[Congressional Record Volume 141, Number 117 (Wednesday, July 19, 1995)]
[Senate]
[Pages S10261-S10266]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]


        DANGEROUS TRENDS IN DOWNSIZING MILITARY HEALTH SERVICES

  Mr. INOUYE. Madam President, I would like to bring to your attention 
a matter of serious concern to me regarding the future of our currently 
superb military forces--and the inextricable link between a quality 
volunteer force and an equally robust, quality, military health care 
system.
  I have followed closely the downsizing of our military forces over 
the past several years. The Active Force will have come down from 2.1 
million service members in 1990 to 1.45 million by 1997, a 32-percent 
reduction from cold war levels. The Navy will see its fleet reduced 
from 546 battle force ships to 346 in the same time period with only 12 
aircraft carriers in commission by the end of the century. The Army 
will go from 18 to 10 active divisions and the Air Force from 24 to 13 
active fighter wing equivalents. The Marine Corps will likewise be 
reduced from a force of 200,000 men and women in uniform to a force of 
174,000.
  We have repeatedly promised that there will be no more Task Force 
Smiths--a tragic result of that period of time just prior to the Korean 
conflict in the early 1950's when we truly had a hollow force. Yet, I 
see us slowly but surely moving toward this state of readiness--or 
should I say, unreadiness. Although it causes me great sadness to even 
contemplate the repeat of such a tragedy, I must tell you that in the 
not-too-distant future, I envision us once again being called upon to 
answer to our brave service members and the American people, ``Why did 
we let another Task Force Smith occur?''
  I have been here long enough to know what is meant by a hollow 
military. In the 1970's, 25 percent of new recruits were category IV--
the lowest recruitable mental group--and, as a result, 30 percent of 
our ships--brandnew ships with brandnew equipment--were not fit for 
combat due to a lack of sailors to man them. For although our military 
possesses superior technology and superior weapons systems, it is the 
people who really determine the readiness of our forces. And these 
people, the men and women in uniform, are recruited from and reflect a 
cross-section of the American population. Although the services met 
their recruiting goals last year--and keep in mind that these goals are 
much lower than they were a few years ago--the military has had to 
dramatically increase their recruiting budget as well as the number of 
their recruiters to do so. Even so, it now takes 1.6 times the number 
of recruiter contacts to achieve one recruit. The reality of our 
national culture today is that the propensity for young people to join 
our military is at a 10-year low, down 39 percent among 16- to 21-year 
old males just since 1991, according to the Army.
  While it concerns me to watch the reduction of our forces, I 
understand and support the need to balance the size of our military 
services with the threats facing us today and in the near future. 
However, we must not lose sight of the reality that major armed 
conflicts are still a very real possibility and could come at any time 
in the form of aggression by regional powers such as Iraq and North 
Korea. In his recent testimony before the Senate Defense Appropriations 
Subcommittee, Vice Admiral Macke, the commander in chief of the United 
States Pacific Command, called North Korea the nation with the highest 
threat potential today. Dr. Henry Kissinger, in his testimony before 
the Senate Armed Services Committee in February, warned that ``more and 
more states are coming into being that feel no responsibility to any 
global international system or international stability.'' He also cited 
the North Korean situation, the proliferation of nuclear and other 
weapons of mass destruction, and the growth of Islamic fundamentalists 
as serious threats to our national security that could involve us once 
again in armed conflict.
  More recently and more frequently, however, we have seen a 
preponderance of internal regional and national conflicts that require 
our armed services to respond with operations short of war. These 
operations not only strain our defense capabilities but drain current 
year defense budgets. When taken into consideration with other security 
threats, I become gravely concerned about the speed and direction of 
our force reductions.
  Of particular concern to me is the downsizing of the services' 
medical structure--both peacetime and wartime personnel and units. 
While I do not wish to tie the hands of the Department or the service 
chiefs as they restructure their forces, I am increasingly concerned 
over the severity of reductions to the services' medical departments. 
In my opinion, the military health service system is being taken down 
too far, too fast.
  The military leaders and decision-makers have a tendency to see 
military health care as less important than the men and women who fly 
airplanes or who drive tanks. However, I caution you that our military 
is essentially a team, and if one member of the team is weak, the 
entire team is weak. Although the medical departments might seem less 
crucial to the preparation for or the outcome of war, I assure you that 
to the men and women in combat, they are absolutely essential members 
of the team. To be effective fighting forces, the servicemembers must 
be able to concentrate on combat and keep their minds completely 
clear--free from worry about their own well-being and, even more 
importantly, free from worry about the health and well-being of their 
spouses and children at home. Without the knowledge and security that 
their families are well cared for, our military personnel will lose 
much of their effectiveness that they have so ably demonstrated during 
the past decade.
  First, I will address combat medicine--caring for the soldiers, 
sailors, marines, and airmen who risk injury and death around the 
world. When I was injured in World War II, it took 9 hours for me to 
get to medical care--9 hours. But in 1945 that was not too bad--
Americans probably did not expect any faster battlefield evacuation and 
care. Today, when a soldier or marine is wounded in combat, he or she 
can be at the hospital within 15 minutes. In fact, we learned in Korea 
and Vietnam that if we could get wounded soldiers to hospitals within 
15 to 30 minutes--and we did that pretty regularly--we could save most 
of those who survived their initial wounding.
  Because of our experiences in these wars, Americans now have come to 
expect emergency medical services [EMS] systems, 911 phone lines, 
paramedics with highly technical skills, and advanced EMS and air 
flight ambulances with sophisticated emergency medical equipment. Most 
of these capabilities also exist in our military combat health support 
systems and soon they will have more advanced combat medical 
technologies such as telemedicine, filmless x rays, and other new 
medical innovations that will further improve battlefield survival 
rates. Americans have come to expect this level of care and our service 
members and their families deserve it.
  Trauma experts talk of the golden hour--the first hour after initial 
injury--when the greatest percentage of patient lives can be saved. Let 
me give you one example. In March 1994, there was a horrible training 
accident involving soldiers of the 82d Airborne Division on the green 
ramp--the area where the paratroopers wait to take off--at Pope Air 
Force Base, adjacent to Fort Bragg, NC. Many soldiers were saved by the 
expert buddy aid training that 

[[Page S 10262]]
all soldiers receive as part of their combat training. However, many 
more were saved by the quick response of medical and non-medical 
personnel who quickly evacuated their comrades to Womack Army Hospital 
there at Fort Bragg. Several of the most seriously burned soldiers were 
evacuated to the outstanding Institute of Surgical Research, frequently 
referred to as the Burn Unit, at Brooke Army Medical Center in San 
Antonio. And, of course, our world-renowned Air Force evacuation system 
composed of DC-9 Nightingale aircraft equipped with sophisticated 
medical equipment and staffed by top-notch flight nurses handled the 
evacuation of these critically injured soldiers.
  All of this takes a lot of medical personnel--trained and experienced 
in emergency care, in trauma care, and in combat medicine--and a lot of 
medical resources such as ambulances--helicopters, wheeled and tracked 
ground ambulances, and, yes, even fixed wing ambulances--as we plan for 
even longer evacuation lines in future conflicts. It means a lot of 
medical facilities--especially hospitals--located throughout the 
evacuation pipeline--combat theater and elsewhere. This requires a 
robust, quality, flexible, military medical force.
  During Operation Desert Shield/Storm, the military medical operations 
plan called for emptying almost all of the military hospitals in the 
continental United States as well as some of those in Europe of medical 
personnel to deploy with the field hospitals to the Middle East. And 
that was before downsizing was implemented in the medical departments. 
Today, the medical departments have lost more than 30 percent of their 
personnel, but are still expected to provide the same level of support 
to
  defense plans that call for conducting two nearly simultaneous major 
regional contingencies [MRC's], possibly in conjunction with one or 
more operations-other-than-war [OOTW] scenarios. I would like someone 
to tell me how this is to be accomplished with 30 percent fewer assets. 
I would also like to know who will provide care for the military family 
members in such a situation.

  As a result of having such a superbly trained and equipped military 
medical capability, an interesting, but potentially dangerous, 
precedent has become evident in recent years. Whenever large numbers of 
people are in need of health care services, whether in this country or 
elsewhere in the world, the United States military medical departments 
are requested. You might not be aware of this, but the first U.S. 
military units to be placed under the command of a foreign nation were 
medical units. Why? Because we have the most sophisticated, 
comprehensive, state of the art combat medical capability in the world 
and other nations sending their sons and daughters off to danger want 
their soldiers to have the best too.
  More than just providing combat health services to our deployed 
service members, a robust health care system is critical to maintaining 
our quality volunteer force. When the draft ended in 1973, many people 
both here in Washington and throughout the United States doubted the 
success of an All Volunteer Force. After all, given the history of the 
draft and the need to force our citizens to serve their country, how 
could anyone reasonably expect that there would be enough young men and 
women who would volunteer to serve--and at a quality that would be 
acceptable. A great many people were very surprised when the All 
Volunteer Force not only met previous recruiting standards, but 
actually exceeded them.
  I believe we were able to do this in large part because one of the 
benefits promised to the potential recruits was world-class quality 
health care, not only for themselves but also for their family members 
throughout their career and even after retirement. No one said, 
``unless we have to downsize.'' I doubt that very many recruiters 
explained or even understood themselves the fine distinction between 
``entitled to'' and ``eligible for'' that separates the statutory 
provision for health care services for family members of active duty 
personnel from the retirees and their military dependents. Or that 
anyone explained about space available care. What the soldiers and 
sailors and marines and airmen heard, what they were promised, was 
lifetime health care for themselves and their dependent family members.
  And how have the services been able to meet their recruiting goals? 
By continuing to promise lifetime health care for themselves and their 
eligible family members. Why? Because the military knows that without 
this benefit, the recruitment of, and particularly the retention of, 
quality, career service members would be nearly impossible.
  Now our retirees and service members see us breaking our promises to 
them. Space available care in our peacetime medical facilities in some 
cases has already disappeared or is rapidly disappearing for our 
retirees and, in many places, even active duty family members are 
forced out on the Civilian Health and Medical Program of the Uniformed 
Services [CHAMPUS] because of drastically downsized or closing medical 
treatment facilities. If we continue to cut retirement benefits, we 
will have a difficult time recruiting soldiers, sailors, marines and 
airmen for our next war. As Maj. Gen. Jim Pennington, U.S. Army, 
retired, said, ``If we do not stop this constant effort to renege on 
the promises to those who have served and kept their part of the 
bargain, we will destroy the Volunteer Force and consequently our 
national defense.''
  How important is military health care to the service member? I can 
tell you, it is very important. I have traveled to a great number of 
military bases and posts and invariably the first or second question I 
am asked is about health care--usually not for service members 
themselves so much as for their family members. Much as we would like 
to believe that there are millions of patriotic Americans willing to 
serve their country without any additional incentives, the reality is 
that our service members want pretty much the same thing most Americans 
want--including families and the ability to take care of their family 
members. In World War II, only 4 percent of the soldiers had 
dependents. In 1973, when the draft ended, 40 percent of our military 
force had dependents. Today, more than 60 percent of our military 
personnel have family members. When our troops are deployed away from 
home--and we are asking them to do that more frequently now--their 
foremost concern is their families. This is just as true, and perhaps 
even more so, during times of armed conflict. I cannot overemphasize 
the importance of the military health care system in providing peace of 
mind and security for our service members and their families, 
especially when faced with the possibility of deployments and combat as 
these men and women are every day.
  Madam President, my concerns with the drawdown of our medical forces 
are in three areas: The civilian workyear reductions directed at the 
Department of Defense--DOD, medical readiness, and the continual 
erosion of retiree health care benefits.


                      Civilian Workyear Reductions

  The DOD is committed to streamlining its civilian workforce in 
accordance with the National Performance Review [NPR] and the 
administration's guidance to increase its efficiency and effectiveness. 
The DOD seeks to do this without sacrificing quality or compromising 
military readiness. Between 1993 and 1999, the DOD projects a 32-
percent reduction in civilian positions. In accordance with the fiscal 
year 1996 President's budget, the DOD has targeted headquarters, 
procurement, finance, and personnel staffs. Downsizing the 
infrastructure in this way should not affect the military services' 
ability to carry out their mission nor to respond quickly and 
effectively.
  The Military Health Service System's [MHSS] share of these 272,900 
civilian reductions is more than 11,000 spaces. However, these 
positions are predominantly in the business of delivering health care--
nurses, lab technicians, and other medical technicians. Less than one-
third of the MHSS civilian work force are in the targeted job series. 
Although the medical ward clerk or medical transcriptionist might 
appear to be optional, they are as critical to the health care team 
effort as are the health care providers.
  The Congress has been concerned about the adverse impact of 
downsizing both the military and civilian work force for a number of 
years. To insure that this downsizing and civilian conversion does not 
cost the American 

[[Page S 10263]]
taxpayers more in contract and other costs, a number of Federal laws 
have been enacted in recent years.
  The Federal Workforce Restructuring Act of 1994, Public Law 103-225, 
prohibits agencies from converting the work of employees included in 
the 272,900 civilian reductions to contract performance unless a cost 
comparison demonstrates that such a conversion would be to the 
financial advantage of the Government.
  Section 8020 of the Defense Appropriations Act for fiscal year 1995, 
Public Law 103-335, provides specific guidance prohibiting the 
conversion to contract of any DOD activity ``until a most efficient and 
cost-effective organization analysis is completed on such activity or 
function and certification of the analysis is made to the Committees on 
Appropriations of the House of Representatives and the Senate.''
  Section 711 of the National Defense Authorization Act for fiscal year 
1991, Public Law 101-510, prohibits reductions of medical personnel 
until the Secretary of Defense certifies to the Congress that the 
number of personnel being reduced is excess to current and projected 
needs of the services and that CHAMPUS costs will not increase.
  And, finally, section 716 of the National Defense Authorization Act 
for fiscal year 1991 requires congressional notification before any 
military medical services are terminated or facilities are closed. 
These restrictions have all been placed on the DOD to ensure that 
reductions to the MHSS have been thoroughly analyzed for their impact 
not only on costs, but also on military readiness and preparedness.
  In my own State, Tripler Army Medical Center staff can expect to pay 
30 percent more for child and maternal health care contract personnel 
to replace existing civilians. And that is for just one medical unit in 
one hospital. I understand that the U.S. Army Medical Command's 
[MEDCOM] experience in contracting for health care services indicates 
that direct hire civilian employees--the same civilians that the DOD 
has been mandated to cut--are almost always the most cost-effective 
alternatives when hiring on the margin one for one.
  For instance, a civilian nurse costs $40,000 per year compared to 
$60,000 for a contract nurse. At Fort Drum, NY, where contracting care 
is required because there is no
  inpatient medical facility on post, the per beneficiary costs are 56 
percent higher than costs at similar military installations. In fact, 
the MEDCOM's experience with commercial activities [CA] studies has 
shown that it is almost always considerably less expensive for the 
military system to provide health services than it is to contract for 
them.

  The inevitability of these mandated civilian cuts affecting nursing 
personnel is particularly worrisome, especially in the Army where 
civilian nurses comprise approximately 50 percent of the work force and 
where military nurses are being consistently cut more than any other 
health care profession. As the medical departments downsize, careful 
consideration must be given to the health professionals such as nurses 
who are actually providing care. The integration of health promotion, 
health maintenance, and wellness should be at the forefront of 
providing quality health care. However, the steep cuts in the 
endstrength of Army nurses jeopardize the ability of the Army Medical 
Department [AMEDD] to deliver on its promises to increase access, 
maintain quality and improve cost-effectiveness of the health care 
services provided in both peacetime and wartime facilities and 
settings. With the drastic losses of both military and civilian nurses, 
the AMEDD has few options other than massive contracting arrangements.
  If these contract costs were applied across the full spectrum of the 
MHSS-directed civilian reductions, what would be that cost? I hope that 
the appropriate DOD personnel are prepared to answer that question, if 
indeed, we are to draw down medical civilian personnel. It just does 
not make good business sense to contract out services that can be 
provided just as well, and far less expensively, in military 
facilities. Yet, we continue to subject our medical departments to a 
civilian work force reduction that is intended largely for 
administrative positions.
  In addition to the experience of the MEDCOM, I understand that the 
RAND Corp., in a study commissioned by the DOD to comply with section 
733 of the National Defense Authorization Act for 1992, Public Law 102-
190, concluded that medical treatment facilities' in-house care is more 
cost effective than their civilian counterparts by 24 percent overall 
and even more in some areas such as primary care. The Civilian Health 
and Medical Program of the Uniformed Services [CHAMPUS] has not been 
the preferred cost-effective alternative to either the medical 
departments who bear the major costs of the program or to the 
beneficiaries who share the cost. The simple fact is that medical 
inflation in the private sector has skyrocketed over the past several 
years.
  These civilian reductions are all the more disturbing given not only 
the studies indicating that the MHSS is the most cost-effective 
alternative, but also given the great strides that the MHSS has made in 
reorganizing and re-engineering toward a business-like culture. For 
example, the activation of the U.S. Army Medical Command [USAMEDCOM] in 
1994 marked a major milestone in re-engineering the Army Medical 
Department [AMEDD]. In phase I of that re-engineering, the Army Surgeon 
General's staff in the Washington area has already been reduced by more 
than 75 percent. We are all very proud that DeWitt Army Community 
Hospital at nearby Fort Belvoir in northern Virginia was a recent 
recipient of Vice President Gore's National Performance Review Hammer 
Award. The DeWitt Army Hospital's Primary Care Reinvention Plan will 
dramatically improve the way health care is provided to the more than 
140,000 beneficiaries in DeWitt's catchment area. The plan includes the 
establishment of six new satellite clinics, expanded clinic hours to 
accommodate working parents, a 24-hour nurse advice system, expanded 
child and adolescent psychiatric services, and the creation of a 
special Well-Woman clinic. These initiatives increase primary care 
access and decrease expensive tertiary care costs. In fact, the MHSS 
abounds with examples such as these cutting-edge innovations in all of 
the services.
  Another long recognized example of the military's enormous 
contribution to America is the military medical research and 
development community which is composed of more than 50-percent 
civilians. These contributions have benefited military readiness, 
military preventive and curative care, and have impacted tremendously 
on the kind of civilian health care that has come to be expected by all 
our citizens. For example, the Army's Medical Research and Material 
Command [USAMRMC] has unique expertise and facilities for all phases of 
vaccine development. This includes a hepatitis A vaccine that was 
recently developed, tested, and demonstrated safe and effective by Army 
scientists working with SmithKline Beecham Pharmaceuticals. To health 
care providers, hepatitis A has proven to be a pervasive, but 
difficult, disease to treat with recovery taking anywhere from several 
weeks to several months. Hepatitis A is a serious health risk for more 
than 24 million U.S. citizens that will visit endemic areas this year. 
In the United States, there are an estimated 143,000 cases occurring 
each year at a cost of $200 million. This vaccine was the first 
licensed by the Food and Drug Administration for use in the United 
States.
  The MHSS has long been acknowledged as a leader in research and an 
expert on many diseases throughout the world. Military units deploying 
to Somalia, the Persian Gulf, Macedonia, and Haiti received 
comprehensive advice books prepared by USAMRMC on avoiding local health 
hazards ranging from disease-carrying insects and poisonous snakes to 
contaminated food and water, heatstroke, and frostbite. This military 
unique research and expertise has made, and continues to make, massive 
contributions to our civilian medical capabilities. In fact, as noted 
in a recent edition of the television program, ``Dateline'', the U.S. 
military has the only capability in our Nation to deal with an invasion 
of potentially lethal infectious agents, such as the filoviruses, to 
the United States.
  In the area of peacetime medical research, the Medical Research and 
Materiel Command has led a very successful effort in breast cancer 
research, HIV-AIDS research, defense women's 

[[Page S 10264]]
health research, and malaria research, to name a few. In fact, the 
Army's successful management of $236.5 million for breast cancer 
research in 1993 and 1994 has won high praise from both scientific and 
advocacy groups. Additionally, they have been able to apply 91 percent 
of the funds directly to research, thus restricting the administrative 
overhead to a mere 9 percent. Their success has prompted the Congress 
to ask the DOD to manage another $150 million for breast cancer 
research in fiscal year 1995.
  Other MHSS treatment facilities have similar initiatives underway. 
Many of these initiatives serve as force multipliers by reducing 
attrition and enhancing soldier confidence. The U.S. Army Center for 
Health Promotion and Preventive Medicine [CHHPM] led the effort to 
develop an outside-the-boot parachute ankle brace that has 
significantly reduced jump-related ankle sprains common in airborne 
soldiers. All of these research and preventive medicine initiatives are 
done for the purpose of improving soldier readiness, providing quality 
health care for beneficiaries, and improving cost efficiencies.
  These successful efforts are possible because of the blending of 
civilian and active duty medical personnel as a team. The active duty 
personnel infuse new energy and fresh ideas gleaned from their many 
varied experiences and provide the mobilization force; the civilians 
provide institutional memory, continuity, stability, and invaluable 
expertise gained from years of specialized concentration in highly 
technical fields. To lose either perspective would severely handicap 
the ability of the MHSS to continue to produce their outstanding 
results.
  My final, but by no means least important concern, is of the impact 
on the morale of the dedicated MHSS civilian employees. Preliminary 
feedback from Tripler Army Medical Center and other health care 
facilities indicates that the civilian work force continues to see 
medical military personnel departing as part of the military drawdown. 
Yet, the workload has not diminished. The beneficiaries--active duty, 
retired, and family members--continue to come for the health care they 
were promised and expect.
  At the same time, the civilian employees see their own jobs at risk 
for contracting, probably at greater expense. Our dedicated medical 
civilians at Tripler and all the MHSS facilities deserve so much better 
for their dedicated service to their customers--the men and women in 
our Armed Forces, both present and past.


                               Readiness

  I am also deeply concerned about the medical readiness of our 
military units and the impact that downsizing will have upon them. The 
persistent reductions to the military medical structure from 
downsizing, civilian reductions, base closures, and bottom-liners--
those faceless men and women who make decisions without having any idea 
of how it affects people--have
 resulted in the instability of the medical system. The MHSS is looking 
at reductions in medical personnel of more than 30 percent at a time 
when the beneficiary population is decreasing by about 10 percent.

  Medical readiness is a service-unique responsibility with each 
service focusing on its mission essential requirements. I applaud joint 
service cooperation as a means of more efficiently utilizing scarce 
resources. The medical departments of the services have demonstrated 
that they can work together in many areas--TRICARE--the DOD's managed 
care program, telemedicine, research, training and more. However, I am 
concerned with the increasing pressure to centralize medical readiness 
and eliminate the individual services' autonomy and flexibility. Each 
service has a unique culture and specialized roles and missions that 
cannot be accommodated in an entirely purple suited DOD system. Each 
must preserve a large degree of autonomy.
  There is no compelling reason to centrally manage the medical 
resources of each service under a DOD civilian umbrella. The structure 
that was created to implement the MHSS's managed care program, TRICARE, 
is not suited to manage the services' medical readiness assets nor 
their respective mobilization missions. I, and all of the Congress, 
will continue to hold each of the service chiefs responsible for 
military medical preparedness in accordance with their title 10 
authority.
  The military trains for its readiness mission by caring for all 
categories of beneficiaries in peacetime. This type of training can not 
be obtained exclusively in a field environment. However, the needs of 
both the peacetime health care system and the field health care system 
must be met, in many cases, by the same personnel who must be able to 
transition quickly and effectively from one system to the other as the 
mission requires.
  I am also concerned about the premises upon which several ongoing 
studies are based for decisions on how downsizing will be accomplished. 
The Nation and even many of our senior policymakers seem to believe 
that the recent Persian Gulf war and the Somalia peacekeeping 
operations are evidence that any future military conflicts will be 
bloodless affairs--that is, wars where there will be no, or at least 
very few, casualties. Well, I have been in combat and I can assure you 
that there is no such thing as a bloodless war. We were very lucky in 
Desert Storm--just plain lucky. There is no reason to assume that we 
will be that lucky again or that any adversary will again miscalculate 
so badly. We must not become complacent and delude ourselves that we no 
longer need medical personnel, hospitals, ambulances, and other medical 
assets for combat health care or the resources to enhance and to 
practice combat medicine. That naive belief is irrational and 
irresponsible in an age of high-technology weapons of mass destruction 
and global instability.
  In the Pacific rim, we need look no further than North Korea to see 
evidence of a potential conflict that would create thousands of 
casualties in the first hours of operation. Major military medical 
centers--like Tripler in Hawaii; the Naval Medical Center, San Diego; 
Madigan in the State of Washington, and Willford Hall in Texas--must be 
maintained if we are to be prepared for these conflicts. Any 
recommendation to downsize these facilities displays ignorance of the 
lifesaving role these facilities would play.
  A recent RAND Corp. study titled, ``Casualties, Public Opinion, and 
U.S. Military Intervention: Implications for U.S. Regional Deterrence 
Strategies,'' concluded that once deterrence and diplomacy fail and war 
begins, public opinion demands that the conflict be escalated to bring 
finality to the operation. Such was the public opinion in the Persian 
Gulf war. Many Americans would have preferred that United States forces 
had continued on to Baghdad to overthrow Saddam Hussein, and many still 
feel that the operation was not completed when it stopped where it did.
  Assuming that such a view is correct, the resulting military 
decisions to escalate the measures deemed necessary to win a decisive 
victory could well lead to more, not fewer, casualties. Our military 
medical facilities must be structured for such an occurrence. 
Therefore, other recent study recommendations to downsize or close many 
of our peacetime medical facilities and to greatly reduce military and 
civilian medical endstrengths imperil military preparedness.
  Every day, the dedicated men and women of the military medical 
departments train in peace for their war mission. To believe that this 
capability can be contracted out, accomplished in civilian medical 
institutions, and be made ready for war given a certain amount of time 
is a certain recipe for disaster.
  I have heard the argument that we can park our tanks in motor pools 
when training dollars are short, but we cannot park our eligible health 
care beneficiaries outside our hospitals. We have seen what happens to 
readiness when we do so. Not only do the beneficiaries not get the care 
they deserve, but medical readiness suffers as well. The Nation can no 
more sacrifice our medical readiness than we can our combat 
preparedness.
  I believe the basis for a sound medical readiness posture lies in the 
medical centers. The medical centers function in much the same way as 
does a Navy battle group. A modern Navy battle group usually consists 
of an aircraft carrier, surface warships, support ships, and 
submarines. The medical centers are somewhat like an aircraft carrier. 
They are very large and do not 

[[Page S 10265]]
directly engage in combat. They serve as command and control and 
training centers for the task force and stand ready to launch their 
expert systems forward as needed.
  Just as the expert systems of the aircraft carriers are its jets and 
pilots, a medical center's experts are its military personnel, who work 
in the medical center during peacetime but staff the field hospitals 
during wartime or operations short of war, and its telemedicine 
capabilities. The surface warships and submarines are like smaller 
hospitals, field hospitals, clinics, and field medical units that 
directly support the combat mission.
  These escort ships need the carrier for command and control of its 
units as well as training for augmentation personnel. Much in the same 
way, smaller base and installation hospitals and field medical units 
rely upon medical centers for the establishment of medical policy and 
procedures--command and control, a pool of qualified and trained 
clinicians, and projection of its medical expertise forward via 
telemedicine.
  The importance of medical centers cannot be overstated. Much of the 
success of the MHSS is due to its medical centers. They serve as a 
medical boot camp for health care personnel such as physicians, nurses, 
and corpsmen; research and development for new medical procedures, 
programs, and materials; reference centers for world-class medical 
knowledge and expertise; and the state-of-the-art inpatient care 
capabilities of modern medicine.
  One essential type of medical boot camp is Graduate Medical Education 
[GME]. As with other components of the MHSS, GME has also come under 
attack. Although it is true that certain segments of military medical 
GME can be restructured and consolidated, the underlying premise of a 
medical center-based GME program cannot be refuted.
  The MHSS benefits tremendously from in-house GME. These benefits 
include providing specialty and subspecialty care and increases in 
physician productivity due to the teaching environment. Other benefits 
include lower patient care expenses, the attraction of more qualified 
physicians to the academic environment of teaching hospitals, and a 
higher retention rate of physicians, especially for those trained in 
military facilities, that leads to lower acquisition and training 
costs.
  Opponents of the MHSS would argue that the need for in-house GME 
would be removed if older, nonactive duty beneficiaries were not 
treated in MTF's. Again, studies have consistently shown that military 
in-house care is less expensive than the civilian sector. If we could 
get Medicare reimbursement legislation passed, the MHSS could continue 
to provide low-cost care to retirees and ultimately lower the cost of 
total Federal expenditures.
  Eliminating GME in the military would force military hospitals to 
rely on the civilian sector for recruiting physicians--the same system 
that is currently overproducing specialists and underproducing primary 
care physicians. Current research literature indicates that only 26 
percent of those completing residency training go on to primary care 
practice. The current mix of specialists is inappropriate for 
accessible and cost-effective care. We should not force the MHSS back 
to the high-cost U.S. national average.
  Our medical centers have also been the projection platforms for 
telemedicine initiatives. Using commercial off-the-shelf equipment--a 
digital system camera and a video teleconferencing system, telemedicine 
enables medical personnel at remote locations to consult with 
physicians at a medical center and to quickly obtain expert advice on 
critical or unusual cases. Telemedicine puts the diagnostic firepower 
of Walter Reed Army Medical Center, the National Naval Medical Center 
in Bethesda,
  Maryland, or Tripler Army Medical Center into the hands of the 
deployed physicians in Somalia, Zagreb, Macedonia, or Haiti.

  Just this past December 1994, the life of a 26-year-old soldier was 
saved in Macedonia. This is not so terribly unusual, except that two of 
the physicians contributed their diagnostic and treatment expertise 
while observing the patient on a television monitor at the Casualty 
Care Research Center in Bethesda, MD. Through Operation Primetime, the 
battalion surgeon with the 1/15th Infantry Battalion, part of the 
United Nations Observers in Macedonia, maintained telemedicine links 
with military medical specialists in Europe and the United States.
  The military medical personnel saved that soldier's life by employing 
medical care forward--once again demonstrating their function as force 
multipliers. I am very enthusiastic about the possibilities of 
expanding telemedicine initiatives even further both in our military 
settings as well as in appropriate civilian settings.


                        Retiree Health Benefits

  The last area of military medicine I will address is the continuous 
erosion of health care benefits for our military retirees and their 
eligible family members. As the services strive to improve the access 
and quality of health care through innovative, business-like plans, the 
massive civilian and military cuts combined with the decreasing health 
care dollars seriously threaten their future ability to provide health 
care services to the full spectrum of beneficiaries.
  The MHSS has embarked on a new managed care plan for non-active duty 
beneficiaries called TRICARE. The comprehensive health care benefit 
under TRICARE will maintain or enhance the scope of services that 
eligible beneficiaries receive today. The MHSS's capability to provide 
everyday health care will improve with TRICARE, a plan centered around 
military hospitals and clinics and supplemented by networks of civilian 
care providers.
  TRICARE presents an opportunity to clearly define military medicine 
as essential to force readiness, as well as to improve benefit security 
and choice of delivery for military beneficiaries. There are parts of 
this plan, however, that concern me. The TRICARE plan requires our 
retirees to share in the cost of care, and the greater the choice of 
physicians they desire, the greater the degree of cost-sharing.
  This is wrong for two reasons. First, it violates the contract we 
made with these former servicemembers when they agreed to serve their 
country in our Armed Forces. We promised them access to free care in 
our military treatment facilities in exchange for lower wages and often 
a career of sacrifices during the time of their service. There was no 
fine print about modest enrollment fees and lower out-of-pocket costs.
  Second, I pick up the Wall Street Journal and read that, ``HMOs Pile 
up Billions in Cash, Try to Decide What to do With it,'' as was 
reported on December 21, 1994. I am outraged that our military 
retirees, many on fixed incomes, will contribute to these 
organizations' dilemma. The largest of these are for-profit 
organizations, growing so fast that they overtook nonprofit HMOs as the 
dominant force in managed care, as reported by the New York Times, on 
December 18, 1994.
  The Nation owes our military retirees and veterans what they were 
promised. Soldiers, sailors, airmen and marines, their families, 
retirees and their families, veterans, and surviving family members--
these are the people who comprise the military family. Despite 
pressures to take a short-sighted view, we must honor our obligations 
to those who have served faithfully. The Congress and the citizens of 
this country must do so not only because it is the right thing to do, 
but because if we do not, we will soon be facing a far more serious 
crisis--another truly hollow force.
  We cannot, must not, have contracts that ask more of our retirees and 
veterans. Any such contract today that does that must be declared null 
and void with the contract we made with them in years past. We cannot 
have contracts that restrict access, compromise care, or ask them to 
make more of a contribution. We placed no such restrictions on our 
service men and women when we sent them to foreign shores.
  Lest we think that our servicemembers' tours of foreign shores are a 
product of days gone by, let me remind you that today we have more than 
300,000 servicemembers serving overseas in 146 countries and 8 U.S. 
territories. In fact, deployments for the Army have increased threefold 
since 1990 and more than 700 Purple Hearts and two Medals of Honor have 
been 

[[Page S 10266]]
awarded since November 1989. The military is growing yet another 
generation of veterans and retirees who have served their country when 
their country called upon them.
  I commend the MHSS for their advances in a standard benefit for all 
beneficiaries, for their commitment to medical advances such as 
telemedicine, and for the hard work in which they are engaged as they 
attempt to right size military health care. However, I caution them 
that I am watching. I will not tolerate a health care system sized on 
the backs of our retirees, a system that listens more to short-sighted 
budget analysts than to good business practices, and to any contract 
that violates the contract this country made with the men and women who 
served when called and have already paid their dues.
  Madam President, the real bottom line is that the overall health of 
the entire voluntary military depends on the health of the Defense 
Health Program. A compromised military health system will rapidly lead 
to a compromised military capability. I greatly fear that we are 
heading down that course. For example, I find it truly alarming that 
for the first time in our Nation's history, the emergency defense 
supplemental bill is being offset dollar for dollar from its own 
defense budget. How long will it be before the Department gets wise and 
when the President says go to Haiti or Bosnia or wherever, the military 
says, ``No, thank you, we can't afford it''. I have been involved in 
our Nation's defense for more than 30 years as a Member of Congress and 
I have traveled extensively around the world during those many years 
and I absolutely believe that the best way to prevent war is to prepare 
for war. The only way to prepare for war is to maintain a healthy, 
robust military. And absolutely critical to that endeavor is a healthy, 
robust military medical health system. Let us not forget the painful 
lessons learned in the past; let us not have another Task Force Smith; 
let us not repeat the same mistakes. Let us work to ensure a safe and 
secure future for this great Nation of ours.
  I would like to acknowledge the contribution of my Congressional 
Nurse Fellow, Lt. Col. Barbara Scherb, who prepared this statement. 
Colonel Scherb is an Army nurse who is currently assigned on a 1-year 
fellowship in my office.


                          ____________________