S.Hrg.119-76

1[Senate Hearing 119-76]2[From the U.S. Government Publishing Office]34                                                         S. Hrg. 119-7656                 STABILIZING THE MILITARY HEALTH SYSTEM7                   TO PREPARE FOR LARGE-SCALE COMBAT8                               OPERATIONS910=======================================================================1112                                HEARING1314                               BEFORE THE1516                      COMMITTEE ON ARMED SERVICES17                          UNITED STATES SENATE1819                    ONE HUNDRED NINETEENTH CONGRESS2021                             FIRST SESSION2223                               __________2425                             MARCH 11, 20252627                               __________2829         Printed for the use of the Committee on Armed Services3031[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]3233                 Available via http: //www.govinfo.gov3435                               __________3637                   U.S. GOVERNMENT PUBLISHING OFFICE3860-344 PDF                  WASHINGTON : 20253940-----------------------------------------------------------------------------------4142                      COMMITTEE ON ARMED SERVICES4344 			ROGER F. WICKER, Mississippi, Chairman4546DEB FISCHER, Nebraska			JACK REED, Rhode Island47TOM COTTON, Arkansas			JEANNE SHAHEEN, New Hampshire48MIKE ROUNDS, South Dakota		KIRSTEN E. GILLIBRAND, New York49JONI ERNST, Iowa			RICHARD BLUMENTHAL, Connecticut50DAN SULLIVAN, Alaska			MAZIE K. HIRONO, Hawaii51KEVIN CRAMER, North Dakota		TIM KAINE, Virginia52RICK SCOTT, Florida			ANGUS S. KING, Jr., Maine53TOMMY TUBERVILLE, Alabama		ELIZABETH WARREN, Massachusetts54MARKWAYNE MULLIN, Oklahoma	        GARY C. PETERS, Michigan55TED BUDD, North Carolina		TAMMY DUCKWORTH, Illinois56ERIC SCHMITT, Missouri			JACKY ROSEN, Nevada57JIM BANKS, INDIANA			MARK KELLY, Arizona58TIM SHEEHY, MONTANA                  	ELISSA SLOTKIN, MICHIGAN5960		   John P. Keast, Staff Director61		Elizabeth L. King, Minority Staff Director6263                                  (ii)6465                            C O N T E N T S6667_________________________________________________________________6869                             March 11, 20257071                                                                   Page7273Stabilizing the Military Health System to Prepare for Large-Scale     174  Combat Operations.7576                           Member Statements7778Statement of Senator Roger Wicker................................     17980Statement of Senator Jack Reed...................................     28182                           Witness Statements8384Robb, Lieutenant General (Dr.) Douglas J., USAF (Ret.), Former        485  Director of the DefenseHealth Agency.8687Friedrichs, Major General (Dr.) Paul A., USAF (Ret.), Former          688  Joint Staff Surgeon.8990Cannon, Colonel (Dr.) Jeremy W., USAFR (Ret.), Professor of          1991  Surgery, Perelman School of Medicine, University of92  Pennsylvania.9394                                 (iii)9596   STABILIZING THE MILITARY HEALTH SYSTEM TO PREPARE FOR LARGE-SCALE97                           COMBAT OPERATIONS9899                              ----------100101                        Tuesday, March 11, 2025102103                              United States Senate,104                               Committee on Armed Services,105                                                    Washington, DC.106    The Committee met, pursuant to notice, at 9:36 a.m., in107room SD-G50, Dirksen Senate Office Building, Senator Roger108Wicker (Chairman of the Committee) presiding.109    Committee Members present: Senators Wicker, Fischer,110Cotton, Rounds, Ernst, Sullivan, Cramer, Scott, Tuberville,111Mullin, Budd, Schmitt, Banks, Sheehy, Reed, Shaheen,112Blumenthal, Kaine, King, Warren, Peters, Rosen, and Kelly.113114           OPENING STATEMENT OF SENATOR ROGER WICKER115116    Chairman Wicker. The hearing will come to order.117    The Committee has convened this hearing to discuss the118State of the Military Health System (MHS). We hope to shine a119light on the challenges facing that system and begin working120toward solutions.121    Our witnesses are experts in the field of military122medicine. Dr. Douglas Robb is a retired Air Force Lieutenant123General and the former director of the Defense Health Agency124(DHA). Dr. Paul Friedrichs is a retired Air Force Major General125and the former Joint Staff Surgeon. And Dr. Jeremy Cannon is a126retired Air Force Colonel and trauma surgeon who currently127serves on the faculty at the University of Pennsylvania School128of Medicine.129    I look forward to their testimony. I want to hear their130recommendations about what Congress and the Department of131Defense should do to provide long-term stability to the132Military Health System.133    Military medicine often follows a familiar but regrettable134cycle. During peacetime, medical teams focus on the treatment135of ordinary illnesses. When conflict erupts, military medicine136is frequently caught unprepared, resulting in unnecessary137casualties.138    This interwar erosion of our unique military medical skills139is known as the ``peacetime effect.'' To disrupt the140``peacetime effect,'' Congress enacted sweeping reforms of the141Military Health System. These reforms, now nearly a decade old,142were designed to refocus military medicine on its primary143purpose: combat casualty care and medical readiness.144    We elevated the Defense Health Agency to a combat support145agency and tasked it with administration of all military146hospitals and clinics, relieving the military departments of147that mission. The goal was to have the military services focus148exclusively on the medical readiness of their forces. These149ideas were recommended by an independent, bipartisan commission150embraced by Pentagon leadership, and signed into law in 2017.151    Unfortunately, opponents of these reforms have delayed152implementation and undermined the effectiveness of the153legislation. For example, in 2019, the military departments154implemented drastic cuts to military medical personnel on the155faulty assumption that it would be easy for DHA to hire156civilians to take their places.157    This assumption was misguided, which became evident during158the COVID pandemic. During that crisis, the existing national159physician shortage accelerated. To this day, private sector160health systems seek out and hire away doctors from the161military, not the other way around. We have all seen this in162our states.163    In 2020, Congress ordered a halt to any additional military164medical reductions, but it was too late. A significant number165of reductions had already occurred, severely reducing the166capability of military hospitals. In many locations, the167private sector was unable to handle the additional patients,168sending more servicemembers to private sector care. This has169proven more expensive and has sapped the military doctors'170experiences that are vital to maintaining proficiency.171    Even worse, the Department of Defense (DOD) has refused to172request adequate funding for DHA, which would allow DHA to173staff adequately and equip its hospitals and clinics. Since1742015, the budget for military hospitals has decreased by nearly17512 percent. The water damage at Walter Reed this January is an176example of the antiquated infrastructure that military medical177teams work with around the world.178    In addition to the problems I have just explained, I would179like our witnesses to highlight how bureaucratic delays within180the Department of Defense have prevented the Military Health181System from preparing for the next potential conflict.182    Combat casualty care is the primary purpose of the Military183Health System. When servicemembers are exposed to danger or are184injured, they need to know that they will receive the best care185possible. We know that troops in combat are more comfortable186taking the risks necessary to accomplish their mission if they187have confidence in military doctors.188    We cannot go back to the way things were before 2017. We189must stop scapegoating the Defense Health Agency. The190Department of Defense must request adequate resources to ensure191the Department's hospitals and clinics are properly staffed and192equipped. This is the best way to ensure the Military Health193System is ready for the potential demands of large-scale combat194operations in the future.195    I thank the witnesses for being willing to testify and now196recognize Ranking Member Reed for his remarks.197198                 STATEMENT OF SENATOR JACK REED199200    Senator Reed. Thank you very much, Chairman Wicker, and201welcome to our witnesses. General Douglas Robb, General Paul202Friedrichs, and Colonel Jeremy Cannon each bring important203perspectives from their extensive careers in military medical204fields. We are fortunate to have such a distinguished panel205before us.206    Throughout history, military medicine has often represented207the leading edge of modern health care. Many of the lifesaving208practices common in today's emergency rooms and clinics were209born out of necessity on the battlefield hospitals of the Civil210War, World Wars I and II, Vietnam, and the wars in Afghanistan211and Iraq.212    Professional expert health care, both in combat and213peacetime, is a vital component of our military. Our service214men and women, and their families, deserve nothing but the best215in this regard.216    I am concerned that our military health care system will be217challenged to meet the demands of a potential large-scale218future conflict, particularly in the Indo-Pacific. We have seen219the terrible challenges of health care in austere environments,220like the front lines of Ukraine, where supplies and medics are221often cutoff from the troops in contact. These risks would be222compounded in the Indo-Pacific where contested logistics and223the tyranny of distance would be major factors.224    Congress has dedicated considerable attention to reforming225the Military Health System in recent years, with an eye toward226any potential future large-scale conflict. The primary227objective of these reforms has been to improve combat casualty228care, assume quality medical care for servicemembers and their229families, and ensure that military medical professionals are230able to deliver the world's best care on the battlefield, at231field hospitals, and at medical centers and clinics.232    However, until relatively recently, the Military Health233System was inadequately designed to meet these missions. For234decades, the individual military branches managed their own235Military Treatment Facilities (MTFs) and the Defense Health236Agency, or DHA, was tasked with managing Defense Department237health care via civilian providers. This system was hampered by238unnecessary complexity, a lack of standardization, inefficiency239and redundancy in the system, and inflated costs. The Military240Health System was too focused on beneficiary care while241insufficient attention was paid to combat casualty care.242    To address this, the fiscal year 2017 National Defense243Authorization Act (NDAA) included provisions restructuring much244of the system. This legislation transferred responsibility for245operating the Military Treatment Facilities entirely to DHA.246This change was intended to allow the military services and247surgeons general to focus on medical readiness for the force248and its health care providers.249    Unfortunately, implementation of this legislation has been250difficult. The military services have not implemented the251changes readily, and they have failed to staff the treatment252facilities with the military personnel needed to provide timely253care. The Department of Defense made progress to break through254the inertia in 2023, when it issued a memorandum with specific255direction to save lives and improve the Military Health System,256to include adequate manning of Military Treatment Facilities,257and this effort marked a major milestone in modernizing the258system.259    More work remains to be done, and I hope that the Trump260administration will continue the momentum in this area. During261today's hearing, I would ask for our witnesses' views on the262key challenges remaining for successfully reforming the263Military Health System and how Congress can help equip the264Department and our warfighters with the medical support needed265for any future conflicts.266    Thank you again to our witnesses, and I look forward to267your testimonies. Thank you, Mr. Chairman.268    Chairman Wicker. All right. We will begin with 5-minute269testimonies from each of our distinguished witnesses.270    Lieutenant General Robb, you are recognized.271272  STATEMENT OF LIEUTENANT GENERAL (DR.) DOUGLAS J. ROBB, USAF273      (RET.), FORMER DIRECTOR OF THE DEFENSE HEALTH AGENCY274275    Dr. Robb. Chairman Wicker, Ranking Member Reed, and276distinguished members of the Committee, thank you for this277opportunity to testify on the urgent need to restore and278sustain our military medical readiness in the face of large-279scale combat operations, and thank you both for what I would280believe is spot-on comments. So thank you very much.281    Just a little background on where my perspective of the282Military Health System originates from, I started my military283career as a boots-on-the-tarmac operational flight doc, both284stateside and overseas. I have served at the Air Force Squadron285hospital, clinic, and medical centers in commander positions,286and at the headquarters level.287    I have also had the honor and privilege to serve our joint288forces as the U.S. Central Command surgeon, joint staff289surgeon, and as the first Director of the Defense Health290Agency.291    Moving forward, a refocus on our ability to support large-292scale combat operations, I believe, will require a293recalibration of current and future resources to support large-294scale casualty flow, from the battlefield or the sea battle to295definitive care, rehabilitation, and eventually reintegration.296All this in the face of incremental pressures from The Office297of the Secretary of Defense (OSD), The Office of Management and298Budget (OMB), and the military departments, resulting in a299decade-plus of flatline actually declining defense health300program budgets, personnel reductions, erosion of our mission-301critical Military Treatment Facilities, and intense competition302for quality health care professionals with the private sector.303    One of the key Military Health System organizational304elements in support of the Military Health System strategy is305the evolving and maturing Defense Health Agency, designated as306a Combat Support Agency (CSA). It was established over a decade307ago. Recently, the DHA's justification, and specifically the308DHA's designation as a Combat Support Agency, has been309challenged and questioned.310    In 2011, the Deputy Secretary of Defense issued a memo311titled ``Review of Governance of Model Options for the Military312Health System.'' That was driven by the Department's313significant growth in health care costs. Fast forward a decade314later--sound familiar?315    The Task Force on Military Health System Governance Reform316was then established--and this is key--that included co-chairs317from the Joint Staff, OSD, and flag and senior executive318service (SES) representation from the Joint Staff, OSD319Personnel and Readiness, Cost Assess and Program Evaluation320(CAPE) and Comptroller, and the service surgeons general, for a321total of nine voting members. And I think it is also important322to recall the task force overwhelmingly recommended a Defense323Health Agency organizational model, with a final vote of seven324for the Defense Health Agency, one for a unified medical325command, and one for what then was called a single-service326model.327    The recommendations were briefed through both Joint Staff328and actually through two Chairmen, and Office of Secretary of329Defense and actually through two Deputy Secretaries of Defense,330with the Defense Health Agency construct signed off by the331Deputy Secretary of Defense with the Chairman's support.332    Another decision that has come into question in recent333years was the designation of the Defense Health Agency as a334Combat Support Agency. The designation was initiated by the335Director of the Joint Staff, with the Chairman's concurrence,336when reviewing the proposed DHA organizational structure and337the relationships with both the Chairman and the OSD. The CSA338designation was then codified.339    Now, a decade later, do I still believe the original340analysis and the recommendation to stand up a Defense Health341Agency as a Combat Support Agency remain valid? And the short342answer is yes. But does a recalibration of the Defense Health343Agency supporting relationship with its Combat Support Agency344responsibilities to the supported entities of the military345departments and the Joint Forces need to be readdressed? And346again I would say yes.347    I share with you several lines of effort that I believe are348essential as we strive to further achieve a more tightly349integrated Military Health System to support our national350military strategy and our national security strategy.351    Number one, reemphasizing, with clear articulation and352execution, of the Assistant Secretary of Defense of Health353Affairs' authority, direction and control of the Defense Health354Agency.355    Number two, I believe we need to establish a direct356organizational linkage at the Defense Health organizational357structure level, with the Chairman of the Joint Chiefs of Staff358and the combatant commands through the Joint Staff Surgeon, to359ensure that the responsibilities are prioritized with the DHA's360execution.361    Finally, the Fiscal Year 2019 NDAA directed the Department362to establish joint force medical requirements process to363synchronize the Military Health System's already established364joint operational requirements governance process. And I think365that is key, that the medics need to play with the Joint366Staff's process for determining requirements.367    In closing, I would like to thank you, and look forward to368support you in assisting the Military Health System's ability369to accomplish our mission of ensuring a medically ready and a370ready medical force in support of our military departments and371combatant commands through the provision of care to our 9.5372million beneficiaries. Thank you.373    Chairman Wicker. Thank you very much, Dr. Robb.374    Major General Friedrichs.375376   STATEMENT OF MAJOR GENERAL (DR.) PAUL A. FRIEDRICHS, USAF377               (RET.), FORMER JOINT STAFF SURGEON378379    Dr. Friedrichs. Chairman Wicker, Ranking Member Reed, and380members of the Committee, thank you so much for the opportunity381to be here. I had the opportunity in my very last briefing to382some members of this Committee in May 2023 to give you a383classified assessment of MHS readiness, and I will start with a384recommendation that if you have not had an update since May3852023, I would implore you to schedule that so that the Joint386Staff Surgeon can give you the most current classified387assessment, because what we will provide today is an388unclassified assessment.389    Second, I will give a disclaimer that the views that I390express are my own, not those of any organization with which I391have been affiliated.392    I provided a detailed written statement to you, and I would393respectfully ask that that be entered into the record of this394hearing.395    Chairman Wicker. All of the statements will be added to the396record at this point, without objection.397    Dr. Friedrichs. Thank you very much, Chairman.398    I have two disclaimers. The first, this is my family399business, so I will speak both from my experience and because400my dad served in the Navy--98, still alive--at the end of World401War II. Multiple other relatives in the Navy. My wife is a402former Army physician who now works for the Department of403Veterans Affairs (VA). We are very proud that one of our404children is a marine. I care about this not only because of all405of the others but because this is what my family has done for406generations.407    My second disclaimer, like General Robb, is I have had the408privilege of serving our country now for 39 years, and the409majority of those years I have spent in joint roles. Congress410got it right in 1986, with the Goldwater-Nichols Act, but the411one thing I wish you would change is to include medics as part412of the military. As long as we preserve this false narrative413that the Military Health System is separate and not covered by414the same expectation of jointness as the rest of the military,415we are going to continue to have these fruitless, bureaucratic416buffoonery actions that distract us from taking care of417patients. I encourage you to treat the Military Health System418like a part of the military.419    We have had tremendous accomplishments over the last 20420years, with the lowest rate of deaths among injured ever seen421in conflict, and we should be incredibly proud of that. When I422deployed, I had what I needed, when I needed it, air-evacuation423available. I flew air-evacuation missions. I operated on424casualties. I never lacked for what I needed. I cannot offer425you the assurance that my successors will have that same426environment in the next conflict, and I am grateful that you427are holding this hearing today.428    I have several very specific recommendations. First, as I429touched on before, we must prioritize the patient over the430patch, put a nail in the heart of this discussion about431reorganizations and what the role of the Military Health System432actually is. We need to commit, and we need your help in the433next NDAA, to clearly articulate , just as both the Chairman434and the Ranking Member said, the Military Health System exists435as part of the military to ensure that we deter those who might436seek to harm our Nation and defeat them if they try to. The437military's role is to take care of the human weapon system. The438health care benefit delivery is part of how we do that, and439part of a commitment that we make. But I implore you to address440that in the next NDAA.441    As I said before, I think that you got it right with the442Goldwater-Nichols Act, and I would encourage you in the next443NDAA to clearly articulate that you view the Military Health444System as part of the military and not exempt from the445requirements that the rest of the military faces. A joint446casualty stream requires a joint casualty care team. That seems447relatively straightforward, and yet that is still something448that we are arguing over, whether medical units should be449interoperable, whether they should have the same equipment or450the same training. The answer is yes.451    Look at Israel. Look at almost every other country with a452large military. They have already made those changes, which you453rightfully began and appropriately began in 2017. We do not454need another reorganization. What we need is execution of the455vision that you laid out.456    The next point that I bring up is resourcing, and both the457Chairman, the Ranking Member, and Dr. Robb touched on this.458Health care is not cheap. The mistaken belief that somehow459military medicine can be done at a lower cost than in the460civilian sector, and be ready for conflict, is just that. It is461a mistake and it is a discredit to those who State that they462care about our patients.463    Finally, I am deeply concerned about our growing464vulnerability to biological threats. The decisions to take down465our overseas partnerships to build better biosurveillance, the466decisions to take down research in biological threats, the467decisions to take down multiple other programs that we had468built as a result of the 2018 National Defense Strategy, which469President Trump signed in the first administration and470President Biden updated, put us at greater risk. And we must471continue to address those risks of the evolving biological472threats, both naturally occurring and deliberate threats. The473confluence of Artificial Intelligence (AI), biotechnology, and474compute is dropping the bar dramatically for biological475threats. We should be working on mitigating that.476    I thank you again for the opportunity to be here and for477your interest in this.478    [The prepared statement of Dr. Friedrichs follows:]479480 Prepared Statement by The Honorable Paul Friedrichs, Maj Gen (ret).,481                                MD, FACS482    Chairman Wicker, Ranking Member Reed and distinguished Members of483the Committee, thank you for the opportunity to testify on this topic.484My last congressional engagement as the Joint Staff Surgeon in 2023 was485with several of you to provide a detailed, classified update on the486gaps between Combatant Command requirements for medical support and the487readiness of the force elements which the Services organize, train and488equip, with support from the Defense Health Agency (DHA), in its role489as a Combat Support Agency. It is an honor to be back to share some490additional observations on this very timely topic on which Congress491needs to act, in order to address critical gaps in our readiness to492care for ill and injured Servicemembers.493    The opinions and advice I share in this statement and in my494testimony are my own; I am not speaking on behalf of any organization495with which I am or have been affiliated.496    I need to acknowledge several conflicts of interest related to this497hearing:498    First, and foremost, this is my family's business. . .and I care499deeply about it. I am the proud son of Seaman Third Class Al500Friedrichs, who turned 98 this past January and who served in our Navy501at the end of WWII. Multiple other relatives served in the Navy. One of502the few really great decisions I have made in my life was to propose to503my wife more than thirty years ago, when she was serving as a doctor in504the Army. Our kids thought it was incredibly cool that their mom really505did wear combat boots. After separating from the Army so that our506family could stay together, she has worked for the Veterans Health507Administration for decades, continuing her commitment to care for those508who volunteer to serve their nation. And one of our children is now a509marine.510    Second, I am deeply grateful to have had the opportunity to serve511our Nation in uniform for 37 years, including three tours as a512Commander, as well as service as the Command Surgeon for Alaskan513Command, Pacific Air Forces, Air Combat Command and United States514Transportation Command, where I oversaw the global aeromedical515evacuation system. My last assignment was for 4 years as the Joint516Staff Surgeon, attempting to integrate and synchronize medical support517to military operations and family members on every continent and in518multiple conflicts and disasters. These experiences have taught me that519the rest of the military deploys and fights as a Joint Force, not as520individual Service forces. I believe to my core that the military521health system is a part of the US military and should adopt the same522commitment to joint, integrated capabilities and readiness that the523rest of the military has embraced, and I commend Congress for the524actions they have taken to try to break down stovepipes and enable525greater standardization, interoperability, and integration.526    Nearly 250 years ago, our Nation was born out of the American527Revolution. Historians estimate that between 25,000 and 75,000 members528of the Continental Army died during this conflict, with three deaths529from illness for every one death from injury. Roughly 1,400 medical530personnel served in the Continental Army, but only 10 percent had any531formal medical training. Since then, we have been on a journey to532continue improving the care we provide to America's sons and daughters533who serve their nation in uniform and this has resulted in a steady and534continuous decline in the percent of injured servicemembers who died of535their wounds. Numerous innovations in both pre-deployment care and the536care we provide to deployed personnel have enabled military medics to537successfully treat and return to duty more and more ill servicemembers,538enhancing combat capabilities. And for those who sustained injuries in539Operational Iraqi Freedom/Operation Enduring Freedom, fewer died than540in any conflict in history. This is an extraordinary testimony to the541work of countless military doctors, nurses, pharmacists, Corpsmen and542other military medics. And it was shaped by congressional direction in543the annual National Defense Authorization Acts (NDAA) and annual544appropriations which translated that guidance into reality. Thank you545for all that you and your predecessors have done to enable these546remarkable results.547    As proud as we should be of these unparalleled accomplishments,548every organization committed to excellence knows the importance of549asking ``What could we have done better?'' High performing healthcare550systems know that ``Good enough'' is not acceptable, especially when it551comes to the health of America's sons and daughters who choose to552defend our Nation. Some of our military medical colleagues reviewed the553available data on every single servicemember who died in recent554conflicts and what they found is remarkable: even with nearly total air555superiority, unfettered communications, aeromedical evacuation on556demand, and largely unhindered supply chains, roughly 25 percent of557those who died prior to 2012 had injuries which should have been558survivable. This is an incredibly important--and painful--lesson: We559could have done even better.560    Unfortunately, we have made insufficient progress toward minimizing561preventable battlefield injuries and death. In some cases, we have562mistakenly confused loyalty to the patch on our uniforms over our563commitment to our patients. We have confused efficiency with564effectiveness. We have argued for years about roles and565responsibilities and competing interpretations of congressional intent.566Thankfully, because the United States is not involved in large scale567combat operations at this time, we have the opportunity, with help from568the members of this Committee, to refocus efforts to ensure that, in569the next conflict, military members will be medically ready before they570deploy and military medics will be well-prepared to care for those571servicemembers who become ill, or who are injured.572    The first priority of the military health system must always be our573commitment to provide the right care at the right place for every574American who volunteers to serve. We must continue to demonstrate to575Servicemembers and their families that the military health system will576be ready to provide the care they need before they deploy, while in577combat, and when they return, and that we will care for their families578and for those who have retired from the military. To do so, structural,579fiscal and policy changes are needed. After studying this for most of580my career, I urge the members of this Committee to reject any581recommendations to revert to stovepipes and siloes of care. There is no582data to support the premise that any one Service delivered better care583in garrison or down range and ample evidence from multiple conflicts584that the best outcomes for patients occur when medics work together585(like the rest of the military does when it deploys). I am dismayed586that some colleagues continue to assert that some Members of Congress587appear to question the merits of integrating medical capabilities as588directed in 2017; this perception has complicated efforts to focus as a589Joint medical team on improving care to Servicemembers who rely on590military medics to be ready when needed. I strongly oppose any591recommendations for another large-scale reorganization of the military592health system; these take years to implement and will continue to593distract my colleagues from the important job of improving care by594requiring them to instead focus on building new bureaucracies. I595believe the DOD has the capabilities it needs, although, as I will596address below, not the resources, to truly achieve the vision of great597care, anywhere for our those who go in harm's way in defense of our598Nation. Attachment One, National Defense Authorization Act599Recommendations, summarizes recommended language for the Committee's600consideration. (NOTE: For any recommendations which fall outside the601purview of this Committee, I respectfully request that Committee staff602share the recommendations with the appropriate Committee, and, if603possible, convey the intent of this Committee related to the604recommendation.)605    1.  Roles and Responsibilities: In 39 years of government service,606and especially in military health system ``governance'' meetings, I607have been dismayed at the amount of time and energy dedicated to this608topic at the expense of discussing how to improve the effectiveness and609efficiency of care. I remain deeply grateful for and supportive of the610changes directed in the 2017 National Defense Authorization Act (NDAA).611Congress wisely recognized that Servicemembers' anatomy and physiology612do not vary based on the patch they wear and that we can deliver better613care if we work as an integrated system, rather a system of competing614systems. Other than a few niche environments (e.g., care in low gravity615environments, undersea medicine, etc.), the Senate should direct616standardization of equipment and training for deployable medical force617elements, as recommended by the Joint Trauma System (JTS) and also that618medical force elements must be interoperable (i.e., a Role 2 medical619force element from one Service can combine with a Role III 3 medical620force element from another Service, when directed by the Combatant621Commander in order to provide the right combination of capabilities to622care for ill and injured servicemembers). Almost every other modern623military has already done so, and, as our Israeli and German and other624colleagues have repeatedly shown, military medics deliver more625effective care more efficiently if we standardize and integrate626capabilities. The only structural changes I recommend are:627628       a.  Dual-hat the Joint Staff Surgeon as the Defense Health629Agency Deputy Director for Combat Support and align key operational630support capabilities under this two-star leader, as described below and631in Attachment 1.632633       b.  Require the Combatant Commands to implement the Combatant634Command Trauma System staffing requirements to ensure readiness to635collect, analyze and share data on ill and injured in their Area of636Operations in order to continue to improve the care our Nation's637defenders receive.638639       c.  Require the Defense Health Agency (DHA) to reinState Defense640Health Agency Procedural Instruction 6040.06, Combatant Command Trauma641Systems.642643    2.  Evolving Threats: Care for ill and injured is challenging and644there are clearly opportunities to improve that care. And the range of645threats to which military medics must be prepared to respond is646growing.647648       a.  Disease, Non-Battle Injury (DNBI): Military service is a649challenging calling, and many medical conditions impact the ability of650an individual to perform his or her duties. The military asks those651seeking to enlist or to become officers to voluntarily identify pre-652existing medical conditions and, based on that information, determines653whether the member is likely to be medically qualified to perform their654assigned duties. The introduction of electronic health records has made655it easier to validate the information provided by those seeking to656serve in the military and, in some cases, has identified medical657conditions which the applicant did not voluntarily report. Some have658claimed that this additional visibility into pre-existing medical659conditions is contributing to lower enlistment rates, although there660has been limited data to support this assertion. These pre-existing,661chronic medical conditions may degrade the member's readiness and662frequently increase the military health system costs once the member is663on active duty. Clarifying the impact of identifying pre-existing664medical conditions on both recruiting and on military health system665costs can help inform decisions about whether to continue to seek this666information. Furthermore, roughly 80 percent of deployed service667members who require medical care have medical conditions unrelated to668traumatic injuries. The most common medical conditions which cause a669servicemember to no longer be ``medically ready'' include dental,670musculoskeletal and mental health conditions. Across the Services, more671than 7 percent of the force is not medically ready prior to deployment,672immediately decreasing the effectiveness of combat units. To preserve673the fighting force, military medics must be able to rapidly diagnose674these conditions and safely and effectively treat them as close to the675front lines as possible. This committee should:676677             i. Require an annual report on actions taken to reduce the678number of uniformed personnel who are not medically ready to no more679than 5 percent of the force and the actions taken to improve the680ability to care for deployed Servicemembers with DNBI as close to their681deployed location as possible in order to sustain the operational682capabilities of their unit.683684             ii.  Require the Services to provide an annual report to685Congress on the number and type of medical waivers granted to those686enlisting in the military (e.g., accession waivers), the number of687personnel who receive accession waivers and are later determined to be688medically unfit for duty, including the number and type of accession689waivers granted as a result of the use of the Military Health System690Genesis application (i.e., the military's electronic health record) and691any data on the impact of the use of GENESIS on accession rates.692693       b.  Antimicrobial Resistance (AMR): One of the risks for694servicemembers with traumatic injuries is developing wound infections,695especially in austere environments. Bacteria or fungi which are696resistant to multiple antibiotics are growing domestically and globally697and this has become an increasing challenge for military casualties in698Europe, Asia and Africa. This Committee should require an annual report699on steps taken by the Miliary health system to detect and to mitigate700AMR in military personnel and should review the proposed Pasteur Act701language to enhance support to develop new antimicrobials to protect702our Servicemembers.703704       c.  Emerging Weapons: Mankind has continued to seek new military705capabilities which will afford an asymmetric advantage over competitors706and potential adversaries. Recently develop new technologies like707hypersonic missiles and directed energy weapons do not appear to create708revolutionary changes in risk, but, overtime, may cause new patterns of709injury which military medical personnel must be prepared to treat.710Waiting until new patterns of injury are seen to begin planning for711appropriate care should be unacceptable. This Committee should:712713             i. Direct the Intelligence Community to prepare an annual714report on new and updated weapons which create risk to servicemembers;715716             ii. Direct DOD to ensure that the Joint Staff Surgeon and717select members of the Joint Trauma System and Service Surgeons' staffs718have sufficient clearances to receive these updates;719720             iii. Direct the Joint Staff Surgeon, in coordination with721the Services, the Joint Trauma Analysis and Prevention of Injury in722Combat program and the JTS, to provide Congress with a classified723annual assessment of changes needed to training and other military724medical capabilities to ensure military medical personnel are ready to725care for casualties from these new or upgraded weapons systems,726including actions taken by the Services to address findings from prior727years' assessments728729       d.  Burden Shifting: In 2020, the National Academies of Science,730Engineering and Medicine published an analysis which highlighted the731lack of resilience and surge capacity in the US healthcare system. The732recent pandemic unfortunately validated that lack of resilience and, as733part of the mitigation efforts to protect the American public, as many734as 70,000 military medics deployed to augment the US healthcare system735through Defense Support to Civil Authorities (DSCA) taskings. The736National Disaster Medical System, which was designed to integrate DOD,737VA and civilian healthcare systems in case of a surge in military or738civilian patients has been allowed to atrophy. The Regional Emerging739Special Pathogen Treatment Centers, which are funded to care for740patients exposed to, or infected with highly contagious infectious741diseases (e.g., Ebola), have very limited bed capacity; and the ability742to move these patients depended on capabilities in other agencies which743apparently have been eliminated. In addition, only the DOD had the744contracting authorities needed to enable Operation Warp Speed to745achieve so much so quickly. And recent actions that reduce capabilities746in other Federal Departments, including the ability to respond to747disasters at home and abroad are typically mitigated by shifting those748responsibilities to the Department of Defense. Because of this, the749Military Health System is likely to see more taskings in the future to750compensate for these reduced capabilities in other parts of the Federal751Government. I recommend this Committee should:752753             i. Require an annual assessment by the Departments of754Defense, Health and Human Services and the Veterans Health755Administration of the resilience of the US healthcare system and the756readiness of the National Disaster Medical System to support DOD757operational requirements during Large Scale Combat Operations,758including the readiness to transport, receive and care for military759personnel, US government employees and US civilians who are exposed to760or infected with highly contagious infectious diseases.761762             ii. Require ASD(HA) to provide an annual summary of all763healthcare support provided to other Departments and Agencies which was764not funded in the DOD budget, as well as any reimbursements received765for that support.766767             iii. Authorize ASPR to execute the same contracting768authorities that DOD utilized during Operation Warp Speed.769770             iv. Sustain ASPR and CDC programs which help State and771local health authorities continue to improve the readiness of their772jurisdictions and make that support contingent on a commitment to773participate in NDMS and, for those hospitals with the appropriate774capabilities, RESPECT.775776       e.  Biological weapons and other threats: The confluence of777artificial intelligence, increasing computational capacity and rapidly778evolving biotechnological advances offers incredible potential for new779treatments. And there will always be people who will seek to misuse780these new technologies for nefarious purposes; these rapid advances781significantly lower the bar for State and non-State actors to use good782technologies in ways that increase the risk to the American public and783to military members in future conflicts. The best deterrent to ensure784these weapons are never used is to demonstrate that we will rapidly785detect their use, attribute it appropriately, and hold those786responsible accountable, while demonstrating the ability of our health787system to rapidly mitigate the impact of acute biological threats. The788foundational research creating these advances was largely based on789research funded by the Federal Government through the National Science790Foundation, National Institutes of Health, and the Department of791Defense. It is critical that the military health system, in792collaboration with the Departments of Health and Human Services,793Energy, Homeland Security and the Veterans Health Administration794continue to invest in research to rapidly develop better tests,795treatments and vaccines for new and emerging biological threats, as796well as in enhanced domestic and global biosurveillance capabilities.797As noted above, the Centers for Disease Control and Prevention and the798Administration for Preparedness and Response should continue to help799fund State and local preparedness efforts to increase resilience to800future biological threats. The Department of State should reinState801funding for programs which enhance biopreparedness capabilities in802other countries to improve our ability to detect if a bioweapon or803other biological threat is occurring outside the US and to assist in804mitigating the impact of those threats. The 2018 National Biodefense805Strategy, which was updated in 2022, and the 2023 Biodefense Posture806Review outline multiple actions needed to enhance our ability to deter807nations and non-nation states from pursuing or considering employing808bioweapons. The Bipartisan Commission on Biodefense in 2024 released809its updated National Blueprint for Biodefense. The 2020 NDAA also810wisely tasked the Defense Science Board to ``carry out a study on the811emerging biotechnologies pertinent to national security,'' and that812report should be released this year. Similarly, the report from the813National Security Commission on Emerging Biotechnologies (NSCEB) is814scheduled for release next month and both these new reports will815provide valuable advice to DOD and to Congress to inform how we best816leverage these technologies to enhance our national, economic and817health security. Unfortunately, it appears that at least some of the818progress made during the past 8 years is being undone by sweeping819reductions in resourcing for scientific research, surveillance, medical820countermeasures and Federal, State and local all hazards response821programs. This Committee should:822823             i. Direct DOD to provide Congress with a classified and824unclassified update on implementation of the 2023 Biodefense Posture825Review (BPR) within 6 months, including any remaining gaps in826capabilities and mitigation plans to address those gaps.827828             ii. Direct DOD to publish an update BPR which addresses829all recommendations relevant to DOD from the 2024 National Blueprint830for Biodefense and the 2025 NSCEB and DSB reports by the end of Fiscal831Year 2025.832833             iii. Direct the DOD to ensure that all DOD hospitals and834operational labs, including those located overseas, provide the Centers835for Disease Control and Prevention the same data that is submitted by836other public health jurisdictions to enhance global and domestic837biosurveillance.838839    3.  Manpower Constraints: Enhancing the readiness of the military840health system to care for ill and injured servicemembers relies, in841part, on having the right number and type of military medics. The842Health Resources and Services Administration (HRSA), in November, 2024,843updated the Health Workforce Projections for multiple career fields.844For nursing, they estimate that the current shortages in nursing cannot845be significantly mitigated until 2037, at the earliest and noted a846``significant geographic maldistribution'' of nurses. This appears to847be largely in rural areas where many military bases are located. For848physicians, the projections are even more dire, with 31 out of 35849physician specialties projected to have insufficient supply by 2037 and850an aggregate shortfall of 187,130 physicians across the US. Efficiency851advocates have asserted that the military health system can eliminate852military medical positions and either hire civilian replacements or853shift the care to the private sector. In reality, the military health854system is able to sustain the current level of care because it trains855many of its medical personnel internally. Given the congressionally856directed restrictions on increasing civilian physician training857programs, closing military training programs will exacerbate both858military and civilian medical workforces shortages and further degrade859readiness due to even greater shortages of uniformed medical personnel.860Efficiency advocates have also attempted to eliminate or substantially861reduce military medical billets for specialty codes which are not862required in Operational or Contingency plans; this seemingly logical863action ignores the reality that mission critical training programs for864critical care nurses, trauma surgeons and other specialties needed in865wartime cannot maintain their accreditation to continue training unless866they are in a hospital with pediatric, obstetrical and other ``non-867mission critical'' departments. And all these workforce challenges are868reportedly being exacerbated by decreasing retention of key medical869officer and enlisted specialists due a perception that they cannot870sustain their medical skills in the current system due to the low871volume of ill or injured patients in most military hospitals. I872recommend that this committee should:873874       a.  Ensure that any proposed reductions in military medical875training pipelines are only implemented if Congress authorizes and876appropriates funding for additional civilian training capacity to877support military requirements.878879       b.  Require the Services to provide updates to ASD(HA) and the880Joint Staff Surgeon on recruiting and retention of officer and enlisted881medical personnel by specialty code or equivalent designator and an882analysis of reasons for separation by specialty code.883884       c.  Direct the ASD(HA) and the Veterans Administration885Undersecretary for Health to provide an assessment within 1 year of886opportunities to increase physician, nurse and other medical training887pipelines by integrating and expanding training programs.888889       d.  Direct the ASD(HA) to develop a plan and cost estimate to890increase the number of officer and enlisted students trained at the891Uniformed Services University to address shortfalls in current training892pipelines and to assist the Services in improving recruiting and893retention of military medical personnel required to meet operational894requirements.895896       e.  Require the Services to account for authorizations required897for military medical training as operational requirements, including898those for specialties which are required to maintain accreditation of899training programs for surgical, critical care, and other operational900capabilities.901902    4.  Logistical Constraints: The military health system (MHS)903prepares and sustains the warfighter, while the defense logistics904enterprise (DLE) prepares and sustains the equipment and supplies used905by the warfighter. The two are inextricably linked. Almost all resupply906of medical units depends on non-medical logistical capabilities and907capacity. Almost all deploying medical personnel travel on non-medical908commercial or military logistical platforms. And almost all movement of909ill and injured servicemembers who cannot return to the fight is910conducted on non-medical logistical platforms. The Joint Staff911Logistics Director (J4) routinely performs a ``Logistic Feasibility912Assessment'' of Operational and Contingency Plans to determine if the913proposed military operation can be logistically supported. No similar914analysis has routinely been performed for medical support. In addition,915as part of previous efficiency efforts, the military health system916converted from a system which planned for combat to one which917prioritized the efficiencies garnered from ``just in time resupply.''918The United States has the highest number of medications in short supply919ever recorded; an analysis in 2024 by the Office of Pandemic920Preparedness and Response Policy found that these shortages were not921consistently found in other key partners (e.g., European countries,922Japan, Korea or India), suggesting that policy actions similar to those923taken by other countries could mitigate some of these shortfalls. In924addition to shortages of finished pharmaceuticals, assessments by the925Joint Staff have found that deployable assemblages which are expected926to be resupplied during large scale combat operations contain927medications and/or equipment from potential adversaries, or from a sole928source which may not continue provide these items during a conflict.929And recent analyses of generic pharmaceuticals have demonstrated930variability in the efficacy of some medications. I recommend that this931Committee should:932933       a.  Direct the CJCS to include a Medical Feasibility Assessment934whenever a Logistics Feasibility Assessment is conducted or updated and935ensure the two are deconflicted as part of regular updates to936Operational and Contingency Plans and ensure the ASD(HA) and Services937review the results to identify gaps which can be mitigated through938changes to policy or Defense Health Program or Service Operations and939Maintenance funding.940941       b.  Require the CJCS to provide an annual report on DOD942operational medical supply chain vulnerabilities and actions taken or943needed to reduce these vulnerabilities.944945       c.  Direct the DOD to provide a report to Congress within 1 year946on options to mitigate gaps in patient movement capabilities and947capacity in the Continental United States during execution of the948Integrated Continental United States Medical Operations Plan, including949leveraging Civilian Reserve Air Fleet assets to execute this mission.950951       d.  Codify that all future United States Transportation Command952Mobility Capability Requirements Studies include medical transportation953requirements for personnel, equipment and patient movement, as954validated by the Joint Staff Surgeon.955956    5.  Partnerships: In the operating room, I was part of a team which957included nurses and anesthesiologists and other key contributors who958cared for the patient who trusted us to cure his or her cancer, or to959repair the damage from a traumatic injury. As a flight surgeon on960aeromedical evacuation missions, I was part of a team which included961medics and pilots and other key personnel who worked together to safely962move an ill or injured Servicemember to the care they needed. As a963medical leader in our Joint Force, I was part of teams which met964Combatant Command requirements by leveraging the best of each Service,965and by partnering with key industry and academic and international966stakeholders to ensure the next ill or injured servicemember was cared967for by a military medic who had the appropriate training and equipment968and supplies to provide the right care at the right place and time. The969American College of Surgeons has been an especially valuable partner970for many years, helping to improve care in both the military and971civilian healthcare systems by sharing information and research through972the Military Health System Strategic Partnership with the American973College of Surgeons (MHSSPACS), enabled by the Mission Zero Act. The974University of Nebraska and the University of Colorado are two examples975of the strong academic partners which have helped military medicine976continue to innovate and improve how we train, equip and sustain the977skills of military medics. In addition, because so many military bases978are located in rural areas, DOD relies heavily on community partners to979provide care for Servicemembers and other DOD beneficiaries. Finally,980our plans to provide necessary medical care in future conflicts and981contingencies are currently built on the assumption that we will be982joined by allies and partners, as we have been in every major conflict983for more than a century. I recommend this Committee:984985       a.  Require the DOD to include medical industrial base partners986identified by the Services and DHA in future Defense Industrial Base987planning efforts and Joint and Service exercises involving other988industry partners.989990       b.  Require ASD(HA) to provide an annual report on access to991care in rural communities impacted by changes in funding for Medicaid,992Medicare or other Federal health programs.993994       c.  Direct the DOD to provide a classified report to Congress on995any assumptions regarding access to or reliance on allies and partner996nations for medical care for US military personnel during future large997scale combat operations and the impact on patient care if the United998States changes its relationship with these nations.9991000       d.  Reauthorize funding for the Mission Zero Act for military1001civilian partnerships.10021003    6.  Research and Innovation: The United States has led the world in1004investments in research which have enabled the United States to be the1005leader in multiple industries which support military medical care.1006Academic research centers which have long provided some of the most1007innovative breakthroughs in medicine are facing significant challenges1008due to the announced implementation of a standardized 15 percent1009Indirect Cost Rate for research funded by the National Institutes of1010Health, regardless of the complexity of the research performed, as well1011as the planned 60 percent reduction in funding for the National Science1012Foundation, and reductions in research funding from the Veterans1013Administration and the United Stated Department of Agriculture and the1014Department of Defense, compounded by the proposed tenfold increase in1015taxes on university endowments which might have helped mitigate the1016impact of some of these changes. Within the military health system,1017research funding has been divided between the congressionally Directed1018Research Program (CDRP), which funds research on topics identified by1019Members of Congress, and the remaining research budget, which should1020address gaps in knowledge and capabilities impacting care for ill and1021injured Servicemembers. I recommend that this Committee:10221023       a.  Require the DOD to provide a report to Congress within 601024days of the impact of actual and proposed reductions in Federal1025research funding on national security and on the ability to continue to1026pursue innovations and treatments for ill and injured Servicemembers.10271028       b.  Direct CJCS to prepare an annual prioritized list of1029military medical knowledge gaps requiring research, based on Combatant1030Command and Service inputs, which will be provided to the ASD(HA) to1031inform research funded by the Defense Health Program.10321033       c.  Require the Director of the Defense Health Agency to provide1034an annual report to Congress showing how research oversight by the DHA1035addresses the operational gaps identified by CJCS, as well as a summary1036of any patents awarded and peer-reviewed publications in the past year1037as a result of military health system-funded research.10381039       d.  Share the CJCS-identified priority gaps in knowledge1040impacting care for ill and injured Servicemembers with Members of1041Congress to help inform decisions about new CDRP projects.10421043    7.  Fiscal Realities: The United States Federal budget dramatically1044exceeds revenues and is unsustainable. The United States healthcare1045system is the most expensive system in the world on a per capita basis1046and delivers some of the worst outcomes of any high income country.1047With the current workforce, the annual US healthcare inflation rate has1048averaged 5.11 percent. The Military Health System is a subset of the US1049healthcare system; 70 percent of care for DOD beneficiaries is now1050purchased in the private sector, but the MHS has seen effectively1051almost no growth in funding for medical care over the past 10 years. In1052addition, numerous new benefits have been authorized without additional1053funding. Because our current Tricare contracts are ``must-pay'' bills1054for the Department, the only way to cover these rising costs is to1055divert resources from the direct care system and from accounts which1056should be funding operational medical requirements. Assertions that1057care can continue to be diverted to the private sector without1058impacting readiness or access have not been supported by data and the1059growing shortages of medical personnel nationally and the rapidly1060rising cost of commercial care appear to make this unsustainable course1061to enhance military medical readiness. Until this is addressed, we will1062continue to see declining operational medical capabilities and rising1063costs as more and more care is shifted to the private sector. Civilian1064healthcare is expensive; military healthcare, because of its unique1065additional requirements, is even more expensive. Like other military1066capabilities, there are no direct analogues in the civilian or1067commercial sector for all the capabilities needed by the military1068health system to be able to care for ill and injured servicemembers1069during a conflict. All of the Federal healthcare delivery systems (DOD,1070Veterans Health Administration, Indian Health Services, etc.) face some1071of the same challenges and all have very large, unfunded infrastructure1072requirements to sustain their ability to deliver care (e.g., DOD1073estimates an additional $10 billion is needed to update or replace1074existing medical infrastructure). In many communities with aging1075Federal medical infrastructure, there is an opportunity to develop1076Joint Venture partnerships similar to the ones at Joint Base Elmendorf-1077Richardson, or Travis Air Force Base. In addition, creative financing1078mechanisms, like the Communities Helping Invest through Property and1079Improvements Needed for Veterans ACT (CHIP-IN Act), which pools1080Federal, State, local and philanthropic resources to fund1081infrastructure requirements, should be reauthorized and expanded to1082include the DOD. Finally, as authorized by Congress in the 2017 NDAA,1083the DHA must ensure accurate tracking and billing for services provided1084to non-DOD beneficiaries both within the direct care system and when1085military medical personnel are working in partner facilities. The1086mistaken belief that the military or other Federal health systems can1087be funded at lower rates than the civilian sector while achieving1088similar or better outcomes and be ready for future conflicts is a1089remarkably optimistic triumph of hope over reality. To begin to address1090this foundational problem, this Committee should:10911092       a.  Require that any implementation of new benefits which are1093authorized in an NDAA cannot occur until there is an assessment by CJCS1094of operational impacts, an independent government cost assessment of1095the cost of mitigating the operational impacts and of the cost1096implementing the benefit in both the direct and private care system,1097and sufficient additional funding is appropriated in the Defense Health1098Program to cover these costs.10991100       b.  Direct that any proposed reductions in services at a1101military treatment facility can only proceed with an endorsement from1102the CJCS that there is no impact on operational requirements, and an1103endorsement from the Services that there is no impact on medical1104officer and enlisted training pipelines, and an independent attestation1105that there is sufficient excess capacity to absorb the workload to be1106shifted to the community , as well as congressional notification at1107least 180 days prior to implementation.11081109       c.  Direct the ASD(HA) to implement the necessary information1110technology tools and to promulgate policy on accounting for work done1111by uniformed medical personnel in civilian or Veterans Health1112Administration facilities.11131114       d.  Reauthorize the CHIP-IN Act and amend it to include DOD1115requirements.11161117       e.  Mandate that the DOD and VA provide a report to Congress in11186 months on how to consolidate inpatient care in communities where one1119or both Departments are requesting funding for infrastructure1120investments which exceed $100 million annually.11211122    8.  Uniformed Military Medical Leadership: Congress wisely1123recognized that successful implementation of the reforms mandated by1124the 1986 Goldwater-Nichols Act required a new type of leader who1125understood the value of Jointness and who had personal experience in1126that environment. For a variety of reasons, military medical leaders1127have been exempted from this requirement, making them the outliers in1128the Department of Defense, with limited understanding of the1129opportunities and challenges implicit in the Joint Force. I recommend1130that this Committee should:11311132       a.  Remove the Goldwater-Nichols Act exception for military1133medical General and Flag Officers;11341135       b.  Require that any future Directors of the Defense Health1136Agency must have previously served as either the Joint Staff Surgeon,1137or as a Combatant Command Surgeon and must have commanded a hospital1138which supported Graduate Medical Education programs.11391140                              ATTACHMENT 11141         suggested national defense authorization act language1142    Clarify that the military health system is a part of the military1143and, to the greatest extent possible, should use the same processes,1144procedures and measures used by the rest of the military, including:1145    A. Civilian oversight of the MHS: As in the rest of the military,1146the MHS is led by civilian leadership nominated by the President and1147confirmed by the Senate, acting under the authority which the Congress1148and the President have invested in the Secretary of Defense. The1149Assistant Secretary of Defense for Health Affairs (ASD(HA):11501151      1.  Serves as the principal medical advisor to the Secretary of1152Defense11531154      2.  Leads and provides oversight of the MHS and the Defense1155Health Program (DHP), including developing and executing an MHS1156Strategic Plan which will:11571158        a.  Require endorsement by the Chairman of the Joint Chiefs of1159Staff (CJCS) and the Secretary of Defense prior to transmittal to1160appropriate congressional Committees annually11611162        b.  Include measurable goals and objectives by quarter and1163fiscal year, including:11641165             i. Readiness metrics approved and monitored by the1166Assistant Secretary of Defense for Readiness, in coordination with the1167CJCS, through the process used by the rest of the military to assess1168readiness of deployable and in-garrison capabilities, including11691170             ii. All patient movement and Role 2 and above medical1171force elements11721173             iii. Any required equipment or other assemblages11741175             iv. Surveillance for and response to bioweapons11761177             v. The percent of servicemembers by unit who are not1178medically ready.11791180             vi. Quality metrics for assessing the effectiveness of1181care provided to DOD beneficiaries both in the direct care and the1182purchased care system, including access to care.11831184             vii. Quality metrics developed by the Joint Trauma System,1185in coordination with the Joint Staff, Combatant Commands and Services,1186to assess the effectiveness of care provided in deployed locations and1187in the patient movement system11881189             viii. Fiscal metrics assessing the efficiency of the1190direct care and purchased system against established targets, including1191targets for beneficiary enrollment and leakage to the purchased care1192system for each Military Treatment Facility11931194             ix. Patient satisfaction metrics for both the direct care1195and purchased care systems11961197             x. Availability of uniformed medical personnel for1198healthcare delivery, by location of assignment, when not deployed11991200             xi. Metrics should be trended over time and, where1201available, should be compared to US national benchmarks12021203        c.  Service input to this plan is necessary, but Service1204concurrence is not required; the plan should clearly identify any goal1205or objective with which one or more Services does not concur.12061207      3.  Establishes necessary policies to ensure the MHS provides1208high quality care for all DOD beneficiaries; Joint Staff and Service1209input to MHS policies is necessary; critical non-concurrence with a1210proposed policy will be adjudicated as follows:12111212        a.  Policies affecting medical operational capabilities:1213Services, Combatant Commands, with support from the Director of the1214Joint Staff, will bring areas of disagreement to the Tank and then make1215recommendations to the Secretary of Defense12161217        b.  All other policies will be adjudicated through governance1218structures overseen by ASD(HA) or the Undersecretary of Defense for1219Personnel and Readiness.12201221      4.  Ensures that research funded by the Defense Health Program1222addresses the CJCS-identified gaps in knowledge impacting care for ill1223and injured Servicemembers.12241225      5.  Serves as the immediate supervisor of the Director of the1226Defense Health Agency (DHA).12271228      6.  Is the final approval authority for all fiscal decisions1229related to the Defense Health Program (DHP) and communicates to1230Department of Defense leadership and to Congress the fiscal1231requirements for providing optimal in-garrison and purchased care, any1232gaps between requirements and resources and plans to mitigate those1233gaps.12341235      7.  Provides the Services with a template for reporting quarterly1236on the location, availability for MTF utilization, and other1237responsibilities of all uniformed and civilian personnel funded or1238aligned in any way with each Service or sub-component.12391240    B.  Chairman of the Joint Chiefs of Staff Oversight of Military1241Medical Operational Support12421243      1.  Operational and Contingency Plans. As defined by the1244President and the Secretary Defense in the Unified Command Plan, CJCS1245will ensure these plans clearly define:12461247        a.  Operational and training requirements for Role 2, 3, 4 and12485 deployed medical force elements and equipment with the goal of1249preserving the fighting force in order to win future conflicts by1250optimizing return to duty as quickly and safely as possible.12511252        b.  Operational requirements and resourcing for blood products1253(e.g., whole blood, freeze dried plasma, etc.) as close to the point of1254injury as possible using planning factors developed by the Joint Staff1255Surgeon, in coordination with the Combatant Command, Services and with1256concurrence from the ASD(HA).12571258        c.  Patient movement requirements for ill and injured1259servicemembers and other combatants who cannot be returned to duty,1260including those exposed to or infected with highly contagious1261infectious diseases.12621263        d.  Explicit acknowledgement of any reliance on allies or1264partners to provide medical care and attestation from Combatant Command1265that the Ally or partner has affirmed they have the necessary1266capabilities and capacity to provide this care to US personnel.12671268        e.  Ensure that the Integrated Continental United States1269Medical Operations Plan (ICMOP) includes12701271             i. Requirements for acute and rehabilitative care for ill1272and injured returning to the US12731274             ii. Requirements for patient movement from Aerial Ports of1275Embarkation and Debarkation to appropriate levels of care.12761277             iii. Planning factors from the Department of Health and1278Human Services and the Veterans Health Administration for available1279beds once the National Disaster Medical System is activated12801281             iv. Planning factors from the Tricare Purchased Care1282contractors for available beds within the purchased care system.12831284             v. Supplemental funding estimates for sustaining care for1285in-garrison DOD beneficiaries and any beneficiaries reliant on DOD1286medical personnel who are tasked to deploy during a contingency12871288             vi. Plans to expand blood collection, processing and1289delivery to DOD to meet operational requirements.12901291      2.  CJCS oversight of medical readiness. In coordination with the1292ASD(R), the Joint staff will monitor, report and address readiness of1293all required medical capabilities listed above, using the same1294processes used for the rest of the military.12951296      3.  CJCS oversight of Combat Support agencies: As with other1297Combat Support Agencies, CJCS will conduct a Combat Support Agency1298Review to assess the readiness and effectiveness of actions taken by1299the Defense Health Agency (DHA) to support Combatant Command (CCMD) and1300Service operational requirements and will provide an annual report to1301Congress summarizing progress and shortfalls in DHA's performance.13021303      4.  CJCS will provide ASD(HA) with a prioritized list of1304knowledge gaps impacting care for ill and injured Servicemembers1305derived from input from the Combatant Commanders and Services.13061307    C.  The Service Secretaries (Army, Navy and Air Force) will:13081309      1.  Organize, train and equip medical force elements to meet1310operational requirements defined by the Combatant Commanders through1311established CJCS and OSD processes.13121313      2.  Organize, train and equip medical force elements to perform1314Joint Trauma System-required activities during contingencies and ensure1315data collection on all ill and injured personnel in accordance with1316JTS-defined requirements.13171318      3.  Standardize all equipment in deployable assemblages across1319Services in accordance with JTS recommendations; exceptions to this1320requirement will require approval by the CJCS and Deputy Secretary of1321Defense, as well as notification to the Senate and House Armed Services1322Committees within 30 days of the exception being granted and before any1323acquisitions for Service-specific equipment is executed.13241325      4.  Implement JTS-identified standardized training for deployable1326force elements (e.g., Role Two ground medical force elements, patient1327movement force elements, etc.)13281329      5.  Report the readiness of all deployable patient movement and1330Role II and above medical force elements and equipment through1331processes established by ASD(R) and the Joint Staff.13321333      6.  Fund operational medical requirements outside the scope of1334the DHP and inform ASD(HA) of any unfunded operational medical1335requirements and planned mitigation measures no later then the1336beginning of the third quarter of each Fiscal Year.13371338      7.  Fund Service-specific research to enhance operational medical1339readiness and inform ASD(HA) of any unfunded operational medical1340requirements and planned mitigation measures no later then the1341beginning of the third quarter of each Fiscal Year.13421343      8.  Provide DHA with quarterly updates on all uniformed and1344civilian personnel as described above.13451346      9.  Ensure that Nominees to serve as the Director of the DHA must1347have served as either the Joint Staff Surgeon, or as a Combatant1348Command Surgeon and have commanded an MTF with inpatient capabilities1349and graduate medical education programs.13501351    D.  Defense Health Agency as a Combat Support Agency:13521353      1.  The Joint Staff Surgeon will be dual-hatted as the DHA Deputy1354Director for Combat Support and will:13551356        a.  Provide direct oversight of the Joint Trauma System1357Director, in order to ensure the JTS:13581359           i. Incorporates best practices and Clinical Practice1360Guidelines into the MHS Genesis and medical education programs for both1361officers and enlisted military medical personnel13621363           ii. Provides requirements to the Services for data1364collection as far forward as possible, with reporting to Combatant1365Command Joint Trauma System offices.13661367           iii. Identifies standardized, interoperable equipment for1368Service-provided deployable medical force elements which support CCMD1369operational requirements.13701371           iv. Identifies and provides to the Services standardized,1372training for Service-provided deployable medical force elements which1373support CCMD operational requirements.13741375        b.  Provide direct oversight of the Director of the Armed1376Services Blood Program, in order to ensure the ASBP:13771378           i. Develops planning factors for operational blood component1379utilization13801381           ii. In coordination with USNORTHCOM, the Department of1382Health and Human Services and other stakeholders, plans to expand US1383blood collection, processing and distribution as needed to meet1384validated operational requirements.13851386        c.  Provide direct oversight of the Director of the Armed1387Forces Medical Examiner System (AFMES), in order to ensure the AFMES:13881389           i. Reviews, in coordination with the Joint Trauma System,1390any deaths of uniformed or civilian military personnel while training,1391in-garrison or during contingency operations, including those for which1392a civilian medical examiner performs the forensic pathology exam13931394           ii .Prepares annual reports identifying opportunities to1395reduce risks to servicemembers.13961397           iii. Sustains accreditation by the National Association of1398Medical Examiners13991400        d.  Provide requirements to update MHS Genesis and other MHS1401systems to optimize data collection, analysis and reporting in order to1402improve outcomes for ill and injured servicemembers.14031404        e.  Provide oversight of public health activities aligned under1405the DHA as required by 10 U.S.C. Sec.  1073c, as amended.14061407           i. Ensure all DOD hospitals and overseas labs are1408transmitting the same standardized surveillance data to the Centers for1409Disease Control and Prevention as do other Public Health Jurisdictions.14101411           ii. Partner with Services to ensure waste water surveillance1412is implemented at DOD installations.14131414           iii. Implement biosurveillance programs to detect and1415mitigate the risk of naturally occurring and deliberate biological1416threats.14171418      2.  The Defense Health Agency will reinState Defense Health1419Agency Procedural Instruction 6040.06, Combatant Command Trauma1420Systems.14211422      3.  Defense Health Agency and Health Care Benefit Delivery-all1423other functions of the DHA related to healthcare benefit delivery will1424be executed in a manner which:14251426           i. Enhances readiness of the military health system to care1427for the ill and injured in future conflicts;14281429           ii. Optimizes access to healthcare for DOD beneficiaries in1430the direct care system and, when necessary, in the purchased care1431system, with the objective of caring for those DOD beneficiaries with1432the greatest medical needs (i.e., the ``highest acuity'') in the direct1433care system, whenever possible;14341435           iii. Optimizes health-related outcomes for DOD beneficiaries1436as effectively and efficiently as possible.14371438    E.  Clarify the intent of Congress related to funding for the1439Military Health System including:14401441      1.  Requiring that any new healthcare benefits are only enacted1442following:14431444        a.  Assessment endorsed by the CJCS of any impact on1445operational readiness of the proposed new benefit.14461447        b.  Completion of an Independent Cost Estimate endorsed by the1448Managed Care Support contractors and the ASD(HA) which mitigates any1449operational impacts and validates the cost of implementing the benefit14501451        c.  Appropriation of sufficient funding for the proposed new1452benefit14531454      2.  Requiring notification to Congress of resource shortfalls1455which preclude delivering care in the direct care system which enhances1456the readiness of the military health system to care for ill and injured1457during future conflicts, or the care to which DOD beneficiaries are1458entitled.14591460    Chairman Wicker. Thank you, Dr. Friedrichs.1461    Colonel Cannon.14621463  STATEMENT OF COLONEL (DR.) JEREMY W. CANNON, USAFR (RET.),1464 PROFESSOR OF SURGERY, PERELMAN SCHOOL OF MEDICINE, UNIVERSITY1465                        OF PENNSYLVANIA14661467    Dr. Cannon. Chairman Wicker, Ranking Member Reed, and1468distinguished members of the Committee, thank you for the1469opportunity to testify. These comments are my own and do not1470reflect an official position of my employer, Penn Medicine, or1471of the Hoover Institution, where I current serve as a Veteran1472Fellow.1473    As a practicing trauma surgeon, I have cared for injured1474warfighters in both Iraq and Afghanistan. I have directed the1475DOD's only Level I trauma center, and now I lead a Penn1476Medicine Navy partnership for trauma training. I know firsthand1477what it takes to save lives on the battlefield and what happens1478when we fail to sustain medical readiness.1479    I want to start by sharing the story of the unexpected1480combat casualty survivor that I took care of in 2010. Note, I1481will use a pseudonym throughout my comments for patient1482privacy.1483    U.S. Army Sergeant Erik Ramirez was on patrol in1484Afghanistan when a sniper's bullet tore through his chest, just1485above his body armor. His injuries were truly catastrophic. But1486thanks to decades of investment and innovation in combat1487casualty care, a military trauma team pulled him up out of his1488certain death spiral by placing him on heart and lung bypass,1489on the battlefield. Days later, I had the honor of caring for1490Sergeant Ramirez in the United States, as he reunited with his1491family.1492    This unequivocal display of medical supremacy was not1493accidental. It was built on years of research, training, and1494policy reforms. But I fear that if Sergeant Ramirez suffered1495this same injury now, he would die a preventable death on the1496battlefield.1497    Today, only 10 percent of military general surgeons get the1498patient volume, acuity, and variety they need to remain combat1499ready. We are actively falling into the trap of the peacetime1500effect.1501    Meanwhile, as the MHS struggles, our enemies continue to1502grow stronger. Projections estimate a peer conflict could1503produce as many as 1,000 casualties per day, for 100 days1504straight, or more, a scale not seen since World War II. Neither1505the current MHS nor the civilian sector can absorb this impact.1506What's more, many of these patients will have survivable1507injuries, yet one in four will die at the hands of an1508unprepared system.1509    How can we meet this living threat? First, we must clearly1510articulate the root problem of our failed readiness efforts. No1511one in DOD truly owns combat casualty care. In 2017, the Joint1512Trauma System (JTS), was codified in law. This Committee must1513now strengthen the statutory language to affirm that JTS owns1514combat casualty care and to provide this precious resource with1515both top-down authority and bottom-up support.1516    Then we must push the MHS to refocus on forward-deployed1517care, the one thing that only military medicine can do. For1518this I recommend three lines of effort.1519    First, clinical training. In order to train the way we1520fight, we must establish five to six high-volume Military1521Treatment Facility Centers of excellence for both trauma and1522burn care. These centers must undergo civilian accreditation1523and fully integrate into a national trauma and emergency1524preparedness system.1525    We also need to strengthen and expand our military-civilian1526partnership sites where military trauma teams manage critically1527injured patients on a daily basis, like my partnership program1528at the University of Pennsylvania. To do so, Congress must1529reauthorize the Pandemic and All-Hazards Preparedness Act and1530fully appropriate the Mission Zero Act.1531    Second, combat casualty research. To succeed on complex1532future battlefields, DOD medical research must refocus on pre-1533hospital care, team training, bleeding control, battlefield1534blood transfusions, regenerative medicine, and long-term1535outcomes. In order to fully understand the effects of1536battlefield treatments we must link DOD Trauma Registry data1537with VA records.1538    Finally, we need to unify military trauma system strategy.1539We must urgently develop and implement a whole-of-society1540roadmap, aligning military, VA, and civilian systems for both1541peacetime readiness and large-scale combat operations.1542    The bottom line, if we maintain the status quo and enter a1543peer conflict unprepared, we will condemn thousands of1544warfighters to preventable death. Without urgent intervention,1545the MHS will continue to slide into medical obsolescence. To1546restore the medical supremacy that saved Sergeant Ramirez, we1547must act now. Mr. Chairman, members of the Committee, our1548warfighters and our Nation deserve medical supremacy.1549    Thank you for your time, and I look forward to the1550comments.1551    [The prepared statement of Dr. Jeremy W. Cannon follows:]15521553   Prepared Statement by Colonel (Dr.) Jeremy W. Cannon, USAFR (Ret.)1554    Professor of Surgery, Perelman School of Medicine University of1555                              Pennsylvania1556    Chairman Wicker, Ranking Member Reed, and distinguished members of1557the Committee, thank you for the opportunity to testify on the urgent1558need to restore and sustain military medical readiness in the face of1559large-scale combat operations (LSCO).1560    As a practicing trauma surgeon with multiple combat deployments, I1561have seen the full gamut of combat casualty care from far forward in1562Iraq and Afghanistan to Brooke Army Medical Center where I served as1563Trauma Medical Director for the Department of Defense's (DOD) Level I1564trauma center during the height of combat operations. I now serve in a1565different capacity as Assistant Dean for Veteran Affairs for Penn1566Medicine and as an attending in the Surgical Intensive Care Unit in our1567Veterans Affairs (VA) Medical Center in Philadelphia.1568    At Penn Medicine, I am also proud to lead an embedded US Navy1569trauma team as the civilian surgeon champion. This partnership enjoys1570enthusiastic support from deeply invested Penn Medicine leaders1571including our Chief Executive Officer, Mr. Kevin Mahoney. As a1572reservist, I worked with RADM (Dr.) David J. Smith in Health Affairs1573where I first appreciated the importance of good policy to mission1574success, and now as a Veteran Fellow at the Hoover Institution, I have1575the opportunity to study the effects of military health policy over1576time. Finally, like many of you and my colleagues here today, I have1577multi-generational family ties to the military with my oldest son now1578training as a Naval Intelligence Officer.1579    I want to start by sharing a story of an unexpected combat casualty1580survivor. In 2010, US Army Sergeant Erik Ramirez* suffered a1581devastating chest injury while on patrol in Afghanistan. A sniper's1582bullet passed just above his body armor, tearing through the airways1583and vessels in his right lung. What happened next was nothing short of1584a medical miracle. After damage control surgery to arrest the bleeding,1585SGT Ramirez was placed on heart and lung bypass on the battlefield.1586With this heroic intervention, he pulled up out of a spiral of certain1587death, and a few short days later, I had the privilege of caring for1588him as he was re-united with his family in San Antonio.1589* Name changed for patient privacy1590    The survival of SGT Ramirez resulted from decades of investment in1591combat casualty care. Through the efforts of many dedicated military1592and civilian visionaries, we established a cutting-edge trauma system1593in the heart of a combat zone. Through these intensive efforts and1594close collaboration with line leaders, we achieved the best survival1595rate on any battlefield in history. In sum, we achieved medical1596overmatch and leveraged our medical supremacy into a strategic1597advantage.1598    But I fear that if SGT Ramirez suffered the same injury in combat1599today, he would not survive. Why? In short, combat casualty care1600training and skills maintenance lose out in peacetime. Since the end of1601combat operations in Iraq and Afghanistan, we have seen a systematic1602erosion of military medical readiness. Today, fewer than 10 percent of1603military general surgeons get the critical case volume and patient1604acuity they need to be combat-ready.(1)1605    What is the cost of this erosion? It can be measured in lives lost:1606one in four battlefield deaths are potentially survivable. This1607reflects what I term the medical ``peacetime effect''--a recurrent1608failure to sustain combat medical capabilities between wars. Although1609this cycle has played out for centuries, today's peacetime effect is1610driving us toward medical obsolescence precisely as our adversaries'1611power is ascendant. Should a large-scale conflict materialize, we1612anticipate casualty numbers as high as 1,000 per day for at least 1001613days--casualty loads not seen since World War II, a scale far beyond1614what our current system can handle.(3) True medical readiness could1615mean the difference between winning and losing.1616    The challenge of maintaining a ready medical force during peacetime1617represents a true ``wicked problem.'' Yet, one of the root causes of1618this erosion in our medical readiness is clear: no single entity in the1619DOD truly owns combat casualty care. COL (Dr.) Bob Mabry, a decorated1620hero of the battle of Mogadishu, warned in his testimony to the House1621Armed Services Committee nearly a decade ago, ``When everyone is1622responsible, no one is responsible.'' To this day, combat casualty care1623responsibility remains fragmented across military departments, the1624Defense Health Agency, and individual service commands. With ongoing1625diffusion of responsibility, we will fail, and our warriors will die1626needlessly.1627    top priority: establish clear ownership of combat casualty care1628    Combat casualty care represents a critical warfighting capability--1629the equivalent of a high-value weapon system, not just a cluster of1630medical tents deployed in a contingency environment. To ensure the1631optimal use of this valuable asset, the Armed Services Committee should1632establish clear ownership of combat casualty care within the DOD. To1633accomplish this objective, I strongly recommend both elevating and1634streamlining the reporting structure for the MHS. Command and control1635of the MHS should be commensurate with the importance of the mission.1636The Joint Trauma System (JTS) must have direct responsibility for and1637authority over all aspects of combat casualty care policy, training,1638and readiness. The JTS Director should report directly to the Secretary1639of Defense through the Joint Staff Surgeon. This organizational1640construct will ensure combat casualty care is fully aligned with our1641contingency operational strategy.1642    With a clear line of responsibility and authority for combat1643casualty care, we can then restore and sustain military medical1644readiness for LSCO by focusing on three key areas:16451) Clinical Training and Sustainment: Joint Military Trauma/Burn1646        Centers of Excellence, National Disaster Medical System, and1647        Civilian Trauma/Burn Partnerships1648    Combat trauma readiness requires military medical personnel to have1649routine exposure to high-acuity trauma cases, something that most1650military treatment facilities (MTFs) currently lack. To correct this,1651we must consolidate military trauma training into a select group of1652five to six joint MTFs verified and designated as trauma and burn1653centers of excellence by civilian accrediting bodies. These trauma/burn1654MTFs must fully participate in the civilian trauma system organized1655around a series of Regional Medical Operations Coordinating Centers1656(RMOCCs).1657    These trauma/burn MTFs must also align with the National Trauma and1658Emergency Preparedness System (NTEPS), a concept developed by the1659American College of Surgeons Committee on Trauma.(4) Utilizing RMOCCs1660as its basic unit of action, NTEPS provides a framework to integrate1661daily trauma care with mass casualty preparedness, ensuring that the US1662trauma system--including military, VA, and civilian resources--can1663seamlessly scale to handle mass population events including large-scale1664combat operations, acts of terrorism, natural disasters, or pandemics.1665At this critical moment, the Armed Services Committee should enact1666statutory authority and identify a lead agency to effect this essential1667alignment between these trauma/burn MTFs and NTEPS.1668    Military, VA, and select civilian patients should preferentially be1669funneled to these regional trauma/burn MTFs. Legislative authority to1670manage civilians in these centers already exists, although coding and1671billing best practices represent opportunities for continued1672improvement. By increasing the clinical volume and acuity in these five1673to six large MTFs, we will also ensure that our military Graduate1674Medical Education (GME) programs provide exceptional training aligned1675with contemporary operational needs.1676    Beyond these five to six trauma/burn MTFs, the current small1677network of military-civilian partnership programs (MCP) must be1678expanded. To meet the scale of the readiness need, existing and future1679MCP sites must be high-volume civilian trauma centers where military1680trauma teams can be embedded as part of an integrated readiness1681plan.(5) Access to burn training and opportunities to embed critical1682wartime GME training slots within these programs should also rank as1683preferred features of prospective sites.1684    Opportunities for the Committee to support MCPs include:1685      Mission Zero Act (MZA)--This initiative funded under the1686Pandemic and All Hazards Preparedness Act (PAHPA) supports military1687trauma teams embedded within high-volume civilian trauma centers,1688including our center at Penn Medicine. To continue this high-yield1689investment in clinical training, PAHPA needs immediate reauthorization1690with full MZA appropriation. Future expansion of this program should1691include DOD funding as well.1692      Military Health System Strategic Partnership with the1693American College of Surgeons (MHSSPACS)--This joint military1694partnership with an academic surgical society seeks to improve surgical1695care for both military and civilian patients by fostering1696collaboration, exchanging best practices, and advancing military1697education, research, and quality initiatives. An expanded role for1698MHSSPACS should include 1) verifying MCPs using accepted requirements1699and quality standards and 2) advising the JTS on military-civilian1700trauma system integration to optimize medical readiness for both the1701MHS and civilian healthcare. MHSSPACS-type partnerships should expand1702to other critical wartime specialties beyond surgery.17032) Research: Focus the DOD Medical Research Budget on Combat Casualty1704        Care1705    The Defense Health Program (DHP) funds a wide range of research,1706but we must refocus efforts principally on combat casualty care--from1707injury prevention to pre-hospital care and acute surgical care through1708to rehabilitation and recovery. Research should prioritize pre-hospital1709care (including prolonged field care), hemorrhage control, battlefield1710resuscitation, rehabilitation, and regenerative medicine. These1711research efforts must also consider potential peer-adversary threats1712within a multidomain (land, air, sea, space, and cyber) battlefield1713environment. I encourage you to work with your colleagues on Defense1714Appropriations to prioritize research funding in these key areas of1715direct relevance to the warfighter with applications to other domains1716of public concern including emergency medical services, law enforcement1717as medical first responders, civilian trauma, and disaster response.1718    We must also eliminate barriers to understanding long-term outcomes1719following combat injuries by linking DOD Trauma Registry (DODTR)1720records with current VA medical records at the individual patient1721level. Further opportunities for improving battlefield survivability1722and optimizing outcomes lie in fostering partnerships with trusted1723academic research institutions with the wherewithal to innovate in1724prehospital care, trauma and burn management, traumatic brain injury,1725and the psychological and ethical aspects of LSCO. Such investments1726will fill a need not addressed by the National Institutes of Health and1727other agencies that fund medical research, and they will benefit both1728warfighters as well as civilians impacted by acts of terrorism, acts of1729war, and natural disasters.17303) Policy: Develop and Implement a Unified Joint Military Trauma System1731        Strategy1732    Decades of reports from the Government Accounting Office, RAND, the1733National Academies, and past congressional hearings all point to the1734same conclusion: we lack a coherent, unified strategy for military1735medical readiness that will deliver expert trauma/burn care on future1736battlefields while also benefiting civilian trauma care and public1737health. In the words of Nadia Schadlow, a colleague at the Hoover1738Institution and the primary author of the 2017 National Defense1739Strategy, generating more reports or commissioning new studies will1740only perpetuate the ``crisis of repetition.''1741    To break this cycle, I am currently working with Uniformed Services1742University and other key stakeholders to develop a comprehensive1743military trauma system policy roadmap that considers the direct care1744component, civilian partnerships, the role of the National Guard and1745reserves, synergy with the VA, involvement with NDMS and NTEPS,1746research priorities, and training requirements. This roadmap will need1747congressional support to succeed.1748  the bottom line: we must demonstrate medical excellence from day one1749    In Iraq and Afghanistan, it took us three to 4 years to develop a1750trauma system in theater and another five to 6 years to achieve the1751medical supremacy that allowed us to save SGT Ramirez. We will not have175210 years in the next war.1753    A near-peer conflict--whether in the Pacific, Europe, or beyond--1754will generate massive casualty numbers from day one. If we enter that1755fight unprepared, we will condemn thousands of our warfighters to1756potentially preventable death. As General Peter Chiarelli painfully1757noted in his testimony for the National Academies, ``You have just got1758to pray your son or daughter or granddaughter is not the first casualty1759of the next war.''1760    Will it take another Pearl Harbor or 9/11? Or do we have the will1761to act now to re-establish and sustain our medical supremacy before the1762first shot is fired? I submit that we cannot allow history to repeat1763itself by sending the next generation of our warriors into combat1764without a fully ready medical service supported by a highly functioning1765JTS. Mr. Chairman, members of the Committee, our warfighters deserve1766military medical supremacy.1767                               references1768    1.  Dalton MK, Remick KN, Mathias M, et al. Analysis of surgical1769volume in military medical treatment facilities and clinical combat1770readiness of US military surgeons. JAMA Surg 2022;157:43-50.1771    2.  Cannon JW, Gross KR, Rasmussen TE. Combating the peacetime1772effect in military medicine. JAMA Surg 2021;156:5-6.1773    3.  Deussing EC, Post ER, Lee CJ, et al. Advancing systematic1774change in the National Disaster Medical System (NDMS): Early1775implementation of the US Department of Defense NDMS pilot program.1776Health Secur. 2024; e-pub ahead of print.1777    4.  Armstrong JH, Bulger E, Kerby JD. National Trauma and Emergency1778Preparedness System (NTEPS). Available at: https://www.facs.org/media/1779u1hpi2ce/nteps-blueprint.pdf. Accessed March 5, 2025.1780    5.  Cannon JW, Holt DB, Potter BK, et al. Partnerships to overcome1781the peacetime effect: Excelsior Surgical Society panel session. J Am1782Coll Surg 2025; e-pub ahead of print.17831784    Chairman Wicker. Thank you, Dr. Cannon, and I commend each1785of you for your excellent testimony.1786    Let me just get quick answers here from all three of you. I1787think what I am hearing from all three of you is that this is1788going to require more than simply good management of what we1789have on the books now. Each of you is recommending changes in1790the statute that need to come in this coming NDAA. Is that1791right, Dr. Robb?1792    Dr. Robb. Yes.1793    Chairman Wicker. And Dr. Friedrichs?1794    Dr. Friedrichs. Yes, sir.1795    Chairman Wicker. And Dr. Cannon?1796    Dr. Cannon. Yes, Mr. Chairman.1797    Chairman Wicker. All right. Let's talk about military1798surgeon readiness for combat care. There was a study out in17992021. It found that the population of military general surgeons1800meeting necessary readiness standards decreased from an already1801low 17 percent in 2015 to about 10 percent in 2019.1802    We will let all three of you take a brief chance at answer1803this. Why is this happening, and what specifically can DOD do1804to reverse this trend? And we will just start with Dr. Robb and1805go down the table.1806    Dr. Robb. We will try to share different perspectives here.1807I think it comes back to the system to be able to resource the1808requirements that we need. So, for example, if you want to look1809at what Dr. Cannon referred to as the five to eight, what we1810call critical Military Treatment Facilities, in order for us to1811provide a higher volume, high acuity care, they need to be1812resourced. And I think that is the challenge that we all face1813right now, is what is that strategic reserve with our Military1814Treatment Facilities, and then how you augment that with the VA1815and the Department of Defense partnerships, and then how do you1816augment that with the military----1817    Chairman Wicker. Is that what he called the centers of1818excellence?1819    Dr. Robb. So I would call them--that is one way to call1820them, but I, coming from the airlifter world--in fact, General1821Friedrichs and I would both say follow the casualty flow. And1822the casualty flow comes in from United States Indo-Pacific1823Command (INDOPACOM) to primarily we will be coming to two or1824three Military Treatment Facilities. From United States1825Southern Command (SOUTHCOM) they will be coming into the1826National Capitol region. And then from Europe, United States1827Central Command (CENTCOM) and United States African Command1828(AFRICOM), they will be coming into primarily National Capitol1829region and then with a popoff at Portsmouth.1830    Chairman Wicker. Okay. Dr. Friedrichs, is this 10 percent1831number a concern, and why do we have 10 percent of military1832surgeon readiness?1833    Dr. Friedrichs. Mr. Chairman, it absolutely is a concern.1834When I did my training in the military, I trained at the old1835Wilford Hall, that was a Level I trauma center. I took care of1836trauma patients because it was a 36 on, 12 off schedule every1837other night. Or I took care of vascular surgery patients. Or I1838took care of cardiothoracic patients. We de-scoped our1839facilities to the point that they take care of low-acuity1840community hospital patients, not trauma patients.1841    So I would reiterate the point that you have heard all1842three of us make. We need our key hospitals to be Level I1843trauma centers in partnership with the American College of1844Surgeons in the communities in which they are located.1845    But to do that we must address the elephant in the room,1846and that is resourcing. The medical inflation rate, on average,1847since 1938, is 5.1 percent per year, and the military has seen1848a net 12 percent reduction in funding. There is no way to fix1849these problems if the Military Health System is viewed as a1850bill payer and not something worth investing in.1851    The second point that I would make is we have got to1852reiterate the intent that you and the Ranking Member mentioned.1853I spent 4 years as the Joint Staff Surgeon. Almost every1854meeting in which I participated in that role focused on roles1855and responsibilities and patches, not on patients. Please,1856again, I implore you, kill this narrative that somehow there is1857a belief that we can unwind things and go back to the good old1858days. We need to go forward toward a more integrated system1859that focuses on patient care and, as you said, on readiness,1860not continuing to focus on bureaucratic buffoonery.1861    Chairman Wicker. Dr. Cannon.1862    Dr. Cannon. Mr. Chairman, it is shocking, astonishing, and1863awful, and it has to be reversed. That 10 percent number1864results from inadequate, actually grossly inadequate, patient1865numbers, volume. They are not doing the cases. They are not1866doing the procedures. They are not doing what they were trained1867to do, and that is because they do not have the patients in the1868facilities. They are, in many cases, not designated or verified1869trauma centers, so they are scrounging around, trying to get1870cases, and it has been, frankly, an uphill climb. So we have1871got to provide them the patients, the cases, the experience to1872right that 10 percent number.1873    Chairman Wicker. Thank you very much, gentlemen. Senator1874Reed, you are next.1875    Senator Reed. Thank you very much, Mr. Chairman, and1876gentlemen, thank you for your excellent testimony.1877    In the 2023 memorandum by the Deputy Secretary of Defense,1878one of the key points, I believe, is the direction to reattract1879beneficiaries to the MTFs, which would increase the patient1880flow, increase the demands on physicians, et cetera, and also1881save money, they believe.1882    Dr. Friedrichs, your response to this approach.1883    Dr. Friedrichs. I strongly support the vision that Deputy1884Secretary Hicks laid out, which is very similar to the vision1885that Deputy Secretary Norquist laid out in the previous1886administration, and almost every administration prior to that.1887Again, to do that we must have resources.1888    I will offer one other option which I think you have heard1889all three of us touch on briefly. Every single patient in the1890Veteran Health Administration started in DOD. I had the great1891privilege of commanding the DOD/VA joint venture facility in1892Anchorage, and I can tell you that when the patient walked in1893the door, they were taken care of by a joint team. It was far1894more efficient than building duplicative adjacent facilities.1895Instead, we built integrated adjacent facilities.1896    There is a $10 billion, unfunded recapitalization bill in1897the DOD, $100 billion, unfunded recapitalization bill in the1898VA. There are real opportunities to bring those higher acuity1899patients from the VA into the DOD facilities, or bring DOD1900medical personnel into the VA facilities, so that we are not1901wasting money on duplicative buildings and instead focusing our1902resources on the patients who need our care.1903    Senator Reed. Thank you. And General Robb, or Dr. Robb, or1904both, do you think the Military Health System is adequately1905focused on the combat-related medical capabilities? I have1906heard comments by all the panel suggesting that they are1907diverted into things that are not effective in a combat1908situation.1909    Dr. Robb. Well, I think, in fact, I would kind of like to1910challenge the misnomer that there is a separation between care1911beneficiaries and medical readiness. And I would argue, the way1912that we get our skills--primary care, specialty care, and just1913as important, our allied health, pharmacy, x-ray techs,1914logistics--we get that by taking care of our beneficiaries.1915    So what I think is so, so, important is that we use--not1916use, but that we care for our patient population to best1917achieve medically ready, in a ready medical force. And what I1918think is really important is that, again, we have to create a1919capability. It has to be an enterprise approach. And when we1920talked about it, again, I will go back to the point of follow1921the casualty flow, and you look at those critical hospitals1922that we believe are important, we must staff those. And we must1923staff those to the fullest extent possible.1924    You cannot reattract patient care into our MTFs unless you1925staff them, and I think that is what is key. If I cannot get an1926appointment, then I cannot get an appointment. So that is what1927is key.1928    So if you talked with Walter Reed, for example, they may1929have enough surgeons, but for various reasons the support staff1930does not exist, so they do not have the throughput that they1931need for surgical cases. The case load is there.1932    So what I think we need is an enterprise approach, and how1933do we resource, okay, the full spectrum of support for our1934critical care hospitals, and then make up the delta with our1935military VA partners and with our military-civilian1936partnerships.1937    Senator Reed. Thank you. Dr. Cannon, your comments, please.1938    Dr. Cannon. Senator, I think it is vitally important to1939have highly functioning, premier medical centers that we can be1940proud of, that our surgeons and other specialists and allied1941health members want to be a part of. Right now, many of these1942facilities are shells of what they used to be. You heard about1943Wilford Hall. That was an amazing facility that did so much1944good for so many decades.1945    The new incarnation, Brooke Army Medical Center, the San1946Antonio Military Medical Center, is also amazing, but it is1947sort of out on the vanguard by itself. We need other premier1948flagship centers. And I think we can do it. We have got the1949pieces in place, but we have got to commit to keeping the1950combat casualty at the center of our focus, and make it happen.1951    Senator Reed. Thank you. My time has just about expired,1952but a yes, no, or perhaps answer. I am concerned about the1953ability to mobilize medical professionals for an all-out fight.1954Is that a valid concern? Yes or no, please.1955    Dr. Robb. Yes.1956    Dr. Friedrichs. It is the billion-dollar concern. The1957Israelis have proved that. And we have a shell game right now1958with our Guard and Reserve and civilian facilities. We are1959going to pull them out, deploy them, and assume that civilian1960facilities, which during COVID required 70,000 military medics1961to take care of the surge in demand, instead lower their staff1962and then take care of a surge in demand. The math does not1963work, even for a Louisiana Public School grad.1964    [Laughter.]1965    Chairman Wicker. Dr. Cannon, go ahead and answer the1966question. Take the time.1967    Dr. Cannon. Yes, I agree. It is a concern.1968    Chairman Wicker. Thank you. Senator Fischer.1969    Senator Fischer. Thank you, Mr. Chairman. Thank you all for1970being here today.1971    I really appreciate the information that you are giving us,1972and also the concern you have with the direction that we are1973not headed yet. In the Fiscal Year 2020 NDAA, a pilot program1974was established to assess the National Disaster Medical System1975(NDMS) and hopefully that it would increase not just capability1976but also capacity within that. In a conflict, you know, we have1977touched on that already. We have to be able to quickly disperse1978and absorb casualties throughout the United States.1979    Dr. Friedrichs, why is it so important for the NDMS to1980maintain this surge capacity?1981    Dr. Friedrichs. Senator Fischer, first, thank you for the1982role that you and your colleagues from Nebraska played in1983championing this and highlighting this. It is important because1984the Military Health System does not have the capacity to care1985for every casualty coming back. We do not have the capacity to1986care for the people in peacetime right now. So to think that1987somehow we can do this on our own is another mistaken belief.1988    During the cold war, we recognized that if our Nation went1989to war, we would go to war together, and that we would do it1990with an integrated system with DOD, the Veterans Health1991Administration, and civilian partners. We must rejuvenate the1992NDMS, not let it continue to atrophy.1993    Senator Fischer. So what is the next step in this pilot1994program?1995    Dr. Friedrichs. So the next step is to make this not a1996pilot program but to reiterate that this is, indeed, the intent1997of Congress, that the NDMS is the framework in which we1998integrate our ability to deal with either surges in military1999patients or, in the event of a natural disaster, surges in2000civilian patients. But that is the framework.2001    A subset of that are the Respect Centers, which you are2002very familiar with, the regional Emerging Special Pathogen2003Centers that are designed to take care of patients exposed or2004infected with high-consequence infectious diseases. And another2005subset of that is the trauma system that Dr. Cannon so nicely2006described.2007    We need your help to articulate in law that we must work as2008a nation and as a team. We are short 300,000 nurses nationally.2009The projections are we will be short 130,000 doctors by 2035.2010There is no way that we can do this individually. We must do it2011together, and I urge you to codify the NDMS pilot and make that2012the intent, moving forward.2013    Senator Fischer. Dr. Cannon, Dr. Robb, anything to add on2014that?2015    Dr. Cannon. Senator, I would just advocate for what my2016colleague, General Friedrichs, just said, but we need to put2017our foot on the gas. We do not have 5 years, 10 years, 202018years. We need the solution really now.2019    Senator Fischer. Dr. Robb?2020    Dr. Robb. Yes, I concur with both their comments. And going2021back, the fact that we dual-purpose these assets, these2022expensive assets, to solve problems both in the military and2023civilian sector, but they are mutually synergistic. So2024absolutely, we need to press forward.2025    Senator Fischer. Thank you. Dr. Friedrichs, you mentioned2026the University of Nebraska Medical Center and working with an2027academic institution. Can you explain to the Committee the2028benefits of those partnership with academic institutions in2029particular, and what that can yield for the Military Health2030System?2031    Dr. Friedrichs. Thank you very much, Senator Fischer. The2032first benefit is we share and exchange information. University2033of Nebraska has established, without a doubt, one of the2034premier programs for treating casualties or patients who are2035exposed to highly contagious infectious diseases, and they have2036got remarkable onsite training, which they built in partnership2037with the United States Air Force. This is a great example of a2038military-civilian partnership in which the exchange of ideas2039improves care, both for military and civilian patients.2040    But the other thing that we can learn from our civilian2041partners is something that I offer to the Committee to2042consider, the CHIP IN Act, which was originally passed to allow2043for blending of funding to build new VA facilities. It should2044be expanded to include the DOD. We cannot afford to keep2045building duplicative facilities, and the CHIP In Act was a2046great way to allow the blending of Federal, State, local, and2047philanthropic funds so that we can most efficiently care for2048this diverse patient population.2049    Again, I commend the University of Nebraska for the2050pioneering work that they have done in showing what a good mil-2051civ partnership looks like.2052    Senator Fischer. Thank you for the shout-out on the CHIP IN2053Act. That bill was written in my office, so thank you very2054much.2055    Dr. Cannon, as a professor of surgery, do you have anything2056to add on that?2057    Dr. Cannon. I would just comment that these mil-civ2058partnership sites can be incredible assets for force2059generation, for building up that next generation of future2060leaders in surgery and other combat-relevant specialties. And2061these are epicenters of academic excellence where we can truly2062inspire that next generation.2063    Senator Fischer. Thank you. Thank you, Mr. Chairman.2064    Chairman Wicker. Thank you, gentlemen. It seems to me that2065the State of Nebraska must have excellent2066    representation in the U.S. Congress.2067    Senator Shaheen.2068    Senator Shaheen. Thank you all very much for being here2069today.2070    Dr. Robb, you discussed the impact of declining budgets on2071the Defense Health Agency. As a former director, can you talk2072about how late budgets and operating under continuing2073resolutions, continued budget uncertainty affects the readiness2074of the Military Health System?2075    Dr. Robb. When I look back--in fact, I will go back in2076history, because I was part of that. When we initially stood up2077to the Defense Health Agency in response to the perception that2078we had 10 percent of the DOD's overall budget, and then fast-2079forward to 12 years later and now we are actually less than 102080percent. And we were meeting not quite but most of our demands2081back then. But as I watch, we have had increasing combatant2082command requirements with a decreasing defense health program.2083    And what that has forced us to do is we have seen a couple2084of challenges, and there are multiple things going on. But the2085military departments, their end strength has gone down, and the2086way we man those hospitals is with a certain percentage of2087military members. And as Dr. Friedrichs said, you just cannot2088buy health care professionals off the streets.2089    So when we cut the end strength then we apportion this care2090downtown, and then that increased TRICARE budget, but then we2091have to pay with bag one money, which is direct care money, to2092pay direct care. So now we actually have an internal shrinking2093of our budget. So it has been challenging for the Defense2094Health Agency to manage a set of Military Treatment Facilities2095with that to be the current business process.2096    Senator Shaheen. And is it fair to say that budget2097uncertainty exacerbates that problem----2098    Dr. Robb. Oh, absolutely.2099    Senator Shaheen.--that continuing resolution exacerbates2100that problem?2101    Dr. Robb. Absolutely. Yes, ma'am. Yes, ma'am.2102    Senator Shaheen. Thank you. Dr. Friedrichs, you mentioned2103the National Guard, and one of the things I know, the National2104Guard, as we all know, is assuming a greater role in actual2105deployments and picking up work for the regular military. I2106could probably say that more eloquently, but they are taking on2107a much bigger role than they did 30 years ago. Yet the National2108Guard does not have the same coverage for health care that our2109regular military does. Despite the challenges that you all have2110identified, it is even a greater problem for the National2111Guard.2112    Can you speak to what we ought to be thinking about as we2113are thinking about how do we ensure that the Guard actually has2114the health care they need so that they are ready to go if they2115are called to deploy or called into combat?2116    Dr. Friedrichs. Thank you, Senator Shaheen, and I will2117start, if I may, first with your premise that there is an2118increasing demand signal. The decision to take down the United2119States Agency for International Development (USAID) and most of2120its capabilities is almost unquestionably going to drive more2121demand on the Department of Defense. USAID provided countless2122services for disaster response and for work with allies and2123partners around the world.2124    Senator Shaheen. And for global health.2125    Dr. Friedrichs. And for global health, and for2126biosurveillance, and many other roles. In the absence of USAID,2127we either agree that when Americans are caught in a disaster2128they are on their own, or we are going to turn to the only2129other organization that has those kinds of capabilities, and2130that is DOD. So we should, I am afraid, expect to see more2131demand on DOD as a result of those changes.2132    To your point about health care preparedness, when we look2133back at why people, shortly after deployment, have to be pulled2134off the line, interestingly it is dental care primarily among2135the Guard and Reserve, who do not have ready access to that. I2136think if we are serious about a smaller force that must be2137ready on a moment's notice, we are going to have to address how2138to ensure that force is ready, when needed, to go forward, and2139that is medically ready, as well as ready and proficient with2140whatever their assigned task is.2141    Senator Shaheen. And we are learning a lot of lessons on2142our industrial base side, from the war in Ukraine right now,2143and a lot of lessons about the conduct of war today. Are we2144learning anything about the health care system and what we2145ought to be thinking about from what is happening in the war in2146Ukraine? Anybody.2147    Dr. Friedrichs. If I may, I will just quickly say, having2148just been with the Ukrainian Surgeon General, absolutely. What2149they have found, first and foremost, is they are in the kind of2150conflict we will likely be in, and in the absence of air2151superiority, contested logistics, you must have a functioning2152system that is integrated. And this gets back to Senator2153Fischer's question about the National Disaster Medical System.2154    They are also learning the importance of supply chains.2155When we looked at this at the Joint Staff, we found that a2156significant percentage of the pharmaceuticals in our deployable2157assemblages actually rely on ingredients from countries that2158may or may not be willing to continue to provide those in the2159next conflict. Same song, next verse, with medical equipment.2160    I urge you, as I said in my written statement, to require2161the Department to give you an accounting for our2162vulnerabilities in that area and a plan to address them. There2163are ways to do that. We need a strong push, I would submit, to2164actually accomplish that.2165    Senator Shaheen. Thank you very much. Thank you all.2166    Chairman Wicker. Thank you, Senator Shaheen.2167    Dr. Cannon and Dr. Robb, do you want to elaborate on what2168Dr. Friedrichs said about USAID?2169    Dr. Cannon. Sure. That is out of my domain so I do not have2170anything.2171    Chairman Wicker. Very well, then. Yes.2172    Dr. Robb. I would concur, one, with his comments, but2173number two, again it is mostly out of my domain currently.2174    Chairman Wicker. All right. Thank you very much. Senator2175Cotton.2176    Senator Cotton. General Friedrichs, I would like to2177continue with the answer you just gave to Senator Shaheen about2178our dependence on other countries for drugs and precursors,2179specifically Communist China. The United States relies heavily2180on Communist China for basic drugs and so-called Active2181Pharmaceutical Ingredients (APIs). Providers obviously need2182this, not just in the civilian world but in the military world,2183especially to treat combat casualties. China, for instance, has218480 percent of the global supply chain of antibiotics.2185    How could Communist China use this dependence of ours to2186its advantage if there were a major conflict in the Pacific?2187    Dr. Friedrichs. Thank you very much, Senator Cotton, and I2188think we have seen examples of this with rare minerals and2189other things that China largely controls the supply chain for,2190in that they will choose to titrate that supply chain based on2191their satisfaction or dissatisfaction with those trying to2192purchase those items.2193    I had the great privilege in my last role of working with2194India, the European Union (EU), Japan, and Korea on a2195consortium in which we began to identify ways to leverage new2196technologies to change and to broaden our supply chains. And I2197encourage this Committee to direct the Department of Defense,2198in partnership with the Department of Health and Human2199Services, to continue exploring those options.2200    What we found was in many cases, as in the case of2201antibiotics that are based on penicillin, the Japanese have2202already made a tremendous investment in the ability to produce2203those APIs within Japan. We should be partnering with them and2204creating an environment in which at least the DOD and the VA2205purchase from Japan to help sustain that production base and2206ensure that we have the access that we need.2207    There are many more examples. I touched on some of them in2208my written statement. But there are ways to mitigate this.2209    Senator Cotton. And your answer to Senator Shaheen said2210that Congress should push the Department of Defense to catalog2211all of these dependencies. It sounds like you are saying we2212also need to push to eliminate, or at least significantly2213curtail, these dependencies, as well. Is that right?2214    Dr. Friedrichs. Absolutely.2215    Senator Cotton. And you mentioned four different sourcing2216options--South Korea, Japan, the EU, and India. Those first2217three are advanced industrial democracies, just like ours. If2218they can produce these items, like acetaminophen or ibuprofen2219or penicillin, at a reasonable cost, surely the United States2220could do so, as well, right?2221    Dr. Friedrichs. I believe that is the case. And what we2222found is that particularly in these countries they have created2223an environment in which it was financially possible for2224companies to produce these items within their country. We have2225not done that here in the United States. But a thoughtful2226industrial policy that was focused on resilience and national2227security, as well as economic security and health security,2228could do that for us, as well.2229    Senator Cotton. It is fair to say that between the two of2230them, the Department of Defense and the Department of Veterans2231Affairs, sure does have a lot of purchasing power to create a2232domestic market for the production of these fairly basic and2233longstanding medicines, right?2234    Dr. Friedrichs. Absolutely. About 8 percent of the market--2235and it get back to Senator Shaheen's point about continuing2236resolutions and predictability. If companies know that they2237have a predictable demand signal, they will build to it. If2238they have an episodic or random demand signal, they will let2239somebody else deal with that.2240    Senator Cotton. General Robb, I have noticed you nodding2241your head vigorously, so please get off your chest everything2242you wanted to add to General Friedrichs' answers.2243    Dr. Robb. Yes. Also, and I am sure you are aware, and this2244has been the direction from questions asked by our Congress,2245the Center for Health Services Research at the Uniformed2246Services University has been tasked, along with the Defense2247Logistics Agency, to catalog and specifically look at what, and2248define the problem what is, the Department of Defense's2249reliance on the medicines that we have talked about that are2250primarily sourced from China and from India, which would then2251help what I would call inform the decisions a way ahead of2252whether you, what I call it, ally shore, or near-shore, or on-2253shore, as Dr. Friedrichs discussed, in looking at a way2254forward.2255    But they are creating that, you know, what is the data to2256drive the decision and the investment. Thank you.2257    Senator Cotton. Thank you, gentlemen, both, for your2258answers. It has long been the case that the Department of2259Defense, acting at congressional direction, has mandated the2260domestic purchase of many uniform items, so I think surely we2261should make sure that our troops have the medicines they need2262to stay healthy, or to recover, as needed.2263    Chairman Wicker. Thank you, Senator Cotton. Senator Kaine.2264    Senator Kaine. Thank you, Mr. Chairman. Thank you to the2265witnesses. I want to particularly recognize Dr. Cannon. I know2266you are very well-prepared for this hearing today because one2267of the leaders that is with you, Kristin Malloy, used to be on2268my staff, and she made sure I seemed a lot smarter than I was2269at any hearing that I attended.2270    You know, I think I want to focus all of your attention on2271the workforce issues, because I am on the Health, Education,2272Labor, and Pension too, and if I go to my hospitals and health2273care providers they are singing the blues about workforce,2274tight labor market, difficulty hiring and retaining folks.2275    I went to the grand opening of the new VA clinic in the2276Fredericksburg area two Fridays ago, and we built it to the2277tune of about $350 million. And we built this state-of-the-art2278clinic, with one step down from a hospital, because there were2279multiple clinics in the area, and veterans were having to go2280from pillar to post to get care rather than a single place.2281    But when we opened it, and I was there for the opening, I2282had staff say, ``We are on a skeleton crew.'' The three VA2283hospitals in Virginia--Salem, Richmond, and Hampton--are laying2284people off. There are hiring freezes. There are plans for even2285more layoffs. So the estimates I was getting at that grand2286opening is they are probably 20 to 50 percent staffed. There is2287another sizable clinic similar that is going to open in2288Chesapeake, supposed to, on April 11th. If it does open on2289time, I am suspecting that it will be a similar thing. And you2290saw the announcements about more cuts coming in the VA.2291    You have talked a little bit about the need to be more2292integrated between DOD facilities and VA facilities, but then2293also on the civilian side, what is your vision for how we equip2294our civilian system to provide a surge capacity or backup2295capacity when we need it, to perform well in combat situations?2296    Please, Dr. Cannon.2297    Dr. Cannon. Senator, thank you for your very insightful2298comments and questions. I am a veteran. I get my care at our VA2299in Philadelphia. My wife is a primary care physician and takes2300care of veterans. So I can speak to your comments about the VA2301from that perspective.2302    I do have a role at Penn Medicine as the Assistant Dean for2303Veteran Affairs for Penn Medicine, but I am quite new in that2304role and still learning the ropes. So I will speak more from my2305end user experience.2306    I would say that certainly there are opportunities for2307synergy. The partnerships between VA facilities and academic2308medical centers I think have been partially realized, but in2309this sort of urgent situation we find ourselves in, we need2310truly a whole-of-society approach, and where there can be2311market synergy, where there can be economies of scale we should2312aggressively pursue that.2313    I know that our Chief Executive Officer (CEO), Kevin2314Mahoney, has made overtures to the VA, and there have been2315agreements signed between the VA. I do not have detailed2316knowledge about that and where that stands. But I think there2317is an opportunity, and we should push for that. And as a2318veteran who receives my care, I hope that we can continue to2319deliver excellent care through better synergy.2320    Senator Kaine. How about Dr. Friedrichs and Dr. Robb?2321    Dr. Friedrichs. Thank you, Senator Kaine, and that is a2322beautiful facility. It will be tragic if it sits there empty2323while veterans are unable to access care because of shortages2324of medical professionals in the VA, in the DOD, and in the2325civilian sector.2326    We are in a less-than-zero-sum game right now, and that is2327both a health security issue but also a national security2328issue.2329    The first recommendation I would make to this Committee,2330direct that the Department of Defense does not close any more2331of our military training programs. For decades, the military2332training programs have been one of the pipelines that, when2333people eventually left the military, which all of us do, they2334go to the civilian sector. We cannot afford to close any more2335training programs when we have so many shortages of doctors and2336nurses and dentists and other things.2337    The second, I implore this Committee, in the NDAA, direct2338the DOD and in partnership with the appropriate VA oversight2339committees, the Veterans Administration, to come back with a2340plan, starting with the D.C. market, to integrate the two2341systems. We have talked about this since I was a Major. I moved2342here in 1997, and we were talking about this. It is time to2343stop talking and start doing it. We cannot afford to keep2344talking about this problem.2345    That hospital in the VA here is ancient. It has got to be2346replaced. We just finished a billion-dollar upgrade at Walter2347Reed. Why in the world are you not demanding that we come back2348with a plan to do that? It is more efficient, and it helps to2349pool the resources.2350    The third point, and the most important one in your Health2351Committee role, is we must address these pipelines as both a2352health security and an economic security and a national2353security concern. As long as the pipelines continue to be2354insufficient to need, there is no way that any of these2355problems are going to get fixed. And I think you have a unique2356opportunity to help bring that into both committees. Thank you,2357Senator.2358    Senator Kaine. Thank you. And Dr. Robb, I will ask that2359question for the record because I am now out of time. I yield2360back to the Chair.2361    Chairman Wicker. All right. Actually, these witnesses will2362not be taking questions for the record. I will let you followup2363for 45 seconds.2364    Senator Kaine. Dr. Robb, then could you approach that2365workforce integration question too? Thanks.2366    Dr. Robb. Yes, and I will go back to where we can share2367resources, and I will foot-stomp. We have very many successful2368joint DOD and VA partnerships. Travis Air Force Base is a great2369example, where the actual VA is inside of David Grant Medical2370Center, share staffs, but more importantly, share patients. We2371have others where we are co-located community-based outpatient2372centers that feed patients into like Anchorage, Alaska. We see2373that down there at Naval Pensacola.2374    So those opportunities, because usually what happens is we2375want access to critical care patients for our proficiency, and2376the VA wants access to resources, which is either excess2377capacity on space or in staff. So I think that continued2378movement forward, not always one size fits all, but that is2379very, very important. Much like the VA is at all the academic2380health centers, I think the Department of Defense, especially2381six or eight strategic places, need to have strategic VA and2382strategic mil-civ partnerships, sharing staff.2383    And I will quickly say, not only does the military learn2384from the civilian opportunities, during Operation Iraqi Freedom2385(OIF) and Operation Endurance Freedom (OEF), actually, the2386American College of Surgeons made sure that they were with us2387so they could learn, firsthand, real-time, on how we were2388treating. So it is a mutually synergistic relationship.2389    Chairman Wicker. Thank you, Dr. Robb. Senator Rounds.2390    Senator Rounds. Thank you, Mr. Chairman, and I am going to2391follow right along that same line because I think what you are2392laying out is basic common sense when it comes to the2393integration of these two systems.2394    My question is, why is it that when we have what is2395considered to be excellent care with the military system, the2396MHS, involved, and then we have to transition these young men2397and women as they leave the armed service into a VA facility,2398in which we start all over again. And we have different ways of2399communicating, and, in fact, let me just ask this. In your2400experiences, how well do we integrate the transfer of2401information from the MHS back into the VA systems today?2402    Dr. Cannon. Senator, I can take a crack at that. I believe2403you are spot on. My experience in transitioning from the DOD to2404the VA was more of a lukewarm handoff than a warm handoff. I2405had to sort of navigate my way to the VA. I now have closed2406that gap and I get my care there, as I mentioned. But it is not2407a smooth process.2408    Why is it still the case that the two health care delivery2409systems are so partitioned? I think you have to go back to2410ancient history almost, in our country. And if you look at2411Secretary Gates' comment about his experience as Secretary of2412Defense, he said, ``The one department that gave me the most2413fits was the Department of the VA.''2414    So there are historic challenges. The VA wants to do it2415their way. Understandably, most of us do want to do it our way.2416But I think there are clear opportunities and a clear demand2417signal to break down those barriers and realize opportunities2418for synergy. So I think we can do that.2419    Senator Rounds. I think the focus should be on whether or2420not we are delivering for the veteran and not necessarily the2421survivability of the VA itself. And I think that sometimes gets2422mixed up.2423    I am just curious, gentlemen. We have talked about trauma2424centers. We have talked about the reintegration, or integrated2425health care system, and so forth. We are not, right now, at the2426same degree of activity and intensity with regard to2427battlefield casualties as we were just a few years ago, and2428therefore the opportunity for these surgeons, these battlefield2429surgeons and others, to actually learn right now is probably2430not as great.2431    How do we keep the intensity or the capabilities of the2432training, how do we keep that up to date when we do not have2433those opportunities? And I am not going to say that they are2434good opportunities. I am glad that we are not in them. But how2435do you allow that surgeon to keep those skills up to speed when2436you do not have the types of casualties that you have on a2437battlefield, that we were experiencing for a number of years?2438    Dr. Friedrichs. Take care of sick patients, sir. I mean,2439there is an analog between taking care of a patient who has2440bladder cancer and needs to have their bladder removed and2441taking care of a patient who has just had a gunshot wound to2442the abdomen and needs to have their bladder reconstructed.2443    We need our military medics taking care of sick patients.2444They do that at hospitals that are well-staffed and well-2445resourced to take care of sick patients. And so that is what we2446have done historically to maintain the proficiency of surgeons2447or of critical care nurses or of medical logistics staff, is2448keep them busy during peacetime taking care of sick patients.2449It is not a perfect analog, but that is the best surrogate, and2450that requires resourcing the system, making sure that sick2451patients can get in the door and get the care they need.2452    And to your point about the VA, I would just say I applaud2453the VA for accelerating moving forward with their electronic2454health record, because that is going to be the secret sauce2455that enables greater sharing between the two departments and2456will enable us to track patients from the day they join the2457military to the day they take their last breath, and really2458learn how to improve both systems.2459    Senator Rounds. Is the current system that you use2460integratable with the VA's new proposed medical records health2461care system?2462    Dr. Friedrichs. I am not an expert on the VA's system. When2463I left the movie they were looking at purchasing the same2464system that the DOD had purchased. I hope that those with2465oversight responsibilities will insist that the two systems are2466integratable, because technologically, there is nothing to2467prevent that. I mean, civilian health care system integrate2468Epic and Cerner all the time, or McKesson and Epic. There2469should be no technological reason why we cannot do that.2470    Senator Rounds. Thank you. General Robb, anything to add to2471that?2472    Dr. Robb. I would share what Dr. Friedrichs said. In fact,2473what I was excited about is I have had the opportunity for2474family members to be in civilian hospitals, and they are able2475to reach into it and see Genesis now. So they know the health2476care that my family members have been getting in the military.2477    I know that has absolutely been the vision between the2478Department of Defense and the Department of VA, and I believe2479that is still what I would call the true north.2480    Senator Rounds. Thank you. Thank you, Mr. Chairman.2481    Chairman Wicker. Thank you, Senator Rounds. Senator King.2482    Senator King. Thank you, Mr. Chairman. First, I want to2483thank you for having this hearing. Very timely and important.2484Second, I want to associate myself with Senator Cotton's2485comments about sort of Berry Amendment for drugs. The idea that2486we have to buy Made in America shirts for our troops but we are2487worried about the availability of crucial drugs, that seems to2488me that is something that should be pursued. We could even call2489it the King-Cotton Amendment, but I will pass on that.2490    [Laughter.]2491    Also, Mr. Chairman, before getting into the questions, and2492these witnesses would not have the answers, but I think in2493light of this hearing, the Committee should make an inquiry2494about whether there have been firings or early retirements2495encouraged within the medical facilities at the Defense2496Department, because we know there is a lot of that going2497around, and I would like to know whether that is happening in2498the Defense Health Agency.2499    Second is the impact of the continuing resolution. That is2500certainly not going to help this situation in terms of2501maintaining demand signals, continuity, pilot programs--all of2502that is gone in a continuing resolution. For the first time in2503my knowledge, I think the first time in American history, we2504are faced with a year-long continuing resolution, which2505basically vitiates the entire budget process.2506    Okay. What we are really talking about, it seems to me, is2507surge capacity. And it is impractical to maintain a capacity2508within the Defense Department, or even Defense plus VA, for the2509kind of casualties that would be generated in a significant2510conflict. Therefore, I see no other alternative than a2511cooperative surge agreement with the private sector. That is2512where capacity is, even though that is fairly limited.2513    Dr. Friedrichs, isn't that really what we are talking about2514here is how do we deal with a conflict way beyond what we are2515seeing now, within the current capacity? Defense Health Agency2516could not do it. VA could not do it. It has got to be2517relationships, and should we not have those relationships in2518advance so this is not something that we scramble to do, as we2519did during COVID, for example?2520    Dr. Friedrichs. Senator King, I could not agree more2521strongly----2522    Senator King.2523    [Inaudible.]2524    Dr. Friedrichs. Thank you, sir. So in the cold war we had2525what was called the Integrated Continental United States2526(CONUS) Medical Operation Plan, which was essentially what you2527just described. It was our shared commitment, as a Nation, to2528care for our Nation's casualties, if and when our Nation went2529to war. That depended on the National Disaster Medical System2530as part of the integrating function between the Federal and the2531civilian health care system. The NDMS has been allowed to2532attrit.2533    I echo the recommendations to reauthorize the Pandemic and2534All Hazards Preparedness Act, because that, in part, enables2535the NDMS. But I implore you to go further. The Integrated CONUS2536Medical Operation Plan needs to be updated, and we started that2537work when I was the Joint Staff Surgeon, and it is continuing2538today. Having the NDMS in name is not sufficient. We actually2539have to build out the numbers, by community, of what beds would2540be available----2541    Senator King. With preexisting conditions and analysis of--2542--2543    Dr. Friedrichs. Yes.2544    Senator King. I just wonder if the Pentagon has war-gamed2545this issue. They war-game everything else.2546    Dr. Friedrichs. Absolutely, sir. We actually did a war game2547on this, that we hosted first when I was the Transportation2548Command Surgeon, and again when I was the Joint Staff Surgeon.2549And what we found was just as you said--it cannot be done2550unless it is a whole-of-the-nation effort. And the only way to2551get to that point is if we do much more detailed planning.2552Taking down funding for State and local readiness officials,2553for example, is not going to help them do more planning or2554preparing.2555    We need to work together to build and flesh out that plan,2556and we must bring industry into that. The defense industrial2557base provides equipment. The health industrial base addresses2558the points that you bring up.2559    Senator King. And we have an analog in United States2560Transportation Command (TRANSCOM), which has agreements with2561the private sector both in terms of airplanes and ships, in the2562case of an emergency. That is where our surge capacity is.2563    So it seems to me, I mean, here we are talking about it,2564but I think there needs to be some very specific good, new2565looks at this relationship in order to be ready, so again we2566are not scrambling.2567    Dr. Robb, you are nodding. I take it you agree?2568    Dr. Robb. Yes. I would absolutely concur. And again, I keep2569going back to the same theme, is we have got to buildup those 62570to 8 to 10 strategic Military Treatment Facilities, we have to2571resource them, and then you create the already established2572military-VA partnerships, and then you just keep expanding that2573ring. But you have to have those relationships codified and in2574place, and that is what Dr. Friedrichs is talking about. You2575cannot just, all of a sudden when it kicks off, pick up the2576phone and say, ``How is it going?''2577    Senator King. You have got to have them in place before the2578crisis hits.2579    Dr. Robb. Absolutely.2580    Senator King. Thank you, gentlemen. I appreciate it. Thank2581you, Mr. Chairman.2582    Chairman Wicker. Thank you very much, Senator King. Senator2583Budd. Catch your breath.2584    Senator Budd. Thank you all for being here. Major General,2585in your opening statement, whether here or able to watch it on2586the closed circuit, you identified the importance of the2587relationship between the Military Health System and the defense2588logistics enterprise.2589    So should deterrence fail and war break out in the Indo-2590Pacific, there are undeniable logistics constraints,2591particularly given the geography of INDOPACOM. The logistics of2592replenishing medical supplies and evacuated wounded2593servicemembers could make all the difference in reducing2594servicemember casualties. You provide a number of2595recommendations in your opening statement to address these2596concerns, including a number of reports and studies, so thank2597you for that.2598    What can our Military Health System do in the short term,2599like immediately, to address logistical constraints, and how2600can DOD leverage medical innovation to address some of those2601constraints?2602    Dr. Friedrichs. Thank you very much, Senator. I think the2603most immediate recommendation that I included in my written2604statement was that whenever we contemplate an operation or we2605are updating plans, we do a medical feasibility assessment,2606very similar to the logistics feasibility assessment that the2607Joint Staff J4 does. We need to ensure that we are informing2608our combatant commanders about what is and is not possible.2609That is something that can be done very easily.2610    The longer answer to your question gets back to the2611discussion that we were just having about partnering with2612industry, both on the equipment and pharmaceutical side and on2613the health care delivery side. We have the Civilian Reserve Air2614Fleet that allows us to commit money to ensure that we have2615industry partners willing to provide aircraft and support when2616we need it. We have no such analog in the health care space,2617even though we know, as multiple Senators pointed out this2618morning, that there is insufficient capacity in the DOD and in2619the VA to care for our casualties.2620    The NDMS currently is a voluntary system in which hospitals2621can say, ``Yes, okay,'' and then when we call them, they say,2622``I'm busy today. I'm not going to participate.'' We actually2623need to codify a system, as we have done with other industrial2624partners, in which there is a commitment and an understanding2625of how the reimbursement would work.2626    The last point that I would make on that going forward is2627in supplemental planning for future operations we have to build2628in that cost. There is no question, if we are bringing back2629thousands of casualties, as Colonel Cannon described, that that2630is going to displace care, and it is going to increase costs at2631hospitals. We have to plan for that. That is why this whole2632planning effort, the Integrated CONUS Medical Operations Plan,2633for which United States Northern Command (NORTHCOM) is the2634lead, in partnership with industry, State, local, and2635Department of Health and Human Services officials, is so2636important, so we can bring back the requirements for funding2637and the challenges that we will need congressional help to2638address.2639    Senator Budd. Thank you. Following up on that, you said we2640need to codify that. Do you have the language ready, or has2641that been written in a way that we could review, either2642individually or as a Committee?2643    Dr. Friedrichs. Senator, I took the liberty of including an2644attachment with suggested language, just in case anyone wanted2645to do that.2646    Senator Budd. We will read it in a few moments. Thank you.2647    Mr. Robb, as you know, the Department relies on a mix of2648military personnel, federal civilians, and contractors to carry2649out its mission. Talk to me about the roles of physician2650extenders such as registered nurses, and what role do physician2651extenders play in ensuring the readiness of the broader force,2652and what challenges do you see to retention of physician2653extenders?2654    Dr. Robb. Thank you for that question, Senator. I think it2655is key that the same issues of what I call proficiency and2656currency that exists for physicians, exists for our physician2657extenders. And the Army does a great job, especially in the way2658they have manned and equipped their fighting forces, of using2659those physician extenders, all the way down to the corpsmen, to2660the fullest extent of their capabilities.2661    And so I would argue, as we have these discussions about2662medical readiness and about our ability to care for what we2663call critical wartime specialties, we must remember, trauma is2664a small percentage of that, but the majority of the care that2665is applied to our fighting forces comes from our primary care2666providers, which would be Physician Assistants (PAs), nurse2667practitioners, general practitioners, family physicians. So we2668must ensure that they also have the critical thinking skills2669and the opportunity to practice at the top of their game.2670    Senator Budd. Thank you all, to the whole panel. Chairman?2671    Chairman Wicker. Senator Budd, yes indeed, in looking at2672the statements, which have all been admitted to the record, by2673unanimous consent, I see on page 14 of Dr. Friedrichs' prepared2674testimony Attachment 1, Suggested National Defense2675Authorization Act Language. So we do appreciate him acting as2676an uncompensated legislative staffer for this Committee. We2677appreciate that. And thanks for the question.2678    Senator Kelly.2679    Senator Kelly. Thank you, Mr. Chairman. General Friedrichs,2680good morning, and thank you, all of you, for being here today.2681General Friedrichs, in a recent war game brief to Congress in2682November 2024, a hypothetical conflict in the Indo-Pacific2683resulted in 3,000 U.S. casualties in 3 weeks, and 10,000 across2684the entire conflict. And I am kind of following up on Senator2685Budd's line of questioning here.2686    These numbers are higher than anything we have seen since2687the Korean War. In a severely injured servicemember's2688transition through the care system and make their way back to2689the United States for treatment, I am concerned that the number2690of DOD providers capable of handling trauma will be grossly2691insufficient. So given that, we are going to need to surge2692capacity, potentially found in the U.S. hospital system and VA2693hospitals, meaning civilian hospitals, VA hospitals.2694    What concerns do you have with relying on U.S. civilian and2695VA hospitals to provide this trauma care to our servicemembers?2696    Dr. Friedrichs. Thank you very much, Senator Kelly, and I2697would start by saying even before we get patients back to the2698United States, in the past we have relied on our allies and2699partners to help care for our casualties. And I am deeply2700concerned if we sever or degrade those relationships we will2701need to rewrite our plans, and the demands on the U.S. health2702care system will be even greater.2703    To your point about the U.S. health care system, the2704Integrated CONUS Medical Operation Plan that we updated in27051998, and then did not look at until 2020, is the plan that2706describes how we will surge capacity. But a key part of that2707gets back to some of the discussions we have had earlier. There2708have to be doctors and nurses and pharmacists and all the other2709staff to do that, and I implore that we continue to look at the2710pipelines that produce those medics as well as the facilities2711in which they work.2712    We had briefly chatted about the opportunity for a medical2713equivalent to the Civilian Reserve Air Fleet that we use to2714ensure access to civilian aircraft, when needed. I believe we2715need some similar construct in the health care system, where we2716partner with industry and recognized that during surge moments2717there is a plan, and there is money available, for us to be2718able to leverage their staff and their facilities.2719    Senator Kelly. Is there a plan?2720    Dr. Friedrichs. There is a plan. We wrote the first version2721of that before I retired, and they are working on an update to2722that. But it would benefit from additional congressional2723oversight to ensure that it is on track and it does not get2724diverted by bureaucratic buffoonery.2725    Senator Kelly. Are there current efforts in the2726relationship building with these hospitals?2727    Dr. Friedrichs. The Defense Health Agency is tasked to have2728that outreach, and as I have met with hospital CEOs and system2729owners, there is certainly an opportunity to do more in that2730space. We must view the health care industry the same way we2731view the aviation industry or the missile-producing industry,2732as our partners. We cannot take care of America's casualties2733without those partners.2734    Senator Kelly. Can you talk to the value in the two Navy2735hospital ships--I do not know if anybody here is prepared to2736talk about it. Because I think there is an effort underway to2737replace those. There is also the training ships for the State2738maritime academies that I think also could serve a role. I2739visited one at the Philly Shipyard a few weeks ago, had an2740operating room on board. Is that part of the system, as you2741envision it?2742    Dr. Friedrichs. Yes, absolutely. The hospital ships are2743integral to our plans for a large-scale combat operation, and2744the two ships we have are some of the oldest ships afloat. They2745have to be replaced.2746    Senator Kelly. I think there is a plan to replace them now.2747Can you speak to how that is going, if you know?2748    Dr. Friedrichs. I pushed incredibly hard for that plan as2749the Joint Staff Surgeon, against intense opposition that we2750should spend the money in other places. I would defer to the2751Navy for the latest update on it, because they can give you the2752most current plan. But my understanding is that we are still2753years away from having the replacement ships available.2754    So we will have to extend the current ships, and I believe,2755the last update I received, which is dated, was through 2035.2756But we do need that additional replacement funding to replace2757those aged ships.2758    Senator Kelly. All right. Thank you, and thank you, Mr.2759Chairman.2760    Chairman Wicker. Thank you, Senator Kelly. Senator Warren.2761    Senator Warren. Thank you, Mr. Chairman. So we need a2762medical health care system that works in wartime, but the one2763we have is failing us in peacetime. And I think we need to do2764better on this. Fixing TRICARE's prescription drug care benefit2765is part of that.2766    Since 2009, TRICARE has outsourced to Express Scripts a2767massive Pharmacy Benefit Manager (PBM). The Defense Health2768Agency, DHA, pays Express Scripts to negotiate with pharmacies,2769deciding where servicemembers can pick up their prescriptions2770and what price they are going to pay. But Express Scripts also2771owns Accredo, a massive pharmacy that participates in TRICARE,2772and DHA has been allowing all kinds of self-dealing between2773these two entities.2774    Here is one. DHA used to require Express Scripts to2775maintain a network of 50,000 pharmacies. But in 2021, Express2776Scripts negotiated that down to 35,000 pharmacies. Then they2777turned around and told thousands of pharmacies, that they do2778not own, either to take money-losing terms or get kicked out of2779TRICARE.2780    General Robb, you used to oversee the TRICARE network2781before this gaming started. Do you have any idea how many2782pharmacies have left, just since 2022?2783    Dr. Robb. And Senator Warren, I have been out of this since27842016.2785    Senator Warren. Okay. I just wondered if you happened to2786know how many had left. I will take a no.2787    Dr. Robb. No, ma'am. No, ma'am, I do not.2788    Senator Warren. Well, it is over 13,000 pharmacies have2789left this network, and most of them are independent pharmacies,2790community pharmacies. That has forced 400,000 servicemembers2791and their families to find new pharmacies, and many of them2792have been pushed to the Express Scripts-owned Accredo.2793    Even worse, Express Scripts has set up Accredo as the2794primary off-base pharmacy where military families can fill2795specialty drug prescriptions. You know, these are the really2796expensive cancer drugs, rheumatoid arthritis drugs, that make2797up over half of the $8 billion in TRICARE prescription drug2798spending. So it is a lot of money here.2799    It does not end there. As we speak, Express Scripts is2800facing a whistleblower lawsuit that alleges the company2801systematically overfilled TRICARE prescriptions at Accredo,2802saddling DOD with, quote, ``billions of dollars in excess2803dispensing fees and drug resupplies.'' And this is not a2804surprise. Express Scripts has been found to massively overfill2805and overpay for prescriptions at Accredo, which they own, in2806other government programs.2807    So General Robb, since last year, an audit uncovered that2808Express Scripts was leveraging its contract with the West2809Virginia Public Employees System to send inflated payments to2810Accredo for expensive specialty drugs, in some cases inflating2811the price by 100fold more than the cost of dispensing exactly2812the same drug at a competing pharmacy.2813    I imagine you think this kind of taxpayer overcharging is2814unacceptable. Is that fair, General Robb?2815    Dr. Robb. I would agree with that, it would be unfair. Yes,2816ma'am.2817    Senator Warren. Okay. DHA is supposed to audit Express2818Scripts' pharmacy data to make sure that that same thing is not2819happening at TRICARE, but DHA said it had not completed an2820audit because DHA had, quote, ``no concerns about data2821accuracy.''2822    You know, talk about being asleep at the wheel here, in2823just the first quarter of 2023, Express Scripts dispensed282470,000 specialty drug prescriptions at Accredo, but the company2825only reported about 40,000 to DHA. In other words, Accredo2826failed to report nearly half of the expensive specialty drugs2827dispensed at its own pharmacy, which were paid for by DHA. So2828they get the money, but they do not tell DHA what is going on2829here.2830    General Robb, after completing their investigation, the2831Government Accountability Office (GAO) sensibly recommended2832that DHA periodically audit Express Scripts' reported data for2833accuracy, which, by the way, is already required in the2834contract. So this is telling them basically to follow through2835on the contract.2836    Do you agree with GAO's recommendation?2837    Dr. Robb. I would agree that they need to follow what is2838the business policy and what is the contractual requirements.2839Yes, ma'am.2840    Senator Warren. All right. You know, I just want to say,2841and I will close up here, DHA is paying Express Scripts2842billions of taxpayer dollars to manage the TRICARE benefit and2843negotiate with itself, and DHA is not even bothering to check2844the books. I think that everyone in this room agrees that2845Express Scripts ought to pass an audit, and that ought to be2846required in this year's NDAA.2847    Thank you, Mr. Chairman.2848    Chairman Wicker. Thank you, Senator Warren.2849    Dr. Friedrichs. Mr. Chairman, may I add a comment to that?2850Is there time?2851    Chairman Wicker. You certainly may, yes.2852    Dr. Friedrichs. Thank you very much. I would hold up the2853Veterans Health Administration's exemplary mail order program,2854which has worked for years, as an opportunity, again going back2855to this concept of how do we deliver better care, and where2856possible, do it more efficiently. There is a real opportunity2857for this Committee, in partnership with the appropriate2858oversight committees, to direct a comparison of the two systems2859and then bring back recommendations for the best practices2860between the two.2861    Pharmaceuticals are growing in costs, and that is not going2862to change. But this is an area in which the Veterans Health2863Administration actually has done this well for years, with high2864patient satisfaction, and more importantly, the patients get2865the meds they need, when they need them. There is a real2866opportunity to learn from the VA here.2867    Chairman Wicker. Thank you very much. Thank you, Senator2868Warren. Mr. Ranking Member, anything more?2869    Senator Reed. Just let me commend the witnesses. You have2870given us lots to think about and lots to do, and so we2871appreciate that. Thank you very much.2872    Chairman Wicker. We are indebted to you and grateful to all2873three of you. Thank you very much.2874    This concludes the hearing.2875    [Whereupon, at 11:04 a.m., the Committee adjourned.]28762877                                 [all]