have so many shortages of doctors and
nurses and dentists and other things.
The second, I implore this Committee, in the NDAA, direct
the DOD and in partnership with the appropriate VA oversight
committees, the Veterans Administration, to come back with a
plan, starting with the D.C. market, to integrate the two
systems. We have talked about this since I was a Major. I moved
here in 1997, and we were talking about this. It is time to
stop talking and start doing it. We cannot afford to keep
talking about this problem.
That hospital in the VA here is ancient. It has got to be
replaced. We just finished a billion-dollar upgrade at Walter
Reed. Why in the world are you not demanding that we come back
with a plan to do that? It is more efficient, and it helps to
pool the resources.
The third point, and the most important one in your Health
Committee role, is we must address these pipelines as both a
health security and an economic security and a national
security concern. As long as the pipelines continue to be
insufficient to need, there is no way that any of these
problems are going to get fixed. And I think you have a unique
opportunity to help bring that into both committees. Thank you,
Senator.
Senator Kaine. Thank you. And Dr. Robb, I will ask that
question for the record because I am now out of time. I yield
back to the Chair.
Chairman Wicker. All right. Actually, these witnesses will
not be taking questions for the record. I will let you followup
for 45 seconds.
Senator Kaine. Dr. Robb, then could you approach that
workforce integration question too? Thanks.
Dr. Robb. Yes, and I will go back to where we can share
resources, and I will foot-stomp. We have very many successful
joint DOD and VA partnerships. Travis Air Force Base is a great
example, where the actual VA is inside of David Grant Medical
Center, share staffs, but more importantly, share patients. We
have others where we are co-located community-based outpatient
centers that feed patients into like Anchorage, Alaska. We see
that down there at Naval Pensacola.
So those opportunities, because usually what happens is we
want access to critical care patients for our proficiency, and
the VA wants access to resources, which is either excess
capacity on space or in staff. So I think that continued
movement forward, not always one size fits all, but that is
very, very important. Much like the VA is at all the academic
health centers, I think the Department of Defense, especially
six or eight strategic places, need to have strategic VA and
strategic mil-civ partnerships, sharing staff.
And I will quickly say, not only does the military learn
from the civilian opportunities, during Operation Iraqi Freedom
(OIF) and Operation Endurance Freedom (OEF), actually, the
American College of Surgeons made sure that they were with us
so they could learn, firsthand, real-time, on how we were
treating. So it is a mutually synergistic relationship.
Chairman Wicker. Thank you, Dr. Robb. Senator Rounds.
Senator Rounds. Thank you, Mr. Chairman, and I am going to
follow right along that same line because I think what you are
laying out is basic common sense when it comes to the
integration of these two systems.
My question is, why is it that when we have what is
considered to be excellent care with the military system, the
MHS, involved, and then we have to transition these young men
and women as they leave the armed service into a VA facility,
in which we start all over again. And we have different ways of
communicating, and, in fact, let me just ask this. In your
experiences, how well do we integrate the transfer of
information from the MHS back into the VA systems today?
Dr. Cannon. Senator, I can take a crack at that. I believe
you are spot on. My experience in transitioning from the DOD to
the VA was more of a lukewarm handoff than a warm handoff. I
had to sort of navigate my way to the VA. I now have closed
that gap and I get my care there, as I mentioned. But it is not
a smooth process.
Why is it still the case that the two health care delivery
systems are so partitioned? I think you have to go back to
ancient history almost, in our country. And if you look at
Secretary Gates' comment about his experience as Secretary of
Defense, he said, ``The one department that gave me the most
fits was the Department of the VA.''
So there are historic challenges. The VA wants to do it
their way. Understandably, most of us do want to do it our way.
But I think there are clear opportunities and a clear demand
signal to break down those barriers and realize opportunities
for synergy. So I think we can do that.
Senator Rounds. I think the focus should be on whether or
not we are delivering for the veteran and not necessarily the
survivability of the VA itself. And I think that sometimes gets
mixed up.
I am just curious, gentlemen. We have talked about trauma
centers. We have talked about the reintegration, or integrated
health care system, and so forth. We are not, right now, at the
same degree of activity and intensity with regard to
battlefield casualties as we were just a few years ago, and
therefore the opportunity for these surgeons, these battlefield
surgeons and others, to actually learn right now is probably
not as great.
How do we keep the intensity or the capabilities of the
training, how do we keep that up to date when we do not have
those opportunities? And I am not going to say that they are
good opportunities. I am glad that we are not in them. But how
do you allow that surgeon to keep those skills up to speed when
you do not have the types of casualties that you have on a
battlefield, that we were experiencing for a number of years?
Dr. Friedrichs. Take care of sick patients, sir. I mean,
there is an analog between taking care of a patient who has
bladder cancer and needs to have their bladder removed and
taking care of a patient who has just had a gunshot wound to
the abdomen and needs to have their bladder reconstructed.
We need our military medics taking care of sick patients.
They do that at hospitals that are well-staffed and well-
resourced to take care of sick patients. And so that is what we
have done historically to maintain the proficiency of surgeons
or of critical care nurses or of medical logistics staff, is
keep them busy during peacetime taking care of sick patients.
It is not a perfect analog, but that is the best surrogate, and
that requires resourcing the system, making sure that sick
patients can get in the door and get the care they need.
And to your point about the VA, I would just say I applaud
the VA for accelerating moving forward with their electronic
health record, because that is going to be the secret sauce
that enables greater sharing between the two departments and
will enable us to track patients from the day they join the
military to the day they take their last breath, and really
learn how to improve both systems.
Senator Rounds. Is the current system that you use
integratable with the VA's new proposed medical records health
care system?
Dr. Friedrichs. I am not an expert on the VA's system. When
I left the movie they were looking at purchasing the same
system that the DOD had purchased. I hope that those with
oversight responsibilities will insist that the two systems are
integratable, because technologically, there is nothing to
prevent that. I mean, civilian health care system integrate
Epic and Cerner all the time, or McKesson and Epic. There
should be no technological reason why we cannot do that.
Senator Rounds. Thank you. General Robb, anything to add to
that?
Dr. Robb. I would share what Dr. Friedrichs said. In fact,
what I was excited about is I have had the opportunity for
family members to be in civilian hospitals, and they are able
to reach into it and see Genesis now. So they know the health
care that my family members have been getting in the military.
I know that has absolutely been the vision between the
Department of Defense and the Department of VA, and I believe
that is still what I would call the true north.
Senator Rounds. Thank you. Thank you, Mr. Chairman.
Chairman Wicker. Thank you, Senator Rounds. Senator King.
Senator King. Thank you, Mr. Chairman. First, I want to
thank you for having this hearing. Very timely and important.
Second, I want to associate myself with Senator Cotton's
comments about sort of Berry Amendment for drugs. The idea that
we have to buy Made in America shirts for our troops but we are
worried about the availability of crucial drugs, that seems to
me that is something that should be pursued. We could even call
it the King-Cotton Amendment, but I will pass on that.
[Laughter.]
Also, Mr. Chairman, before getting into the questions, and
these witnesses would not have the answers, but I think in
light of this hearing, the Committee should make an inquiry
about whether there have been firings or early retirements
encouraged within the medical facilities at the Defense
Department, because we know there is a lot of that going
around, and I would like to know whether that is happening in
the Defense Health Agency.
Second is the impact of the continuing resolution. That is
certainly not going to help this situation in terms of
maintaining demand signals, continuity, pilot programs--all of
that is gone in a continuing resolution. For the first time in
my knowledge, I think the first time in American history, we
are faced with a year-long continuing resolution, which
basically vitiates the entire budget process.
Okay. What we are really talking about, it seems to me, is
surge capacity. And it is impractical to maintain a capacity
within the Defense Department, or even Defense plus VA, for the
kind of casualties that would be generated in a significant
conflict. Therefore, I see no other alternative than a
cooperative surge agreement with the private sector. That is
where capacity is, even though that is fairly limited.
Dr. Friedrichs, isn't that really what we are talking about
here is how do we deal with a conflict way beyond what we are
seeing now, within the current capacity? Defense Health Agency
could not do it. VA could not do it. It has got to be
relationships, and should we not have those relationships in
advance so this is not something that we scramble to do, as we
did during COVID, for example?
Dr. Friedrichs. Senator King, I could not agree more
strongly----
Senator King.
[Inaudible.]
Dr. Friedrichs. Thank you, sir. So in the cold war we had
what was called the Integrated Continental United States
(CONUS) Medical Operation Plan, which was essentially what you
just described. It was our shared commitment, as a Nation, to
care for our Nation's casualties, if and when our Nation went
to war. That depended on the National Disaster Medical System
as part of the integrating function between the Federal and the
civilian health care system. The NDMS has been allowed to
attrit.
I echo the recommendations to reauthorize the Pandemic and
All Hazards Preparedness Act, because that, in part, enables
the NDMS. But I implore you to go further. The Integrated CONUS
Medical Operation Plan needs to be updated, and we started that
work when I was the Joint Staff Surgeon, and it is continuing
today. Having the NDMS in name is not sufficient. We actually
have to build out the numbers, by community, of what beds would
be available----
Senator King. With preexisting conditions and analysis of--
--
Dr. Friedrichs. Yes.
Senator King. I just wonder if the Pentagon has war-gamed
this issue. They war-game everything else.
Dr. Friedrichs. Absolutely, sir. We actually did a war game
on this, that we hosted first when I was the Transportation
Command Surgeon, and again when I was the Joint Staff Surgeon.
And what we found was just as you said--it cannot be done
unless it is a whole-of-the-nation effort. And the only way to
get to that point is if we do much more detailed planning.
Taking down funding for State and local readiness officials,
for example, is not going to help them do more planning or
preparing.
We need to work together to build and flesh out that plan,
and we must bring industry into that. The defense industrial
base provides equipment. The health industrial base addresses
the points that you bring up.
Senator King. And we have an analog in United States
Transportation Command (TRANSCOM), which has agreements with
the private sector both in terms of airplanes and ships, in the
case of an emergency. That is where our surge capacity is.
So it seems to me, I mean, here we are talking about it,
but I think there needs to be some very specific good, new
looks at this relationship in order to be ready, so again we
are not scrambling.
Dr. Robb, you are nodding. I take it you agree?
Dr. Robb. Yes. I would absolutely concur. And again, I keep
going back to the same theme, is we have got to buildup those 6
to 8 to 10 strategic Military Treatment Facilities, we have to
resource them, and then you create the already established
military-VA partnerships, and then you just keep expanding that
ring. But you have to have those relationships codified and in
place, and that is what Dr. Friedrichs is talking about. You
cannot just, all of a sudden when it kicks off, pick up the
phone and say, ``How is it going?''
Senator King. You have got to have them in place before the
crisis hits.
Dr. Robb. Absolutely.
Senator King. Thank you, gentlemen. I appreciate it. Thank
you, Mr. Chairman.
Chairman Wicker. Thank you very much, Senator King. Senator
Budd. Catch your breath.
Senator Budd. Thank you all for being here. Major General,
in your opening statement, whether here or able to watch it on
the closed circuit, you identified the importance of the
relationship between the Military Health System and the defense
logistics enterprise.
So should deterrence fail and war break out in the Indo-
Pacific, there are undeniable logistics constraints,
particularly given the geography of INDOPACOM. The logistics of
replenishing medical supplies and evacuated wounded
servicemembers could make all the difference in reducing
servicemember casualties. You provide a number of
recommendations in your opening statement to address these
concerns, including a number of reports and studies, so thank
you for that.
What can our Military Health System do in the short term,
like immediately, to address logistical constraints, and how
can DOD leverage medical innovation to address some of those
constraints?
Dr. Friedrichs. Thank you very much, Senator. I think the
most immediate recommendation that I included in my written
statement was that whenever we contemplate an operation or we
are updating plans, we do a medical feasibility assessment,
very similar to the logistics feasibility assessment that the
Joint Staff J4 does. We need to ensure that we are informing
our combatant commanders about what is and is not possible.
That is something that can be done very easily.
The longer answer to your question gets back to the
discussion that we were just having about partnering with
industry, both on the equipment and pharmaceutical side and on
the health care delivery side. We have the Civilian Reserve Air
Fleet that allows us to commit money to ensure that we have
industry partners willing to provide aircraft and support when
we need it. We have no such analog in the health care space,
even though we know, as multiple Senators pointed out this
morning, that there is insufficient capacity in the DOD and in
the VA to care for our casualties.
The NDMS currently is a voluntary system in which hospitals
can say, ``Yes, okay,'' and then when we call them, they say,
``I'm busy today. I'm not going to participate.'' We actually
need to codify a system, as we have done with other industrial
partners, in which there is a commitment and an understanding
of how the reimbursement would work.
The last point that I would make on that going forward is
in supplemental planning for future operations we have to build
in that cost. There is no question, if we are bringing back
thousands of casualties, as Colonel Cannon described, that that
is going to displace care, and it is going to increase costs at
hospitals. We have to plan for that. That is why this whole
planning effort, the Integrated CONUS Medical Operations Plan,
for which United States Northern Command (NORTHCOM) is the
lead, in partnership with industry, State, local, and
Department of Health and Human Services officials, is so
important, so we can bring back the requirements for funding
and the challenges that we will need congressional help to
address.
Senator Budd. Thank you. Following up on that, you said we
need to codify that. Do you have the language ready, or has
that been written in a way that we could review, either
individually or as a Committee?
Dr. Friedrichs. Senator, I took the liberty of including an
attachment with suggested language, just in case anyone wanted
to do that.
Senator Budd. We will read it in a few moments. Thank you.
Mr. Robb, as you know, the Department relies on a mix of
military personnel, federal civilians, and contractors to carry
out its mission. Talk to me about the roles of physician
extenders such as registered nurses, and what role do physician
extenders play in ensuring the readiness of the broader force,
and what challenges do you see to retention of physician
extenders?
Dr. Robb. Thank you for that question, Senator. I think it
is key that the same issues of what I call proficiency and
currency that exists for physicians, exists for our physician
extenders. And the Army does a great job, especially in the way
they have manned and equipped their fighting forces, of using
those physician extenders, all the way down to the corpsmen, to
the fullest extent of their capabilities.
And so I would argue, as we have these discussions about
medical readiness and about our ability to care for what we
call critical wartime specialties, we must remember, trauma is
a small percentage of that, but the majority of the care that
is applied to our fighting forces comes from our primary care
providers, which would be Physician Assistants (PAs), nurse
practitioners, general practitioners, family physicians. So we
must ensure that they also have the critical thinking skills
and the opportunity to practice at the top of their game.
Senator Budd. Thank you all, to the whole panel. Chairman?
Chairman Wicker. Senator Budd, yes indeed, in looking at
the statements, which have all been admitted to the record, by
unanimous consent, I see on page 14 of Dr. Friedrichs' prepared
testimony Attachment 1, Suggested National Defense
Authorization Act Language. So we do appreciate him acting as
an uncompensated legislative staffer for this Committee. We
appreciate that. And thanks for the question.
Senator Kelly.
Senator Kelly. Thank you, Mr. Chairman. General Friedrichs,
good morning, and thank you, all of you, for being here today.
General Friedrichs, in a recent war game brief to Congress in
November 2024, a hypothetical conflict in the Indo-Pacific
resulted in 3,000 U.S. casualties in 3 weeks, and 10,000 across
the entire conflict. And I am kind of following up on Senator
Budd's line of questioning here.
These numbers are higher than anything we have seen since
the Korean War. In a severely injured servicemember's
transition through the care system and make their way back to
the United States for treatment, I am concerned that the number
of DOD providers capable of handling trauma will be grossly
insufficient. So given that, we are going to need to surge
capacity, potentially found in the U.S. hospital system and VA
hospitals, meaning civilian hospitals, VA hospitals.
What concerns do you have with relying on U.S. civilian and
VA hospitals to provide this trauma care to our servicemembers?
Dr. Friedrichs. Thank you very much, Senator Kelly, and I
would start by saying even before we get patients back to the
United States, in the past we have relied on our allies and
partners to help care for our casualties. And I am deeply
concerned if we sever or degrade those relationships we will
need to rewrite our plans, and the demands on the U.S. health
care system will be even greater.
To your point about the U.S. health care system, the
Integrated CONUS Medical Operation Plan that we updated in
1998, and then did not look at until 2020, is the plan that
describes how we will surge capacity. But a key part of that
gets back to some of the discussions we have had earlier. There
have to be doctors and nurses and pharmacists and all the other
staff to do that, and I implore that we continue to look at the
pipelines that produce those medics as well as the facilities
in which they work.
We had briefly chatted about the opportunity for a medical
equivalent to the Civilian Reserve Air Fleet that we use to
ensure access to civilian aircraft, when needed. I believe we
need some similar construct in the health care system, where we
partner with industry and recognized that during surge moments
there is a plan, and there is money available, for us to be
able to leverage their staff and their facilities.
Senator Kelly. Is there a plan?
Dr. Friedrichs. There is a plan. We wrote the first version
of that before I retired, and they are working on an update to
that. But it would benefit from additional congressional
oversight to ensure that it is on track and it does not get
diverted by bureaucratic buffoonery.
Senator Kelly. Are there current efforts in the
relationship building with these hospitals?
Dr. Friedrichs. The Defense Health Agency is tasked to have
that outreach, and as I have met with hospital CEOs and system
owners, there is certainly an opportunity to do more in that
space. We must view the health care industry the same way we
view the aviation industry or the missile-producing industry,
as our partners. We cannot take care of America's casualties
without those partners.
Senator Kelly. Can you talk to the value in the two Navy
hospital ships--I do not know if anybody here is prepared to
talk about it. Because I think there is an effort underway to
replace those. There is also the training ships for the State
maritime academies that I think also could serve a role. I
visited one at the Philly Shipyard a few weeks ago, had an
operating room on board. Is that part of the system, as you
envision it?
Dr. Friedrichs. Yes, absolutely. The hospital ships are
integral to our plans for a large-scale combat operation, and
the two ships we have are some of the oldest ships afloat. They
have to be replaced.
Senator Kelly. I think there is a plan to replace them now.
Can you speak to how that is going, if you know?
Dr. Friedrichs. I pushed incredibly hard for that plan as
the Joint Staff Surgeon, against intense opposition that we
should spend the money in other places. I would defer to the
Navy for the latest update on it, because they can give you the
most current plan. But my understanding is that we are still
years away from having the replacement ships available.
So we will have to extend the current ships, and I believe,
the last update I received, which is dated, was through 2035.
But we do need that additional replacement funding to replace
those aged ships.
Senator Kelly. All right. Thank you, and thank you, Mr.
Chairman.
Chairman Wicker. Thank you, Senator Kelly. Senator Warren.
Senator Warren. Thank you, Mr. Chairman. So we need a
medical health care system that works in wartime, but the one
we have is failing us in peacetime. And I think we need to do
better on this. Fixing TRICARE's prescription drug care benefit
is part of that.
Since 2009, TRICARE has outsourced to Express Scripts a
massive Pharmacy Benefit Manager (PBM). The Defense Health
Agency, DHA, pays Express Scripts to negotiate with pharmacies,
deciding where servicemembers can pick up their prescriptions
and what price they are going to pay. But Express Scripts also
owns Accredo, a massive pharmacy that participates in TRICARE,
and DHA has been allowing all kinds of self-dealing between
these two entities.
Here is one. DHA used to require Express Scripts to
maintain a network of 50,000 pharmacies. But in 2021, Express
Scripts negotiated that down to 35,000 pharmacies. Then they
turned around and told thousands of pharmacies, that they do
not own, either to take money-losing terms or get kicked out of
TRICARE.
General Robb, you used to oversee the TRICARE network
before this gaming started. Do you have any idea how many
pharmacies have left, just since 2022?
Dr. Robb. And Senator Warren, I have been out of this since
2016.
Senator Warren. Okay. I just wondered if you happened to
know how many had left. I will take a no.
Dr. Robb. No, ma'am. No, ma'am, I do not.
Senator Warren. Well, it is over 13,000 pharmacies have
left this network, and most of them are independent pharmacies,
community pharmacies. That has forced 400,000 servicemembers
and their families to find new pharmacies, and many of them
have been pushed to the Express Scripts-owned Accredo.
Even worse, Express Scripts has set up Accredo as the
primary off-base pharmacy where military families can fill
specialty drug prescriptions. You know, these are the really
expensive cancer drugs, rheumatoid arthritis drugs, that make
up over half of the $8 billion in TRICARE prescription drug
spending. So it is a lot of money here.
It does not end there. As we speak, Express Scripts is
facing a whistleblower lawsuit that alleges the company
systematically overfilled TRICARE prescriptions at Accredo,
saddling DOD with, quote, ``billions of dollars in excess
dispensing fees and drug resupplies.'' And this is not a
surprise. Express Scripts has been found to massively overfill
and overpay for prescriptions at Accredo, which they own, in
other government programs.
So General Robb, since last year, an audit uncovered that
Express Scripts was leveraging its contract with the West
Virginia Public Employees System to send inflated payments to
Accredo for expensive specialty drugs, in some cases inflating
the price by 100fold more than the cost of dispensing exactly
the same drug at a competing pharmacy.
I imagine you think this kind of taxpayer overcharging is
unacceptable. Is that fair, General Robb?
Dr. Robb. I would agree with that, it would be unfair. Yes,
ma'am.
Senator Warren. Okay. DHA is supposed to audit Express
Scripts' pharmacy data to make sure that that same thing is not
happening at TRICARE, but DHA said it had not completed an
audit because DHA had, quote, ``no concerns about data
accuracy.''
You know, talk about being asleep at the wheel here, in
just the first quarter of 2023, Express Scripts dispensed
70,000 specialty drug prescriptions at Accredo, but the company
only reported about 40,000 to DHA. In other words, Accredo
failed to report nearly half of the expensive specialty drugs
dispensed at its own pharmacy, which were paid for by DHA. So
they get the money, but they do not tell DHA what is going on
here.
General Robb, after completing their investigation, the
Government Accountability Office (GAO) sensibly recommended
that DHA periodically audit Express Scripts' reported data for
accuracy, which, by the way, is already required in the
contract. So this is telling them basically to follow through
on the contract.
Do you agree with GAO's recommendation?
Dr. Robb. I would agree that they need to follow what is
the business policy and what is the contractual requirements.
Yes, ma'am.
Senator Warren. All right. You know, I just want to say,
and I will close up here, DHA is paying Express Scripts
billions of taxpayer dollars to manage the TRICARE benefit and
negotiate with itself, and DHA is not even bothering to check
the books. I think that everyone in this room agrees that
Express Scripts ought to pass an audit, and that ought to be
required in this year's NDAA.
Thank you, Mr. Chairman.
Chairman Wicker. Thank you, Senator Warren.
Dr. Friedrichs. Mr. Chairman, may I add a comment to that?
Is there time?
Chairman Wicker. You certainly may, yes.
Dr. Friedrichs. Thank you very much. I would hold up the
Veterans Health Administration's exemplary mail order program,
which has worked for years, as an opportunity, again going back
to this concept of how do we deliver better care, and where
possible, do it more efficiently. There is a real opportunity
for this Committee, in partnership with the appropriate
oversight committees, to direct a comparison of the two systems
and then bring back recommendations for the best practices
between the two.
Pharmaceuticals are growing in costs, and that is not going
to change. But this is an area in which the Veterans Health
Administration actually has done this well for years, with high
patient satisfaction, and more importantly, the patients get
the meds they need, when they need them. There is a real
opportunity to learn from the VA here.
Chairman Wicker. Thank you very much. Thank you, Senator
Warren. Mr. Ranking Member, anything more?
Senator Reed. Just let me commend the witnesses. You have
given us lots to think about and lots to do, and so we
appreciate that. Thank you very much.
Chairman Wicker. We are indebted to you and grateful to all
three of you. Thank you very much.
This concludes the hearing.
[Whereupon, at 11:04 a.m., the Committee adjourned.]
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