[Senate Hearing 119-76]
[From the U.S. Government Publishing Office]


                                                         S. Hrg. 119-76

                 STABILIZING THE MILITARY HEALTH SYSTEM
                   TO PREPARE FOR LARGE-SCALE COMBAT
                               OPERATIONS

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

                                HEARING

                               BEFORE THE
                               
                      COMMITTEE ON ARMED SERVICES
                          UNITED STATES SENATE

                    ONE HUNDRED NINETEENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 11, 2025

                               __________

         Printed for the use of the Committee on Armed Services
         
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                 Available via http: //www.govinfo.gov

                               __________

                   U.S. GOVERNMENT PUBLISHING OFFICE                    
60-344 PDF                  WASHINGTON : 2025                  
          
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                      COMMITTEE ON ARMED SERVICES

 			ROGER F. WICKER, Mississippi, Chairman
  			
DEB FISCHER, Nebraska			JACK REED, Rhode Island
TOM COTTON, Arkansas			JEANNE SHAHEEN, New Hampshire
MIKE ROUNDS, South Dakota		KIRSTEN E. GILLIBRAND, New York
JONI ERNST, Iowa			RICHARD BLUMENTHAL, Connecticut
DAN SULLIVAN, Alaska			MAZIE K. HIRONO, Hawaii
KEVIN CRAMER, North Dakota		TIM KAINE, Virginia
RICK SCOTT, Florida			ANGUS S. KING, Jr., Maine
TOMMY TUBERVILLE, Alabama		ELIZABETH WARREN, Massachusetts
MARKWAYNE MULLIN, Oklahoma	        GARY C. PETERS, Michigan
TED BUDD, North Carolina		TAMMY DUCKWORTH, Illinois
ERIC SCHMITT, Missouri			JACKY ROSEN, Nevada
JIM BANKS, INDIANA			MARK KELLY, Arizona
TIM SHEEHY, MONTANA                  	ELISSA SLOTKIN, MICHIGAN                                     
                                  

		   John P. Keast, Staff Director
		Elizabeth L. King, Minority Staff Director


                                  (ii)

  
                            C O N T E N T S

_________________________________________________________________

                             March 11, 2025

                                                                   Page

Stabilizing the Military Health System to Prepare for Large-Scale     1
  Combat Operations.

                           Member Statements

Statement of Senator Roger Wicker................................     1

Statement of Senator Jack Reed...................................     2

                           Witness Statements

Robb, Lieutenant General (Dr.) Douglas J., USAF (Ret.), Former        4
  Director of the DefenseHealth Agency.

Friedrichs, Major General (Dr.) Paul A., USAF (Ret.), Former          6
  Joint Staff Surgeon.

Cannon, Colonel (Dr.) Jeremy W., USAFR (Ret.), Professor of          19
  Surgery, Perelman School of Medicine, University of 
  Pennsylvania.

                                 (iii)

 
   STABILIZING THE MILITARY HEALTH SYSTEM TO PREPARE FOR LARGE-SCALE 
                           COMBAT OPERATIONS

                              ----------                              


                        Tuesday, March 11, 2025

                              United States Senate,
                               Committee on Armed Services,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:36 a.m., in 
room SD-G50, Dirksen Senate Office Building, Senator Roger 
Wicker (Chairman of the Committee) presiding.
    Committee Members present: Senators Wicker, Fischer, 
Cotton, Rounds, Ernst, Sullivan, Cramer, Scott, Tuberville, 
Mullin, Budd, Schmitt, Banks, Sheehy, Reed, Shaheen, 
Blumenthal, Kaine, King, Warren, Peters, Rosen, and Kelly.

           OPENING STATEMENT OF SENATOR ROGER WICKER

    Chairman Wicker. The hearing will come to order.
    The Committee has convened this hearing to discuss the 
State of the Military Health System (MHS). We hope to shine a 
light on the challenges facing that system and begin working 
toward solutions.
    Our witnesses are experts in the field of military 
medicine. Dr. Douglas Robb is a retired Air Force Lieutenant 
General and the former director of the Defense Health Agency 
(DHA). Dr. Paul Friedrichs is a retired Air Force Major General 
and the former Joint Staff Surgeon. And Dr. Jeremy Cannon is a 
retired Air Force Colonel and trauma surgeon who currently 
serves on the faculty at the University of Pennsylvania School 
of Medicine.
    I look forward to their testimony. I want to hear their 
recommendations about what Congress and the Department of 
Defense should do to provide long-term stability to the 
Military Health System.
    Military medicine often follows a familiar but regrettable 
cycle. During peacetime, medical teams focus on the treatment 
of ordinary illnesses. When conflict erupts, military medicine 
is frequently caught unprepared, resulting in unnecessary 
casualties.
    This interwar erosion of our unique military medical skills 
is known as the ``peacetime effect.'' To disrupt the 
``peacetime effect,'' Congress enacted sweeping reforms of the 
Military Health System. These reforms, now nearly a decade old, 
were designed to refocus military medicine on its primary 
purpose: combat casualty care and medical readiness.
    We elevated the Defense Health Agency to a combat support 
agency and tasked it with administration of all military 
hospitals and clinics, relieving the military departments of 
that mission. The goal was to have the military services focus 
exclusively on the medical readiness of their forces. These 
ideas were recommended by an independent, bipartisan commission 
embraced by Pentagon leadership, and signed into law in 2017.
    Unfortunately, opponents of these reforms have delayed 
implementation and undermined the effectiveness of the 
legislation. For example, in 2019, the military departments 
implemented drastic cuts to military medical personnel on the 
faulty assumption that it would be easy for DHA to hire 
civilians to take their places.
    This assumption was misguided, which became evident during 
the COVID pandemic. During that crisis, the existing national 
physician shortage accelerated. To this day, private sector 
health systems seek out and hire away doctors from the 
military, not the other way around. We have all seen this in 
our states.
    In 2020, Congress ordered a halt to any additional military 
medical reductions, but it was too late. A significant number 
of reductions had already occurred, severely reducing the 
capability of military hospitals. In many locations, the 
private sector was unable to handle the additional patients, 
sending more servicemembers to private sector care. This has 
proven more expensive and has sapped the military doctors' 
experiences that are vital to maintaining proficiency.
    Even worse, the Department of Defense (DOD) has refused to 
request adequate funding for DHA, which would allow DHA to 
staff adequately and equip its hospitals and clinics. Since 
2015, the budget for military hospitals has decreased by nearly 
12 percent. The water damage at Walter Reed this January is an 
example of the antiquated infrastructure that military medical 
teams work with around the world.
    In addition to the problems I have just explained, I would 
like our witnesses to highlight how bureaucratic delays within 
the Department of Defense have prevented the Military Health 
System from preparing for the next potential conflict.
    Combat casualty care is the primary purpose of the Military 
Health System. When servicemembers are exposed to danger or are 
injured, they need to know that they will receive the best care 
possible. We know that troops in combat are more comfortable 
taking the risks necessary to accomplish their mission if they 
have confidence in military doctors.
    We cannot go back to the way things were before 2017. We 
must stop scapegoating the Defense Health Agency. The 
Department of Defense must request adequate resources to ensure 
the Department's hospitals and clinics are properly staffed and 
equipped. This is the best way to ensure the Military Health 
System is ready for the potential demands of large-scale combat 
operations in the future.
    I thank the witnesses for being willing to testify and now 
recognize Ranking Member Reed for his remarks.

                 STATEMENT OF SENATOR JACK REED

    Senator Reed. Thank you very much, Chairman Wicker, and 
welcome to our witnesses. General Douglas Robb, General Paul 
Friedrichs, and Colonel Jeremy Cannon each bring important 
perspectives from their extensive careers in military medical 
fields. We are fortunate to have such a distinguished panel 
before us.
    Throughout history, military medicine has often represented 
the leading edge of modern health care. Many of the lifesaving 
practices common in today's emergency rooms and clinics were 
born out of necessity on the battlefield hospitals of the Civil 
War, World Wars I and II, Vietnam, and the wars in Afghanistan 
and Iraq.
    Professional expert health care, both in combat and 
peacetime, is a vital component of our military. Our service 
men and women, and their families, deserve nothing but the best 
in this regard.
    I am concerned that our military health care system will be 
challenged to meet the demands of a potential large-scale 
future conflict, particularly in the Indo-Pacific. We have seen 
the terrible challenges of health care in austere environments, 
like the front lines of Ukraine, where supplies and medics are 
often cutoff from the troops in contact. These risks would be 
compounded in the Indo-Pacific where contested logistics and 
the tyranny of distance would be major factors.
    Congress has dedicated considerable attention to reforming 
the Military Health System in recent years, with an eye toward 
any potential future large-scale conflict. The primary 
objective of these reforms has been to improve combat casualty 
care, assume quality medical care for servicemembers and their 
families, and ensure that military medical professionals are 
able to deliver the world's best care on the battlefield, at 
field hospitals, and at medical centers and clinics.
    However, until relatively recently, the Military Health 
System was inadequately designed to meet these missions. For 
decades, the individual military branches managed their own 
Military Treatment Facilities (MTFs) and the Defense Health 
Agency, or DHA, was tasked with managing Defense Department 
health care via civilian providers. This system was hampered by 
unnecessary complexity, a lack of standardization, inefficiency 
and redundancy in the system, and inflated costs. The Military 
Health System was too focused on beneficiary care while 
insufficient attention was paid to combat casualty care.
    To address this, the fiscal year 2017 National Defense 
Authorization Act (NDAA) included provisions restructuring much 
of the system. This legislation transferred responsibility for 
operating the Military Treatment Facilities entirely to DHA. 
This change was intended to allow the military services and 
surgeons general to focus on medical readiness for the force 
and its health care providers.
    Unfortunately, implementation of this legislation has been 
difficult. The military services have not implemented the 
changes readily, and they have failed to staff the treatment 
facilities with the military personnel needed to provide timely 
care. The Department of Defense made progress to break through 
the inertia in 2023, when it issued a memorandum with specific 
direction to save lives and improve the Military Health System, 
to include adequate manning of Military Treatment Facilities, 
and this effort marked a major milestone in modernizing the 
system.
    More work remains to be done, and I hope that the Trump 
administration will continue the momentum in this area. During 
today's hearing, I would ask for our witnesses' views on the 
key challenges remaining for successfully reforming the 
Military Health System and how Congress can help equip the 
Department and our warfighters with the medical support needed 
for any future conflicts.
    Thank you again to our witnesses, and I look forward to 
your testimonies. Thank you, Mr. Chairman.
    Chairman Wicker. All right. We will begin with 5-minute 
testimonies from each of our distinguished witnesses.
    Lieutenant General Robb, you are recognized.

  STATEMENT OF LIEUTENANT GENERAL (DR.) DOUGLAS J. ROBB, USAF 
      (RET.), FORMER DIRECTOR OF THE DEFENSE HEALTH AGENCY

    Dr. Robb. Chairman Wicker, Ranking Member Reed, and 
distinguished members of the Committee, thank you for this 
opportunity to testify on the urgent need to restore and 
sustain our military medical readiness in the face of large-
scale combat operations, and thank you both for what I would 
believe is spot-on comments. So thank you very much.
    Just a little background on where my perspective of the 
Military Health System originates from, I started my military 
career as a boots-on-the-tarmac operational flight doc, both 
stateside and overseas. I have served at the Air Force Squadron 
hospital, clinic, and medical centers in commander positions, 
and at the headquarters level.
    I have also had the honor and privilege to serve our joint 
forces as the U.S. Central Command surgeon, joint staff 
surgeon, and as the first Director of the Defense Health 
Agency.
    Moving forward, a refocus on our ability to support large-
scale combat operations, I believe, will require a 
recalibration of current and future resources to support large-
scale casualty flow, from the battlefield or the sea battle to 
definitive care, rehabilitation, and eventually reintegration. 
All this in the face of incremental pressures from The Office 
of the Secretary of Defense (OSD), The Office of Management and 
Budget (OMB), and the military departments, resulting in a 
decade-plus of flatline actually declining defense health 
program budgets, personnel reductions, erosion of our mission-
critical Military Treatment Facilities, and intense competition 
for quality health care professionals with the private sector.
    One of the key Military Health System organizational 
elements in support of the Military Health System strategy is 
the evolving and maturing Defense Health Agency, designated as 
a Combat Support Agency (CSA). It was established over a decade 
ago. Recently, the DHA's justification, and specifically the 
DHA's designation as a Combat Support Agency, has been 
challenged and questioned.
    In 2011, the Deputy Secretary of Defense issued a memo 
titled ``Review of Governance of Model Options for the Military 
Health System.'' That was driven by the Department's 
significant growth in health care costs. Fast forward a decade 
later--sound familiar?
    The Task Force on Military Health System Governance Reform 
was then established--and this is key--that included co-chairs 
from the Joint Staff, OSD, and flag and senior executive 
service (SES) representation from the Joint Staff, OSD 
Personnel and Readiness, Cost Assess and Program Evaluation 
(CAPE) and Comptroller, and the service surgeons general, for a 
total of nine voting members. And I think it is also important 
to recall the task force overwhelmingly recommended a Defense 
Health Agency organizational model, with a final vote of seven 
for the Defense Health Agency, one for a unified medical 
command, and one for what then was called a single-service 
model.
    The recommendations were briefed through both Joint Staff 
and actually through two Chairmen, and Office of Secretary of 
Defense and actually through two Deputy Secretaries of Defense, 
with the Defense Health Agency construct signed off by the 
Deputy Secretary of Defense with the Chairman's support.
    Another decision that has come into question in recent 
years was the designation of the Defense Health Agency as a 
Combat Support Agency. The designation was initiated by the 
Director of the Joint Staff, with the Chairman's concurrence, 
when reviewing the proposed DHA organizational structure and 
the relationships with both the Chairman and the OSD. The CSA 
designation was then codified.
    Now, a decade later, do I still believe the original 
analysis and the recommendation to stand up a Defense Health 
Agency as a Combat Support Agency remain valid? And the short 
answer is yes. But does a recalibration of the Defense Health 
Agency supporting relationship with its Combat Support Agency 
responsibilities to the supported entities of the military 
departments and the Joint Forces need to be readdressed? And 
again I would say yes.
    I share with you several lines of effort that I believe are 
essential as we strive to further achieve a more tightly 
integrated Military Health System to support our national 
military strategy and our national security strategy.
    Number one, reemphasizing, with clear articulation and 
execution, of the Assistant Secretary of Defense of Health 
Affairs' authority, direction and control of the Defense Health 
Agency.
    Number two, I believe we need to establish a direct 
organizational linkage at the Defense Health organizational 
structure level, with the Chairman of the Joint Chiefs of Staff 
and the combatant commands through the Joint Staff Surgeon, to 
ensure that the responsibilities are prioritized with the DHA's 
execution.
    Finally, the Fiscal Year 2019 NDAA directed the Department 
to establish joint force medical requirements process to 
synchronize the Military Health System's already established 
joint operational requirements governance process. And I think 
that is key, that the medics need to play with the Joint 
Staff's process for determining requirements.
    In closing, I would like to thank you, and look forward to 
support you in assisting the Military Health System's ability 
to accomplish our mission of ensuring a medically ready and a 
ready medical force in support of our military departments and 
combatant commands through the provision of care to our 9.5 
million beneficiaries. Thank you.
    Chairman Wicker. Thank you very much, Dr. Robb.
    Major General Friedrichs.

   STATEMENT OF MAJOR GENERAL (DR.) PAUL A. FRIEDRICHS, USAF 
               (RET.), FORMER JOINT STAFF SURGEON

    Dr. Friedrichs. Chairman Wicker, Ranking Member Reed, and 
members of the Committee, thank you so much for the opportunity 
to be here. I had the opportunity in my very last briefing to 
some members of this Committee in May 2023 to give you a 
classified assessment of MHS readiness, and I will start with a 
recommendation that if you have not had an update since May 
2023, I would implore you to schedule that so that the Joint 
Staff Surgeon can give you the most current classified 
assessment, because what we will provide today is an 
unclassified assessment.
    Second, I will give a disclaimer that the views that I 
express are my own, not those of any organization with which I 
have been affiliated.
    I provided a detailed written statement to you, and I would 
respectfully ask that that be entered into the record of this 
hearing.
    Chairman Wicker. All of the statements will be added to the 
record at this point, without objection.
    Dr. Friedrichs. Thank you very much, Chairman.
    I have two disclaimers. The first, this is my family 
business, so I will speak both from my experience and because 
my dad served in the Navy--98, still alive--at the end of World 
War II. Multiple other relatives in the Navy. My wife is a 
former Army physician who now works for the Department of 
Veterans Affairs (VA). We are very proud that one of our 
children is a marine. I care about this not only because of all 
of the others but because this is what my family has done for 
generations.
    My second disclaimer, like General Robb, is I have had the 
privilege of serving our country now for 39 years, and the 
majority of those years I have spent in joint roles. Congress 
got it right in 1986, with the Goldwater-Nichols Act, but the 
one thing I wish you would change is to include medics as part 
of the military. As long as we preserve this false narrative 
that the Military Health System is separate and not covered by 
the same expectation of jointness as the rest of the military, 
we are going to continue to have these fruitless, bureaucratic 
buffoonery actions that distract us from taking care of 
patients. I encourage you to treat the Military Health System 
like a part of the military.
    We have had tremendous accomplishments over the last 20 
years, with the lowest rate of deaths among injured ever seen 
in conflict, and we should be incredibly proud of that. When I 
deployed, I had what I needed, when I needed it, air-evacuation 
available. I flew air-evacuation missions. I operated on 
casualties. I never lacked for what I needed. I cannot offer 
you the assurance that my successors will have that same 
environment in the next conflict, and I am grateful that you 
are holding this hearing today.
    I have several very specific recommendations. First, as I 
touched on before, we must prioritize the patient over the 
patch, put a nail in the heart of this discussion about 
reorganizations and what the role of the Military Health System 
actually is. We need to commit, and we need your help in the 
next NDAA, to clearly articulate , just as both the Chairman 
and the Ranking Member said, the Military Health System exists 
as part of the military to ensure that we deter those who might 
seek to harm our Nation and defeat them if they try to. The 
military's role is to take care of the human weapon system. The 
health care benefit delivery is part of how we do that, and 
part of a commitment that we make. But I implore you to address 
that in the next NDAA.
    As I said before, I think that you got it right with the 
Goldwater-Nichols Act, and I would encourage you in the next 
NDAA to clearly articulate that you view the Military Health 
System as part of the military and not exempt from the 
requirements that the rest of the military faces. A joint 
casualty stream requires a joint casualty care team. That seems 
relatively straightforward, and yet that is still something 
that we are arguing over, whether medical units should be 
interoperable, whether they should have the same equipment or 
the same training. The answer is yes.
    Look at Israel. Look at almost every other country with a 
large military. They have already made those changes, which you 
rightfully began and appropriately began in 2017. We do not 
need another reorganization. What we need is execution of the 
vision that you laid out.
    The next point that I bring up is resourcing, and both the 
Chairman, the Ranking Member, and Dr. Robb touched on this. 
Health care is not cheap. The mistaken belief that somehow 
military medicine can be done at a lower cost than in the 
civilian sector, and be ready for conflict, is just that. It is 
a mistake and it is a discredit to those who State that they 
care about our patients.
    Finally, I am deeply concerned about our growing 
vulnerability to biological threats. The decisions to take down 
our overseas partnerships to build better biosurveillance, the 
decisions to take down research in biological threats, the 
decisions to take down multiple other programs that we had 
built as a result of the 2018 National Defense Strategy, which 
President Trump signed in the first administration and 
President Biden updated, put us at greater risk. And we must 
continue to address those risks of the evolving biological 
threats, both naturally occurring and deliberate threats. The 
confluence of Artificial Intelligence (AI), biotechnology, and 
compute is dropping the bar dramatically for biological 
threats. We should be working on mitigating that.
    I thank you again for the opportunity to be here and for 
your interest in this.
    [The prepared statement of Dr. Friedrichs follows:]

 Prepared Statement by The Honorable Paul Friedrichs, Maj Gen (ret)., 
                                MD, FACS
    Chairman Wicker, Ranking Member Reed and distinguished Members of 
the Committee, thank you for the opportunity to testify on this topic. 
My last congressional engagement as the Joint Staff Surgeon in 2023 was 
with several of you to provide a detailed, classified update on the 
gaps between Combatant Command requirements for medical support and the 
readiness of the force elements which the Services organize, train and 
equip, with support from the Defense Health Agency (DHA), in its role 
as a Combat Support Agency. It is an honor to be back to share some 
additional observations on this very timely topic on which Congress 
needs to act, in order to address critical gaps in our readiness to 
care for ill and injured Servicemembers.
    The opinions and advice I share in this statement and in my 
testimony are my own; I am not speaking on behalf of any organization 
with which I am or have been affiliated.
    I need to acknowledge several conflicts of interest related to this 
hearing:
    First, and foremost, this is my family's business. . .and I care 
deeply about it. I am the proud son of Seaman Third Class Al 
Friedrichs, who turned 98 this past January and who served in our Navy 
at the end of WWII. Multiple other relatives served in the Navy. One of 
the few really great decisions I have made in my life was to propose to 
my wife more than thirty years ago, when she was serving as a doctor in 
the Army. Our kids thought it was incredibly cool that their mom really 
did wear combat boots. After separating from the Army so that our 
family could stay together, she has worked for the Veterans Health 
Administration for decades, continuing her commitment to care for those 
who volunteer to serve their nation. And one of our children is now a 
marine.
    Second, I am deeply grateful to have had the opportunity to serve 
our Nation in uniform for 37 years, including three tours as a 
Commander, as well as service as the Command Surgeon for Alaskan 
Command, Pacific Air Forces, Air Combat Command and United States 
Transportation Command, where I oversaw the global aeromedical 
evacuation system. My last assignment was for 4 years as the Joint 
Staff Surgeon, attempting to integrate and synchronize medical support 
to military operations and family members on every continent and in 
multiple conflicts and disasters. These experiences have taught me that 
the rest of the military deploys and fights as a Joint Force, not as 
individual Service forces. I believe to my core that the military 
health system is a part of the US military and should adopt the same 
commitment to joint, integrated capabilities and readiness that the 
rest of the military has embraced, and I commend Congress for the 
actions they have taken to try to break down stovepipes and enable 
greater standardization, interoperability, and integration.
    Nearly 250 years ago, our Nation was born out of the American 
Revolution. Historians estimate that between 25,000 and 75,000 members 
of the Continental Army died during this conflict, with three deaths 
from illness for every one death from injury. Roughly 1,400 medical 
personnel served in the Continental Army, but only 10 percent had any 
formal medical training. Since then, we have been on a journey to 
continue improving the care we provide to America's sons and daughters 
who serve their nation in uniform and this has resulted in a steady and 
continuous decline in the percent of injured servicemembers who died of 
their wounds. Numerous innovations in both pre-deployment care and the 
care we provide to deployed personnel have enabled military medics to 
successfully treat and return to duty more and more ill servicemembers, 
enhancing combat capabilities. And for those who sustained injuries in 
Operational Iraqi Freedom/Operation Enduring Freedom, fewer died than 
in any conflict in history. This is an extraordinary testimony to the 
work of countless military doctors, nurses, pharmacists, Corpsmen and 
other military medics. And it was shaped by congressional direction in 
the annual National Defense Authorization Acts (NDAA) and annual 
appropriations which translated that guidance into reality. Thank you 
for all that you and your predecessors have done to enable these 
remarkable results.
    As proud as we should be of these unparalleled accomplishments, 
every organization committed to excellence knows the importance of 
asking ``What could we have done better?'' High performing healthcare 
systems know that ``Good enough'' is not acceptable, especially when it 
comes to the health of America's sons and daughters who choose to 
defend our Nation. Some of our military medical colleagues reviewed the 
available data on every single servicemember who died in recent 
conflicts and what they found is remarkable: even with nearly total air 
superiority, unfettered communications, aeromedical evacuation on 
demand, and largely unhindered supply chains, roughly 25 percent of 
those who died prior to 2012 had injuries which should have been 
survivable. This is an incredibly important--and painful--lesson: We 
could have done even better.
    Unfortunately, we have made insufficient progress toward minimizing 
preventable battlefield injuries and death. In some cases, we have 
mistakenly confused loyalty to the patch on our uniforms over our 
commitment to our patients. We have confused efficiency with 
effectiveness. We have argued for years about roles and 
responsibilities and competing interpretations of congressional intent. 
Thankfully, because the United States is not involved in large scale 
combat operations at this time, we have the opportunity, with help from 
the members of this Committee, to refocus efforts to ensure that, in 
the next conflict, military members will be medically ready before they 
deploy and military medics will be well-prepared to care for those 
servicemembers who become ill, or who are injured.
    The first priority of the military health system must always be our 
commitment to provide the right care at the right place for every 
American who volunteers to serve. We must continue to demonstrate to 
Servicemembers and their families that the military health system will 
be ready to provide the care they need before they deploy, while in 
combat, and when they return, and that we will care for their families 
and for those who have retired from the military. To do so, structural, 
fiscal and policy changes are needed. After studying this for most of 
my career, I urge the members of this Committee to reject any 
recommendations to revert to stovepipes and siloes of care. There is no 
data to support the premise that any one Service delivered better care 
in garrison or down range and ample evidence from multiple conflicts 
that the best outcomes for patients occur when medics work together 
(like the rest of the military does when it deploys). I am dismayed 
that some colleagues continue to assert that some Members of Congress 
appear to question the merits of integrating medical capabilities as 
directed in 2017; this perception has complicated efforts to focus as a 
Joint medical team on improving care to Servicemembers who rely on 
military medics to be ready when needed. I strongly oppose any 
recommendations for another large-scale reorganization of the military 
health system; these take years to implement and will continue to 
distract my colleagues from the important job of improving care by 
requiring them to instead focus on building new bureaucracies. I 
believe the DOD has the capabilities it needs, although, as I will 
address below, not the resources, to truly achieve the vision of great 
care, anywhere for our those who go in harm's way in defense of our 
Nation. Attachment One, National Defense Authorization Act 
Recommendations, summarizes recommended language for the Committee's 
consideration. (NOTE: For any recommendations which fall outside the 
purview of this Committee, I respectfully request that Committee staff 
share the recommendations with the appropriate Committee, and, if 
possible, convey the intent of this Committee related to the 
recommendation.)
    1.  Roles and Responsibilities: In 39 years of government service, 
and especially in military health system ``governance'' meetings, I 
have been dismayed at the amount of time and energy dedicated to this 
topic at the expense of discussing how to improve the effectiveness and 
efficiency of care. I remain deeply grateful for and supportive of the 
changes directed in the 2017 National Defense Authorization Act (NDAA). 
Congress wisely recognized that Servicemembers' anatomy and physiology 
do not vary based on the patch they wear and that we can deliver better 
care if we work as an integrated system, rather a system of competing 
systems. Other than a few niche environments (e.g., care in low gravity 
environments, undersea medicine, etc.), the Senate should direct 
standardization of equipment and training for deployable medical force 
elements, as recommended by the Joint Trauma System (JTS) and also that 
medical force elements must be interoperable (i.e., a Role 2 medical 
force element from one Service can combine with a Role III 3 medical 
force element from another Service, when directed by the Combatant 
Commander in order to provide the right combination of capabilities to 
care for ill and injured servicemembers). Almost every other modern 
military has already done so, and, as our Israeli and German and other 
colleagues have repeatedly shown, military medics deliver more 
effective care more efficiently if we standardize and integrate 
capabilities. The only structural changes I recommend are:

       a.  Dual-hat the Joint Staff Surgeon as the Defense Health 
Agency Deputy Director for Combat Support and align key operational 
support capabilities under this two-star leader, as described below and 
in Attachment 1.

       b.  Require the Combatant Commands to implement the Combatant 
Command Trauma System staffing requirements to ensure readiness to 
collect, analyze and share data on ill and injured in their Area of 
Operations in order to continue to improve the care our Nation's 
defenders receive.

       c.  Require the Defense Health Agency (DHA) to reinState Defense 
Health Agency Procedural Instruction 6040.06, Combatant Command Trauma 
Systems.

    2.  Evolving Threats: Care for ill and injured is challenging and 
there are clearly opportunities to improve that care. And the range of 
threats to which military medics must be prepared to respond is 
growing.

       a.  Disease, Non-Battle Injury (DNBI): Military service is a 
challenging calling, and many medical conditions impact the ability of 
an individual to perform his or her duties. The military asks those 
seeking to enlist or to become officers to voluntarily identify pre-
existing medical conditions and, based on that information, determines 
whether the member is likely to be medically qualified to perform their 
assigned duties. The introduction of electronic health records has made 
it easier to validate the information provided by those seeking to 
serve in the military and, in some cases, has identified medical 
conditions which the applicant did not voluntarily report. Some have 
claimed that this additional visibility into pre-existing medical 
conditions is contributing to lower enlistment rates, although there 
has been limited data to support this assertion. These pre-existing, 
chronic medical conditions may degrade the member's readiness and 
frequently increase the military health system costs once the member is 
on active duty. Clarifying the impact of identifying pre-existing 
medical conditions on both recruiting and on military health system 
costs can help inform decisions about whether to continue to seek this 
information. Furthermore, roughly 80 percent of deployed service 
members who require medical care have medical conditions unrelated to 
traumatic injuries. The most common medical conditions which cause a 
servicemember to no longer be ``medically ready'' include dental, 
musculoskeletal and mental health conditions. Across the Services, more 
than 7 percent of the force is not medically ready prior to deployment, 
immediately decreasing the effectiveness of combat units. To preserve 
the fighting force, military medics must be able to rapidly diagnose 
these conditions and safely and effectively treat them as close to the 
front lines as possible. This committee should:

             i. Require an annual report on actions taken to reduce the 
number of uniformed personnel who are not medically ready to no more 
than 5 percent of the force and the actions taken to improve the 
ability to care for deployed Servicemembers with DNBI as close to their 
deployed location as possible in order to sustain the operational 
capabilities of their unit.

             ii.  Require the Services to provide an annual report to 
Congress on the number and type of medical waivers granted to those 
enlisting in the military (e.g., accession waivers), the number of 
personnel who receive accession waivers and are later determined to be 
medically unfit for duty, including the number and type of accession 
waivers granted as a result of the use of the Military Health System 
Genesis application (i.e., the military's electronic health record) and 
any data on the impact of the use of GENESIS on accession rates.

       b.  Antimicrobial Resistance (AMR): One of the risks for 
servicemembers with traumatic injuries is developing wound infections, 
especially in austere environments. Bacteria or fungi which are 
resistant to multiple antibiotics are growing domestically and globally 
and this has become an increasing challenge for military casualties in 
Europe, Asia and Africa. This Committee should require an annual report 
on steps taken by the Miliary health system to detect and to mitigate 
AMR in military personnel and should review the proposed Pasteur Act 
language to enhance support to develop new antimicrobials to protect 
our Servicemembers.

       c.  Emerging Weapons: Mankind has continued to seek new military 
capabilities which will afford an asymmetric advantage over competitors 
and potential adversaries. Recently develop new technologies like 
hypersonic missiles and directed energy weapons do not appear to create 
revolutionary changes in risk, but, overtime, may cause new patterns of 
injury which military medical personnel must be prepared to treat. 
Waiting until new patterns of injury are seen to begin planning for 
appropriate care should be unacceptable. This Committee should:

             i. Direct the Intelligence Community to prepare an annual 
report on new and updated weapons which create risk to servicemembers;

             ii. Direct DOD to ensure that the Joint Staff Surgeon and 
select members of the Joint Trauma System and Service Surgeons' staffs 
have sufficient clearances to receive these updates;

             iii. Direct the Joint Staff Surgeon, in coordination with 
the Services, the Joint Trauma Analysis and Prevention of Injury in 
Combat program and the JTS, to provide Congress with a classified 
annual assessment of changes needed to training and other military 
medical capabilities to ensure military medical personnel are ready to 
care for casualties from these new or upgraded weapons systems, 
including actions taken by the Services to address findings from prior 
years' assessments

       d.  Burden Shifting: In 2020, the National Academies of Science, 
Engineering and Medicine published an analysis which highlighted the 
lack of resilience and surge capacity in the US healthcare system. The 
recent pandemic unfortunately validated that lack of resilience and, as 
part of the mitigation efforts to protect the American public, as many 
as 70,000 military medics deployed to augment the US healthcare system 
through Defense Support to Civil Authorities (DSCA) taskings. The 
National Disaster Medical System, which was designed to integrate DOD, 
VA and civilian healthcare systems in case of a surge in military or 
civilian patients has been allowed to atrophy. The Regional Emerging 
Special Pathogen Treatment Centers, which are funded to care for 
patients exposed to, or infected with highly contagious infectious 
diseases (e.g., Ebola), have very limited bed capacity; and the ability 
to move these patients depended on capabilities in other agencies which 
apparently have been eliminated. In addition, only the DOD had the 
contracting authorities needed to enable Operation Warp Speed to 
achieve so much so quickly. And recent actions that reduce capabilities 
in other Federal Departments, including the ability to respond to 
disasters at home and abroad are typically mitigated by shifting those 
responsibilities to the Department of Defense. Because of this, the 
Military Health System is likely to see more taskings in the future to 
compensate for these reduced capabilities in other parts of the Federal 
Government. I recommend this Committee should:

             i. Require an annual assessment by the Departments of 
Defense, Health and Human Services and the Veterans Health 
Administration of the resilience of the US healthcare system and the 
readiness of the National Disaster Medical System to support DOD 
operational requirements during Large Scale Combat Operations, 
including the readiness to transport, receive and care for military 
personnel, US government employees and US civilians who are exposed to 
or infected with highly contagious infectious diseases.

             ii. Require ASD(HA) to provide an annual summary of all 
healthcare support provided to other Departments and Agencies which was 
not funded in the DOD budget, as well as any reimbursements received 
for that support.

             iii. Authorize ASPR to execute the same contracting 
authorities that DOD utilized during Operation Warp Speed.

             iv. Sustain ASPR and CDC programs which help State and 
local health authorities continue to improve the readiness of their 
jurisdictions and make that support contingent on a commitment to 
participate in NDMS and, for those hospitals with the appropriate 
capabilities, RESPECT.

       e.  Biological weapons and other threats: The confluence of 
artificial intelligence, increasing computational capacity and rapidly 
evolving biotechnological advances offers incredible potential for new 
treatments. And there will always be people who will seek to misuse 
these new technologies for nefarious purposes; these rapid advances 
significantly lower the bar for State and non-State actors to use good 
technologies in ways that increase the risk to the American public and 
to military members in future conflicts. The best deterrent to ensure 
these weapons are never used is to demonstrate that we will rapidly 
detect their use, attribute it appropriately, and hold those 
responsible accountable, while demonstrating the ability of our health 
system to rapidly mitigate the impact of acute biological threats. The 
foundational research creating these advances was largely based on 
research funded by the Federal Government through the National Science 
Foundation, National Institutes of Health, and the Department of 
Defense. It is critical that the military health system, in 
collaboration with the Departments of Health and Human Services, 
Energy, Homeland Security and the Veterans Health Administration 
continue to invest in research to rapidly develop better tests, 
treatments and vaccines for new and emerging biological threats, as 
well as in enhanced domestic and global biosurveillance capabilities. 
As noted above, the Centers for Disease Control and Prevention and the 
Administration for Preparedness and Response should continue to help 
fund State and local preparedness efforts to increase resilience to 
future biological threats. The Department of State should reinState 
funding for programs which enhance biopreparedness capabilities in 
other countries to improve our ability to detect if a bioweapon or 
other biological threat is occurring outside the US and to assist in 
mitigating the impact of those threats. The 2018 National Biodefense 
Strategy, which was updated in 2022, and the 2023 Biodefense Posture 
Review outline multiple actions needed to enhance our ability to deter 
nations and non-nation states from pursuing or considering employing 
bioweapons. The Bipartisan Commission on Biodefense in 2024 released 
its updated National Blueprint for Biodefense. The 2020 NDAA also 
wisely tasked the Defense Science Board to ``carry out a study on the 
emerging biotechnologies pertinent to national security,'' and that 
report should be released this year. Similarly, the report from the 
National Security Commission on Emerging Biotechnologies (NSCEB) is 
scheduled for release next month and both these new reports will 
provide valuable advice to DOD and to Congress to inform how we best 
leverage these technologies to enhance our national, economic and 
health security. Unfortunately, it appears that at least some of the 
progress made during the past 8 years is being undone by sweeping 
reductions in resourcing for scientific research, surveillance, medical 
countermeasures and Federal, State and local all hazards response 
programs. This Committee should:

             i. Direct DOD to provide Congress with a classified and 
unclassified update on implementation of the 2023 Biodefense Posture 
Review (BPR) within 6 months, including any remaining gaps in 
capabilities and mitigation plans to address those gaps.

             ii. Direct DOD to publish an update BPR which addresses 
all recommendations relevant to DOD from the 2024 National Blueprint 
for Biodefense and the 2025 NSCEB and DSB reports by the end of Fiscal 
Year 2025.

             iii. Direct the DOD to ensure that all DOD hospitals and 
operational labs, including those located overseas, provide the Centers 
for Disease Control and Prevention the same data that is submitted by 
other public health jurisdictions to enhance global and domestic 
biosurveillance.

    3.  Manpower Constraints: Enhancing the readiness of the military 
health system to care for ill and injured servicemembers relies, in 
part, on having the right number and type of military medics. The 
Health Resources and Services Administration (HRSA), in November, 2024, 
updated the Health Workforce Projections for multiple career fields. 
For nursing, they estimate that the current shortages in nursing cannot 
be significantly mitigated until 2037, at the earliest and noted a 
``significant geographic maldistribution'' of nurses. This appears to 
be largely in rural areas where many military bases are located. For 
physicians, the projections are even more dire, with 31 out of 35 
physician specialties projected to have insufficient supply by 2037 and 
an aggregate shortfall of 187,130 physicians across the US. Efficiency 
advocates have asserted that the military health system can eliminate 
military medical positions and either hire civilian replacements or 
shift the care to the private sector. In reality, the military health 
system is able to sustain the current level of care because it trains 
many of its medical personnel internally. Given the congressionally 
directed restrictions on increasing civilian physician training 
programs, closing military training programs will exacerbate both 
military and civilian medical workforces shortages and further degrade 
readiness due to even greater shortages of uniformed medical personnel. 
Efficiency advocates have also attempted to eliminate or substantially 
reduce military medical billets for specialty codes which are not 
required in Operational or Contingency plans; this seemingly logical 
action ignores the reality that mission critical training programs for 
critical care nurses, trauma surgeons and other specialties needed in 
wartime cannot maintain their accreditation to continue training unless 
they are in a hospital with pediatric, obstetrical and other ``non-
mission critical'' departments. And all these workforce challenges are 
reportedly being exacerbated by decreasing retention of key medical 
officer and enlisted specialists due a perception that they cannot 
sustain their medical skills in the current system due to the low 
volume of ill or injured patients in most military hospitals. I 
recommend that this committee should:

       a.  Ensure that any proposed reductions in military medical 
training pipelines are only implemented if Congress authorizes and 
appropriates funding for additional civilian training capacity to 
support military requirements.

       b.  Require the Services to provide updates to ASD(HA) and the 
Joint Staff Surgeon on recruiting and retention of officer and enlisted 
medical personnel by specialty code or equivalent designator and an 
analysis of reasons for separation by specialty code.

       c.  Direct the ASD(HA) and the Veterans Administration 
Undersecretary for Health to provide an assessment within 1 year of 
opportunities to increase physician, nurse and other medical training 
pipelines by integrating and expanding training programs.

       d.  Direct the ASD(HA) to develop a plan and cost estimate to 
increase the number of officer and enlisted students trained at the 
Uniformed Services University to address shortfalls in current training 
pipelines and to assist the Services in improving recruiting and 
retention of military medical personnel required to meet operational 
requirements.

       e.  Require the Services to account for authorizations required 
for military medical training as operational requirements, including 
those for specialties which are required to maintain accreditation of 
training programs for surgical, critical care, and other operational 
capabilities.

    4.  Logistical Constraints: The military health system (MHS) 
prepares and sustains the warfighter, while the defense logistics 
enterprise (DLE) prepares and sustains the equipment and supplies used 
by the warfighter. The two are inextricably linked. Almost all resupply 
of medical units depends on non-medical logistical capabilities and 
capacity. Almost all deploying medical personnel travel on non-medical 
commercial or military logistical platforms. And almost all movement of 
ill and injured servicemembers who cannot return to the fight is 
conducted on non-medical logistical platforms. The Joint Staff 
Logistics Director (J4) routinely performs a ``Logistic Feasibility 
Assessment'' of Operational and Contingency Plans to determine if the 
proposed military operation can be logistically supported. No similar 
analysis has routinely been performed for medical support. In addition, 
as part of previous efficiency efforts, the military health system 
converted from a system which planned for combat to one which 
prioritized the efficiencies garnered from ``just in time resupply.'' 
The United States has the highest number of medications in short supply 
ever recorded; an analysis in 2024 by the Office of Pandemic 
Preparedness and Response Policy found that these shortages were not 
consistently found in other key partners (e.g., European countries, 
Japan, Korea or India), suggesting that policy actions similar to those 
taken by other countries could mitigate some of these shortfalls. In 
addition to shortages of finished pharmaceuticals, assessments by the 
Joint Staff have found that deployable assemblages which are expected 
to be resupplied during large scale combat operations contain 
medications and/or equipment from potential adversaries, or from a sole 
source which may not continue provide these items during a conflict. 
And recent analyses of generic pharmaceuticals have demonstrated 
variability in the efficacy of some medications. I recommend that this 
Committee should:

       a.  Direct the CJCS to include a Medical Feasibility Assessment 
whenever a Logistics Feasibility Assessment is conducted or updated and 
ensure the two are deconflicted as part of regular updates to 
Operational and Contingency Plans and ensure the ASD(HA) and Services 
review the results to identify gaps which can be mitigated through 
changes to policy or Defense Health Program or Service Operations and 
Maintenance funding.

       b.  Require the CJCS to provide an annual report on DOD 
operational medical supply chain vulnerabilities and actions taken or 
needed to reduce these vulnerabilities.

       c.  Direct the DOD to provide a report to Congress within 1 year 
on options to mitigate gaps in patient movement capabilities and 
capacity in the Continental United States during execution of the 
Integrated Continental United States Medical Operations Plan, including 
leveraging Civilian Reserve Air Fleet assets to execute this mission.

       d.  Codify that all future United States Transportation Command 
Mobility Capability Requirements Studies include medical transportation 
requirements for personnel, equipment and patient movement, as 
validated by the Joint Staff Surgeon.

    5.  Partnerships: In the operating room, I was part of a team which 
included nurses and anesthesiologists and other key contributors who 
cared for the patient who trusted us to cure his or her cancer, or to 
repair the damage from a traumatic injury. As a flight surgeon on 
aeromedical evacuation missions, I was part of a team which included 
medics and pilots and other key personnel who worked together to safely 
move an ill or injured Servicemember to the care they needed. As a 
medical leader in our Joint Force, I was part of teams which met 
Combatant Command requirements by leveraging the best of each Service, 
and by partnering with key industry and academic and international 
stakeholders to ensure the next ill or injured servicemember was cared 
for by a military medic who had the appropriate training and equipment 
and supplies to provide the right care at the right place and time. The 
American College of Surgeons has been an especially valuable partner 
for many years, helping to improve care in both the military and 
civilian healthcare systems by sharing information and research through 
the Military Health System Strategic Partnership with the American 
College of Surgeons (MHSSPACS), enabled by the Mission Zero Act. The 
University of Nebraska and the University of Colorado are two examples 
of the strong academic partners which have helped military medicine 
continue to innovate and improve how we train, equip and sustain the 
skills of military medics. In addition, because so many military bases 
are located in rural areas, DOD relies heavily on community partners to 
provide care for Servicemembers and other DOD beneficiaries. Finally, 
our plans to provide necessary medical care in future conflicts and 
contingencies are currently built on the assumption that we will be 
joined by allies and partners, as we have been in every major conflict 
for more than a century. I recommend this Committee:

       a.  Require the DOD to include medical industrial base partners 
identified by the Services and DHA in future Defense Industrial Base 
planning efforts and Joint and Service exercises involving other 
industry partners.

       b.  Require ASD(HA) to provide an annual report on access to 
care in rural communities impacted by changes in funding for Medicaid, 
Medicare or other Federal health programs.

       c.  Direct the DOD to provide a classified report to Congress on 
any assumptions regarding access to or reliance on allies and partner 
nations for medical care for US military personnel during future large 
scale combat operations and the impact on patient care if the United 
States changes its relationship with these nations.

       d.  Reauthorize funding for the Mission Zero Act for military 
civilian partnerships.

    6.  Research and Innovation: The United States has led the world in 
investments in research which have enabled the United States to be the 
leader in multiple industries which support military medical care. 
Academic research centers which have long provided some of the most 
innovative breakthroughs in medicine are facing significant challenges 
due to the announced implementation of a standardized 15 percent 
Indirect Cost Rate for research funded by the National Institutes of 
Health, regardless of the complexity of the research performed, as well 
as the planned 60 percent reduction in funding for the National Science 
Foundation, and reductions in research funding from the Veterans 
Administration and the United Stated Department of Agriculture and the 
Department of Defense, compounded by the proposed tenfold increase in 
taxes on university endowments which might have helped mitigate the 
impact of some of these changes. Within the military health system, 
research funding has been divided between the congressionally Directed 
Research Program (CDRP), which funds research on topics identified by 
Members of Congress, and the remaining research budget, which should 
address gaps in knowledge and capabilities impacting care for ill and 
injured Servicemembers. I recommend that this Committee:

       a.  Require the DOD to provide a report to Congress within 60 
days of the impact of actual and proposed reductions in Federal 
research funding on national security and on the ability to continue to 
pursue innovations and treatments for ill and injured Servicemembers.

       b.  Direct CJCS to prepare an annual prioritized list of 
military medical knowledge gaps requiring research, based on Combatant 
Command and Service inputs, which will be provided to the ASD(HA) to 
inform research funded by the Defense Health Program.

       c.  Require the Director of the Defense Health Agency to provide 
an annual report to Congress showing how research oversight by the DHA 
addresses the operational gaps identified by CJCS, as well as a summary 
of any patents awarded and peer-reviewed publications in the past year 
as a result of military health system-funded research.

       d.  Share the CJCS-identified priority gaps in knowledge 
impacting care for ill and injured Servicemembers with Members of 
Congress to help inform decisions about new CDRP projects.

    7.  Fiscal Realities: The United States Federal budget dramatically 
exceeds revenues and is unsustainable. The United States healthcare 
system is the most expensive system in the world on a per capita basis 
and delivers some of the worst outcomes of any high income country. 
With the current workforce, the annual US healthcare inflation rate has 
averaged 5.11 percent. The Military Health System is a subset of the US 
healthcare system; 70 percent of care for DOD beneficiaries is now 
purchased in the private sector, but the MHS has seen effectively 
almost no growth in funding for medical care over the past 10 years. In 
addition, numerous new benefits have been authorized without additional 
funding. Because our current Tricare contracts are ``must-pay'' bills 
for the Department, the only way to cover these rising costs is to 
divert resources from the direct care system and from accounts which 
should be funding operational medical requirements. Assertions that 
care can continue to be diverted to the private sector without 
impacting readiness or access have not been supported by data and the 
growing shortages of medical personnel nationally and the rapidly 
rising cost of commercial care appear to make this unsustainable course 
to enhance military medical readiness. Until this is addressed, we will 
continue to see declining operational medical capabilities and rising 
costs as more and more care is shifted to the private sector. Civilian 
healthcare is expensive; military healthcare, because of its unique 
additional requirements, is even more expensive. Like other military 
capabilities, there are no direct analogues in the civilian or 
commercial sector for all the capabilities needed by the military 
health system to be able to care for ill and injured servicemembers 
during a conflict. All of the Federal healthcare delivery systems (DOD, 
Veterans Health Administration, Indian Health Services, etc.) face some 
of the same challenges and all have very large, unfunded infrastructure 
requirements to sustain their ability to deliver care (e.g., DOD 
estimates an additional $10 billion is needed to update or replace 
existing medical infrastructure). In many communities with aging 
Federal medical infrastructure, there is an opportunity to develop 
Joint Venture partnerships similar to the ones at Joint Base Elmendorf-
Richardson, or Travis Air Force Base. In addition, creative financing 
mechanisms, like the Communities Helping Invest through Property and 
Improvements Needed for Veterans ACT (CHIP-IN Act), which pools 
Federal, State, local and philanthropic resources to fund 
infrastructure requirements, should be reauthorized and expanded to 
include the DOD. Finally, as authorized by Congress in the 2017 NDAA, 
the DHA must ensure accurate tracking and billing for services provided 
to non-DOD beneficiaries both within the direct care system and when 
military medical personnel are working in partner facilities. The 
mistaken belief that the military or other Federal health systems can 
be funded at lower rates than the civilian sector while achieving 
similar or better outcomes and be ready for future conflicts is a 
remarkably optimistic triumph of hope over reality. To begin to address 
this foundational problem, this Committee should:

       a.  Require that any implementation of new benefits which are 
authorized in an NDAA cannot occur until there is an assessment by CJCS 
of operational impacts, an independent government cost assessment of 
the cost of mitigating the operational impacts and of the cost 
implementing the benefit in both the direct and private care system, 
and sufficient additional funding is appropriated in the Defense Health 
Program to cover these costs.

       b.  Direct that any proposed reductions in services at a 
military treatment facility can only proceed with an endorsement from 
the CJCS that there is no impact on operational requirements, and an 
endorsement from the Services that there is no impact on medical 
officer and enlisted training pipelines, and an independent attestation 
that there is sufficient excess capacity to absorb the workload to be 
shifted to the community , as well as congressional notification at 
least 180 days prior to implementation.

       c.  Direct the ASD(HA) to implement the necessary information 
technology tools and to promulgate policy on accounting for work done 
by uniformed medical personnel in civilian or Veterans Health 
Administration facilities.

       d.  Reauthorize the CHIP-IN Act and amend it to include DOD 
requirements.

       e.  Mandate that the DOD and VA provide a report to Congress in 
6 months on how to consolidate inpatient care in communities where one 
or both Departments are requesting funding for infrastructure 
investments which exceed $100 million annually.

    8.  Uniformed Military Medical Leadership: Congress wisely 
recognized that successful implementation of the reforms mandated by 
the 1986 Goldwater-Nichols Act required a new type of leader who 
understood the value of Jointness and who had personal experience in 
that environment. For a variety of reasons, military medical leaders 
have been exempted from this requirement, making them the outliers in 
the Department of Defense, with limited understanding of the 
opportunities and challenges implicit in the Joint Force. I recommend 
that this Committee should:

       a.  Remove the Goldwater-Nichols Act exception for military 
medical General and Flag Officers;

       b.  Require that any future Directors of the Defense Health 
Agency must have previously served as either the Joint Staff Surgeon, 
or as a Combatant Command Surgeon and must have commanded a hospital 
which supported Graduate Medical Education programs.

                              ATTACHMENT 1
         suggested national defense authorization act language
    Clarify that the military health system is a part of the military 
and, to the greatest extent possible, should use the same processes, 
procedures and measures used by the rest of the military, including:
    A. Civilian oversight of the MHS: As in the rest of the military, 
the MHS is led by civilian leadership nominated by the President and 
confirmed by the Senate, acting under the authority which the Congress 
and the President have invested in the Secretary of Defense. The 
Assistant Secretary of Defense for Health Affairs (ASD(HA):

      1.  Serves as the principal medical advisor to the Secretary of 
Defense

      2.  Leads and provides oversight of the MHS and the Defense 
Health Program (DHP), including developing and executing an MHS 
Strategic Plan which will:

        a.  Require endorsement by the Chairman of the Joint Chiefs of 
Staff (CJCS) and the Secretary of Defense prior to transmittal to 
appropriate congressional Committees annually

        b.  Include measurable goals and objectives by quarter and 
fiscal year, including:

             i. Readiness metrics approved and monitored by the 
Assistant Secretary of Defense for Readiness, in coordination with the 
CJCS, through the process used by the rest of the military to assess 
readiness of deployable and in-garrison capabilities, including

             ii. All patient movement and Role 2 and above medical 
force elements

             iii. Any required equipment or other assemblages

             iv. Surveillance for and response to bioweapons

             v. The percent of servicemembers by unit who are not 
medically ready.

             vi. Quality metrics for assessing the effectiveness of 
care provided to DOD beneficiaries both in the direct care and the 
purchased care system, including access to care.

             vii. Quality metrics developed by the Joint Trauma System, 
in coordination with the Joint Staff, Combatant Commands and Services, 
to assess the effectiveness of care provided in deployed locations and 
in the patient movement system

             viii. Fiscal metrics assessing the efficiency of the 
direct care and purchased system against established targets, including 
targets for beneficiary enrollment and leakage to the purchased care 
system for each Military Treatment Facility

             ix. Patient satisfaction metrics for both the direct care 
and purchased care systems

             x. Availability of uniformed medical personnel for 
healthcare delivery, by location of assignment, when not deployed

             xi. Metrics should be trended over time and, where 
available, should be compared to US national benchmarks

        c.  Service input to this plan is necessary, but Service 
concurrence is not required; the plan should clearly identify any goal 
or objective with which one or more Services does not concur.

      3.  Establishes necessary policies to ensure the MHS provides 
high quality care for all DOD beneficiaries; Joint Staff and Service 
input to MHS policies is necessary; critical non-concurrence with a 
proposed policy will be adjudicated as follows:

        a.  Policies affecting medical operational capabilities: 
Services, Combatant Commands, with support from the Director of the 
Joint Staff, will bring areas of disagreement to the Tank and then make 
recommendations to the Secretary of Defense

        b.  All other policies will be adjudicated through governance 
structures overseen by ASD(HA) or the Undersecretary of Defense for 
Personnel and Readiness.

      4.  Ensures that research funded by the Defense Health Program 
addresses the CJCS-identified gaps in knowledge impacting care for ill 
and injured Servicemembers.

      5.  Serves as the immediate supervisor of the Director of the 
Defense Health Agency (DHA).

      6.  Is the final approval authority for all fiscal decisions 
related to the Defense Health Program (DHP) and communicates to 
Department of Defense leadership and to Congress the fiscal 
requirements for providing optimal in-garrison and purchased care, any 
gaps between requirements and resources and plans to mitigate those 
gaps.

      7.  Provides the Services with a template for reporting quarterly 
on the location, availability for MTF utilization, and other 
responsibilities of all uniformed and civilian personnel funded or 
aligned in any way with each Service or sub-component.

    B.  Chairman of the Joint Chiefs of Staff Oversight of Military 
Medical Operational Support

      1.  Operational and Contingency Plans. As defined by the 
President and the Secretary Defense in the Unified Command Plan, CJCS 
will ensure these plans clearly define:

        a.  Operational and training requirements for Role 2, 3, 4 and 
5 deployed medical force elements and equipment with the goal of 
preserving the fighting force in order to win future conflicts by 
optimizing return to duty as quickly and safely as possible.

        b.  Operational requirements and resourcing for blood products 
(e.g., whole blood, freeze dried plasma, etc.) as close to the point of 
injury as possible using planning factors developed by the Joint Staff 
Surgeon, in coordination with the Combatant Command, Services and with 
concurrence from the ASD(HA).

        c.  Patient movement requirements for ill and injured 
servicemembers and other combatants who cannot be returned to duty, 
including those exposed to or infected with highly contagious 
infectious diseases.

        d.  Explicit acknowledgement of any reliance on allies or 
partners to provide medical care and attestation from Combatant Command 
that the Ally or partner has affirmed they have the necessary 
capabilities and capacity to provide this care to US personnel.

        e.  Ensure that the Integrated Continental United States 
Medical Operations Plan (ICMOP) includes

             i. Requirements for acute and rehabilitative care for ill 
and injured returning to the US

             ii. Requirements for patient movement from Aerial Ports of 
Embarkation and Debarkation to appropriate levels of care.

             iii. Planning factors from the Department of Health and 
Human Services and the Veterans Health Administration for available 
beds once the National Disaster Medical System is activated

             iv. Planning factors from the Tricare Purchased Care 
contractors for available beds within the purchased care system.

             v. Supplemental funding estimates for sustaining care for 
in-garrison DOD beneficiaries and any beneficiaries reliant on DOD 
medical personnel who are tasked to deploy during a contingency

             vi. Plans to expand blood collection, processing and 
delivery to DOD to meet operational requirements.

      2.  CJCS oversight of medical readiness. In coordination with the 
ASD(R), the Joint staff will monitor, report and address readiness of 
all required medical capabilities listed above, using the same 
processes used for the rest of the military.

      3.  CJCS oversight of Combat Support agencies: As with other 
Combat Support Agencies, CJCS will conduct a Combat Support Agency 
Review to assess the readiness and effectiveness of actions taken by 
the Defense Health Agency (DHA) to support Combatant Command (CCMD) and 
Service operational requirements and will provide an annual report to 
Congress summarizing progress and shortfalls in DHA's performance.

      4.  CJCS will provide ASD(HA) with a prioritized list of 
knowledge gaps impacting care for ill and injured Servicemembers 
derived from input from the Combatant Commanders and Services.

    C.  The Service Secretaries (Army, Navy and Air Force) will:

      1.  Organize, train and equip medical force elements to meet 
operational requirements defined by the Combatant Commanders through 
established CJCS and OSD processes.

      2.  Organize, train and equip medical force elements to perform 
Joint Trauma System-required activities during contingencies and ensure 
data collection on all ill and injured personnel in accordance with 
JTS-defined requirements.

      3.  Standardize all equipment in deployable assemblages across 
Services in accordance with JTS recommendations; exceptions to this 
requirement will require approval by the CJCS and Deputy Secretary of 
Defense, as well as notification to the Senate and House Armed Services 
Committees within 30 days of the exception being granted and before any 
acquisitions for Service-specific equipment is executed.

      4.  Implement JTS-identified standardized training for deployable 
force elements (e.g., Role Two ground medical force elements, patient 
movement force elements, etc.)

      5.  Report the readiness of all deployable patient movement and 
Role II and above medical force elements and equipment through 
processes established by ASD(R) and the Joint Staff.

      6.  Fund operational medical requirements outside the scope of 
the DHP and inform ASD(HA) of any unfunded operational medical 
requirements and planned mitigation measures no later then the 
beginning of the third quarter of each Fiscal Year.

      7.  Fund Service-specific research to enhance operational medical 
readiness and inform ASD(HA) of any unfunded operational medical 
requirements and planned mitigation measures no later then the 
beginning of the third quarter of each Fiscal Year.

      8.  Provide DHA with quarterly updates on all uniformed and 
civilian personnel as described above.

      9.  Ensure that Nominees to serve as the Director of the DHA must 
have served as either the Joint Staff Surgeon, or as a Combatant 
Command Surgeon and have commanded an MTF with inpatient capabilities 
and graduate medical education programs.

    D.  Defense Health Agency as a Combat Support Agency:

      1.  The Joint Staff Surgeon will be dual-hatted as the DHA Deputy 
Director for Combat Support and will:

        a.  Provide direct oversight of the Joint Trauma System 
Director, in order to ensure the JTS:

           i. Incorporates best practices and Clinical Practice 
Guidelines into the MHS Genesis and medical education programs for both 
officers and enlisted military medical personnel

           ii. Provides requirements to the Services for data 
collection as far forward as possible, with reporting to Combatant 
Command Joint Trauma System offices.

           iii. Identifies standardized, interoperable equipment for 
Service-provided deployable medical force elements which support CCMD 
operational requirements.

           iv. Identifies and provides to the Services standardized, 
training for Service-provided deployable medical force elements which 
support CCMD operational requirements.

        b.  Provide direct oversight of the Director of the Armed 
Services Blood Program, in order to ensure the ASBP:

           i. Develops planning factors for operational blood component 
utilization

           ii. In coordination with USNORTHCOM, the Department of 
Health and Human Services and other stakeholders, plans to expand US 
blood collection, processing and distribution as needed to meet 
validated operational requirements.

        c.  Provide direct oversight of the Director of the Armed 
Forces Medical Examiner System (AFMES), in order to ensure the AFMES:

           i. Reviews, in coordination with the Joint Trauma System, 
any deaths of uniformed or civilian military personnel while training, 
in-garrison or during contingency operations, including those for which 
a civilian medical examiner performs the forensic pathology exam

           ii .Prepares annual reports identifying opportunities to 
reduce risks to servicemembers.

           iii. Sustains accreditation by the National Association of 
Medical Examiners

        d.  Provide requirements to update MHS Genesis and other MHS 
systems to optimize data collection, analysis and reporting in order to 
improve outcomes for ill and injured servicemembers.

        e.  Provide oversight of public health activities aligned under 
the DHA as required by 10 U.S.C. Sec.  1073c, as amended.

           i. Ensure all DOD hospitals and overseas labs are 
transmitting the same standardized surveillance data to the Centers for 
Disease Control and Prevention as do other Public Health Jurisdictions.

           ii. Partner with Services to ensure waste water surveillance 
is implemented at DOD installations.

           iii. Implement biosurveillance programs to detect and 
mitigate the risk of naturally occurring and deliberate biological 
threats.

      2.  The Defense Health Agency will reinState Defense Health 
Agency Procedural Instruction 6040.06, Combatant Command Trauma 
Systems.

      3.  Defense Health Agency and Health Care Benefit Delivery-all 
other functions of the DHA related to healthcare benefit delivery will 
be executed in a manner which:

           i. Enhances readiness of the military health system to care 
for the ill and injured in future conflicts;

           ii. Optimizes access to healthcare for DOD beneficiaries in 
the direct care system and, when necessary, in the purchased care 
system, with the objective of caring for those DOD beneficiaries with 
the greatest medical needs (i.e., the ``highest acuity'') in the direct 
care system, whenever possible;

           iii. Optimizes health-related outcomes for DOD beneficiaries 
as effectively and efficiently as possible.

    E.  Clarify the intent of Congress related to funding for the 
Military Health System including:

      1.  Requiring that any new healthcare benefits are only enacted 
following:

        a.  Assessment endorsed by the CJCS of any impact on 
operational readiness of the proposed new benefit.

        b.  Completion of an Independent Cost Estimate endorsed by the 
Managed Care Support contractors and the ASD(HA) which mitigates any 
operational impacts and validates the cost of implementing the benefit

        c.  Appropriation of sufficient funding for the proposed new 
benefit

      2.  Requiring notification to Congress of resource shortfalls 
which preclude delivering care in the direct care system which enhances 
the readiness of the military health system to care for ill and injured 
during future conflicts, or the care to which DOD beneficiaries are 
entitled.

    Chairman Wicker. Thank you, Dr. Friedrichs.
    Colonel Cannon.

  STATEMENT OF COLONEL (DR.) JEREMY W. CANNON, USAFR (RET.), 
 PROFESSOR OF SURGERY, PERELMAN SCHOOL OF MEDICINE, UNIVERSITY 
                        OF PENNSYLVANIA

    Dr. Cannon. Chairman Wicker, Ranking Member Reed, and 
distinguished members of the Committee, thank you for the 
opportunity to testify. These comments are my own and do not 
reflect an official position of my employer, Penn Medicine, or 
of the Hoover Institution, where I current serve as a Veteran 
Fellow.
    As a practicing trauma surgeon, I have cared for injured 
warfighters in both Iraq and Afghanistan. I have directed the 
DOD's only Level I trauma center, and now I lead a Penn 
Medicine Navy partnership for trauma training. I know firsthand 
what it takes to save lives on the battlefield and what happens 
when we fail to sustain medical readiness.
    I want to start by sharing the story of the unexpected 
combat casualty survivor that I took care of in 2010. Note, I 
will use a pseudonym throughout my comments for patient 
privacy.
    U.S. Army Sergeant Erik Ramirez was on patrol in 
Afghanistan when a sniper's bullet tore through his chest, just 
above his body armor. His injuries were truly catastrophic. But 
thanks to decades of investment and innovation in combat 
casualty care, a military trauma team pulled him up out of his 
certain death spiral by placing him on heart and lung bypass, 
on the battlefield. Days later, I had the honor of caring for 
Sergeant Ramirez in the United States, as he reunited with his 
family.
    This unequivocal display of medical supremacy was not 
accidental. It was built on years of research, training, and 
policy reforms. But I fear that if Sergeant Ramirez suffered 
this same injury now, he would die a preventable death on the 
battlefield.
    Today, only 10 percent of military general surgeons get the 
patient volume, acuity, and variety they need to remain combat 
ready. We are actively falling into the trap of the peacetime 
effect.
    Meanwhile, as the MHS struggles, our enemies continue to 
grow stronger. Projections estimate a peer conflict could 
produce as many as 1,000 casualties per day, for 100 days 
straight, or more, a scale not seen since World War II. Neither 
the current MHS nor the civilian sector can absorb this impact. 
What's more, many of these patients will have survivable 
injuries, yet one in four will die at the hands of an 
unprepared system.
    How can we meet this living threat? First, we must clearly 
articulate the root problem of our failed readiness efforts. No 
one in DOD truly owns combat casualty care. In 2017, the Joint 
Trauma System (JTS), was codified in law. This Committee must 
now strengthen the statutory language to affirm that JTS owns 
combat casualty care and to provide this precious resource with 
both top-down authority and bottom-up support.
    Then we must push the MHS to refocus on forward-deployed 
care, the one thing that only military medicine can do. For 
this I recommend three lines of effort.
    First, clinical training. In order to train the way we 
fight, we must establish five to six high-volume Military 
Treatment Facility Centers of excellence for both trauma and 
burn care. These centers must undergo civilian accreditation 
and fully integrate into a national trauma and emergency 
preparedness system.
    We also need to strengthen and expand our military-civilian 
partnership sites where military trauma teams manage critically 
injured patients on a daily basis, like my partnership program 
at the University of Pennsylvania. To do so, Congress must 
reauthorize the Pandemic and All-Hazards Preparedness Act and 
fully appropriate the Mission Zero Act.
    Second, combat casualty research. To succeed on complex 
future battlefields, DOD medical research must refocus on pre-
hospital care, team training, bleeding control, battlefield 
blood transfusions, regenerative medicine, and long-term 
outcomes. In order to fully understand the effects of 
battlefield treatments we must link DOD Trauma Registry data 
with VA records.
    Finally, we need to unify military trauma system strategy. 
We must urgently develop and implement a whole-of-society 
roadmap, aligning military, VA, and civilian systems for both 
peacetime readiness and large-scale combat operations.
    The bottom line, if we maintain the status quo and enter a 
peer conflict unprepared, we will condemn thousands of 
warfighters to preventable death. Without urgent intervention, 
the MHS will continue to slide into medical obsolescence. To 
restore the medical supremacy that saved Sergeant Ramirez, we 
must act now. Mr. Chairman, members of the Committee, our 
warfighters and our Nation deserve medical supremacy.
    Thank you for your time, and I look forward to the 
comments.
    [The prepared statement of Dr. Jeremy W. Cannon follows:]

   Prepared Statement by Colonel (Dr.) Jeremy W. Cannon, USAFR (Ret.)
    Professor of Surgery, Perelman School of Medicine University of 
                              Pennsylvania
    Chairman Wicker, Ranking Member Reed, and distinguished members of 
the Committee, thank you for the opportunity to testify on the urgent 
need to restore and sustain military medical readiness in the face of 
large-scale combat operations (LSCO).
    As a practicing trauma surgeon with multiple combat deployments, I 
have seen the full gamut of combat casualty care from far forward in 
Iraq and Afghanistan to Brooke Army Medical Center where I served as 
Trauma Medical Director for the Department of Defense's (DOD) Level I 
trauma center during the height of combat operations. I now serve in a 
different capacity as Assistant Dean for Veteran Affairs for Penn 
Medicine and as an attending in the Surgical Intensive Care Unit in our 
Veterans Affairs (VA) Medical Center in Philadelphia.
    At Penn Medicine, I am also proud to lead an embedded US Navy 
trauma team as the civilian surgeon champion. This partnership enjoys 
enthusiastic support from deeply invested Penn Medicine leaders 
including our Chief Executive Officer, Mr. Kevin Mahoney. As a 
reservist, I worked with RADM (Dr.) David J. Smith in Health Affairs 
where I first appreciated the importance of good policy to mission 
success, and now as a Veteran Fellow at the Hoover Institution, I have 
the opportunity to study the effects of military health policy over 
time. Finally, like many of you and my colleagues here today, I have 
multi-generational family ties to the military with my oldest son now 
training as a Naval Intelligence Officer.
    I want to start by sharing a story of an unexpected combat casualty 
survivor. In 2010, US Army Sergeant Erik Ramirez* suffered a 
devastating chest injury while on patrol in Afghanistan. A sniper's 
bullet passed just above his body armor, tearing through the airways 
and vessels in his right lung. What happened next was nothing short of 
a medical miracle. After damage control surgery to arrest the bleeding, 
SGT Ramirez was placed on heart and lung bypass on the battlefield. 
With this heroic intervention, he pulled up out of a spiral of certain 
death, and a few short days later, I had the privilege of caring for 
him as he was re-united with his family in San Antonio.
* Name changed for patient privacy
    The survival of SGT Ramirez resulted from decades of investment in 
combat casualty care. Through the efforts of many dedicated military 
and civilian visionaries, we established a cutting-edge trauma system 
in the heart of a combat zone. Through these intensive efforts and 
close collaboration with line leaders, we achieved the best survival 
rate on any battlefield in history. In sum, we achieved medical 
overmatch and leveraged our medical supremacy into a strategic 
advantage.
    But I fear that if SGT Ramirez suffered the same injury in combat 
today, he would not survive. Why? In short, combat casualty care 
training and skills maintenance lose out in peacetime. Since the end of 
combat operations in Iraq and Afghanistan, we have seen a systematic 
erosion of military medical readiness. Today, fewer than 10 percent of 
military general surgeons get the critical case volume and patient 
acuity they need to be combat-ready.(1)
    What is the cost of this erosion? It can be measured in lives lost: 
one in four battlefield deaths are potentially survivable. This 
reflects what I term the medical ``peacetime effect''--a recurrent 
failure to sustain combat medical capabilities between wars. Although 
this cycle has played out for centuries, today's peacetime effect is 
driving us toward medical obsolescence precisely as our adversaries' 
power is ascendant. Should a large-scale conflict materialize, we 
anticipate casualty numbers as high as 1,000 per day for at least 100 
days--casualty loads not seen since World War II, a scale far beyond 
what our current system can handle.(3) True medical readiness could 
mean the difference between winning and losing.
    The challenge of maintaining a ready medical force during peacetime 
represents a true ``wicked problem.'' Yet, one of the root causes of 
this erosion in our medical readiness is clear: no single entity in the 
DOD truly owns combat casualty care. COL (Dr.) Bob Mabry, a decorated 
hero of the battle of Mogadishu, warned in his testimony to the House 
Armed Services Committee nearly a decade ago, ``When everyone is 
responsible, no one is responsible.'' To this day, combat casualty care 
responsibility remains fragmented across military departments, the 
Defense Health Agency, and individual service commands. With ongoing 
diffusion of responsibility, we will fail, and our warriors will die 
needlessly.
    top priority: establish clear ownership of combat casualty care
    Combat casualty care represents a critical warfighting capability--
the equivalent of a high-value weapon system, not just a cluster of 
medical tents deployed in a contingency environment. To ensure the 
optimal use of this valuable asset, the Armed Services Committee should 
establish clear ownership of combat casualty care within the DOD. To 
accomplish this objective, I strongly recommend both elevating and 
streamlining the reporting structure for the MHS. Command and control 
of the MHS should be commensurate with the importance of the mission. 
The Joint Trauma System (JTS) must have direct responsibility for and 
authority over all aspects of combat casualty care policy, training, 
and readiness. The JTS Director should report directly to the Secretary 
of Defense through the Joint Staff Surgeon. This organizational 
construct will ensure combat casualty care is fully aligned with our 
contingency operational strategy.
    With a clear line of responsibility and authority for combat 
casualty care, we can then restore and sustain military medical 
readiness for LSCO by focusing on three key areas:
1) Clinical Training and Sustainment: Joint Military Trauma/Burn 
        Centers of Excellence, National Disaster Medical System, and 
        Civilian Trauma/Burn Partnerships
    Combat trauma readiness requires military medical personnel to have 
routine exposure to high-acuity trauma cases, something that most 
military treatment facilities (MTFs) currently lack. To correct this, 
we must consolidate military trauma training into a select group of 
five to six joint MTFs verified and designated as trauma and burn 
centers of excellence by civilian accrediting bodies. These trauma/burn 
MTFs must fully participate in the civilian trauma system organized 
around a series of Regional Medical Operations Coordinating Centers 
(RMOCCs).
    These trauma/burn MTFs must also align with the National Trauma and 
Emergency Preparedness System (NTEPS), a concept developed by the 
American College of Surgeons Committee on Trauma.(4) Utilizing RMOCCs 
as its basic unit of action, NTEPS provides a framework to integrate 
daily trauma care with mass casualty preparedness, ensuring that the US 
trauma system--including military, VA, and civilian resources--can 
seamlessly scale to handle mass population events including large-scale 
combat operations, acts of terrorism, natural disasters, or pandemics. 
At this critical moment, the Armed Services Committee should enact 
statutory authority and identify a lead agency to effect this essential 
alignment between these trauma/burn MTFs and NTEPS.
    Military, VA, and select civilian patients should preferentially be 
funneled to these regional trauma/burn MTFs. Legislative authority to 
manage civilians in these centers already exists, although coding and 
billing best practices represent opportunities for continued 
improvement. By increasing the clinical volume and acuity in these five 
to six large MTFs, we will also ensure that our military Graduate 
Medical Education (GME) programs provide exceptional training aligned 
with contemporary operational needs.
    Beyond these five to six trauma/burn MTFs, the current small 
network of military-civilian partnership programs (MCP) must be 
expanded. To meet the scale of the readiness need, existing and future 
MCP sites must be high-volume civilian trauma centers where military 
trauma teams can be embedded as part of an integrated readiness 
plan.(5) Access to burn training and opportunities to embed critical 
wartime GME training slots within these programs should also rank as 
preferred features of prospective sites.
    Opportunities for the Committee to support MCPs include:
      Mission Zero Act (MZA)--This initiative funded under the 
Pandemic and All Hazards Preparedness Act (PAHPA) supports military 
trauma teams embedded within high-volume civilian trauma centers, 
including our center at Penn Medicine. To continue this high-yield 
investment in clinical training, PAHPA needs immediate reauthorization 
with full MZA appropriation. Future expansion of this program should 
include DOD funding as well.
      Military Health System Strategic Partnership with the 
American College of Surgeons (MHSSPACS)--This joint military 
partnership with an academic surgical society seeks to improve surgical 
care for both military and civilian patients by fostering 
collaboration, exchanging best practices, and advancing military 
education, research, and quality initiatives. An expanded role for 
MHSSPACS should include 1) verifying MCPs using accepted requirements 
and quality standards and 2) advising the JTS on military-civilian 
trauma system integration to optimize medical readiness for both the 
MHS and civilian healthcare. MHSSPACS-type partnerships should expand 
to other critical wartime specialties beyond surgery.
2) Research: Focus the DOD Medical Research Budget on Combat Casualty 
        Care
    The Defense Health Program (DHP) funds a wide range of research, 
but we must refocus efforts principally on combat casualty care--from 
injury prevention to pre-hospital care and acute surgical care through 
to rehabilitation and recovery. Research should prioritize pre-hospital 
care (including prolonged field care), hemorrhage control, battlefield 
resuscitation, rehabilitation, and regenerative medicine. These 
research efforts must also consider potential peer-adversary threats 
within a multidomain (land, air, sea, space, and cyber) battlefield 
environment. I encourage you to work with your colleagues on Defense 
Appropriations to prioritize research funding in these key areas of 
direct relevance to the warfighter with applications to other domains 
of public concern including emergency medical services, law enforcement 
as medical first responders, civilian trauma, and disaster response.
    We must also eliminate barriers to understanding long-term outcomes 
following combat injuries by linking DOD Trauma Registry (DODTR) 
records with current VA medical records at the individual patient 
level. Further opportunities for improving battlefield survivability 
and optimizing outcomes lie in fostering partnerships with trusted 
academic research institutions with the wherewithal to innovate in 
prehospital care, trauma and burn management, traumatic brain injury, 
and the psychological and ethical aspects of LSCO. Such investments 
will fill a need not addressed by the National Institutes of Health and 
other agencies that fund medical research, and they will benefit both 
warfighters as well as civilians impacted by acts of terrorism, acts of 
war, and natural disasters.
3) Policy: Develop and Implement a Unified Joint Military Trauma System 
        Strategy
    Decades of reports from the Government Accounting Office, RAND, the 
National Academies, and past congressional hearings all point to the 
same conclusion: we lack a coherent, unified strategy for military 
medical readiness that will deliver expert trauma/burn care on future 
battlefields while also benefiting civilian trauma care and public 
health. In the words of Nadia Schadlow, a colleague at the Hoover 
Institution and the primary author of the 2017 National Defense 
Strategy, generating more reports or commissioning new studies will 
only perpetuate the ``crisis of repetition.''
    To break this cycle, I am currently working with Uniformed Services 
University and other key stakeholders to develop a comprehensive 
military trauma system policy roadmap that considers the direct care 
component, civilian partnerships, the role of the National Guard and 
reserves, synergy with the VA, involvement with NDMS and NTEPS, 
research priorities, and training requirements. This roadmap will need 
congressional support to succeed.
  the bottom line: we must demonstrate medical excellence from day one
    In Iraq and Afghanistan, it took us three to 4 years to develop a 
trauma system in theater and another five to 6 years to achieve the 
medical supremacy that allowed us to save SGT Ramirez. We will not have 
10 years in the next war.
    A near-peer conflict--whether in the Pacific, Europe, or beyond--
will generate massive casualty numbers from day one. If we enter that 
fight unprepared, we will condemn thousands of our warfighters to 
potentially preventable death. As General Peter Chiarelli painfully 
noted in his testimony for the National Academies, ``You have just got 
to pray your son or daughter or granddaughter is not the first casualty 
of the next war.''
    Will it take another Pearl Harbor or 9/11? Or do we have the will 
to act now to re-establish and sustain our medical supremacy before the 
first shot is fired? I submit that we cannot allow history to repeat 
itself by sending the next generation of our warriors into combat 
without a fully ready medical service supported by a highly functioning 
JTS. Mr. Chairman, members of the Committee, our warfighters deserve 
military medical supremacy.
                               references
    1.  Dalton MK, Remick KN, Mathias M, et al. Analysis of surgical 
volume in military medical treatment facilities and clinical combat 
readiness of US military surgeons. JAMA Surg 2022;157:43-50.
    2.  Cannon JW, Gross KR, Rasmussen TE. Combating the peacetime 
effect in military medicine. JAMA Surg 2021;156:5-6.
    3.  Deussing EC, Post ER, Lee CJ, et al. Advancing systematic 
change in the National Disaster Medical System (NDMS): Early 
implementation of the US Department of Defense NDMS pilot program. 
Health Secur. 2024; e-pub ahead of print.
    4.  Armstrong JH, Bulger E, Kerby JD. National Trauma and Emergency 
Preparedness System (NTEPS). Available at: https://www.facs.org/media/
u1hpi2ce/nteps-blueprint.pdf. Accessed March 5, 2025.
    5.  Cannon JW, Holt DB, Potter BK, et al. Partnerships to overcome 
the peacetime effect: Excelsior Surgical Society panel session. J Am 
Coll Surg 2025; e-pub ahead of print.

    Chairman Wicker. Thank you, Dr. Cannon, and I commend each 
of you for your excellent testimony.
    Let me just get quick answers here from all three of you. I 
think what I am hearing from all three of you is that this is 
going to require more than simply good management of what we 
have on the books now. Each of you is recommending changes in 
the statute that need to come in this coming NDAA. Is that 
right, Dr. Robb?
    Dr. Robb. Yes.
    Chairman Wicker. And Dr. Friedrichs?
    Dr. Friedrichs. Yes, sir.
    Chairman Wicker. And Dr. Cannon?
    Dr. Cannon. Yes, Mr. Chairman.
    Chairman Wicker. All right. Let's talk about military 
surgeon readiness for combat care. There was a study out in 
2021. It found that the population of military general surgeons 
meeting necessary readiness standards decreased from an already 
low 17 percent in 2015 to about 10 percent in 2019.
    We will let all three of you take a brief chance at answer 
this. Why is this happening, and what specifically can DOD do 
to reverse this trend? And we will just start with Dr. Robb and 
go down the table.
    Dr. Robb. We will try to share different perspectives here. 
I think it comes back to the system to be able to resource the 
requirements that we need. So, for example, if you want to look 
at what Dr. Cannon referred to as the five to eight, what we 
call critical Military Treatment Facilities, in order for us to 
provide a higher volume, high acuity care, they need to be 
resourced. And I think that is the challenge that we all face 
right now, is what is that strategic reserve with our Military 
Treatment Facilities, and then how you augment that with the VA 
and the Department of Defense partnerships, and then how do you 
augment that with the military----
    Chairman Wicker. Is that what he called the centers of 
excellence?
    Dr. Robb. So I would call them--that is one way to call 
them, but I, coming from the airlifter world--in fact, General 
Friedrichs and I would both say follow the casualty flow. And 
the casualty flow comes in from United States Indo-Pacific 
Command (INDOPACOM) to primarily we will be coming to two or 
three Military Treatment Facilities. From United States 
Southern Command (SOUTHCOM) they will be coming into the 
National Capitol region. And then from Europe, United States 
Central Command (CENTCOM) and United States African Command 
(AFRICOM), they will be coming into primarily National Capitol 
region and then with a popoff at Portsmouth.
    Chairman Wicker. Okay. Dr. Friedrichs, is this 10 percent 
number a concern, and why do we have 10 percent of military 
surgeon readiness?
    Dr. Friedrichs. Mr. Chairman, it absolutely is a concern. 
When I did my training in the military, I trained at the old 
Wilford Hall, that was a Level I trauma center. I took care of 
trauma patients because it was a 36 on, 12 off schedule every 
other night. Or I took care of vascular surgery patients. Or I 
took care of cardiothoracic patients. We de-scoped our 
facilities to the point that they take care of low-acuity 
community hospital patients, not trauma patients.
    So I would reiterate the point that you have heard all 
three of us make. We need our key hospitals to be Level I 
trauma centers in partnership with the American College of 
Surgeons in the communities in which they are located.
    But to do that we must address the elephant in the room, 
and that is resourcing. The medical inflation rate, on average, 
since 1938, is 5.1 percent per year, and the military has seen 
a net 12 percent reduction in funding. There is no way to fix 
these problems if the Military Health System is viewed as a 
bill payer and not something worth investing in.
    The second point that I would make is we have got to 
reiterate the intent that you and the Ranking Member mentioned. 
I spent 4 years as the Joint Staff Surgeon. Almost every 
meeting in which I participated in that role focused on roles 
and responsibilities and patches, not on patients. Please, 
again, I implore you, kill this narrative that somehow there is 
a belief that we can unwind things and go back to the good old 
days. We need to go forward toward a more integrated system 
that focuses on patient care and, as you said, on readiness, 
not continuing to focus on bureaucratic buffoonery.
    Chairman Wicker. Dr. Cannon.
    Dr. Cannon. Mr. Chairman, it is shocking, astonishing, and 
awful, and it has to be reversed. That 10 percent number 
results from inadequate, actually grossly inadequate, patient 
numbers, volume. They are not doing the cases. They are not 
doing the procedures. They are not doing what they were trained 
to do, and that is because they do not have the patients in the 
facilities. They are, in many cases, not designated or verified 
trauma centers, so they are scrounging around, trying to get 
cases, and it has been, frankly, an uphill climb. So we have 
got to provide them the patients, the cases, the experience to 
right that 10 percent number.
    Chairman Wicker. Thank you very much, gentlemen. Senator 
Reed, you are next.
    Senator Reed. Thank you very much, Mr. Chairman, and 
gentlemen, thank you for your excellent testimony.
    In the 2023 memorandum by the Deputy Secretary of Defense, 
one of the key points, I believe, is the direction to reattract 
beneficiaries to the MTFs, which would increase the patient 
flow, increase the demands on physicians, et cetera, and also 
save money, they believe.
    Dr. Friedrichs, your response to this approach.
    Dr. Friedrichs. I strongly support the vision that Deputy 
Secretary Hicks laid out, which is very similar to the vision 
that Deputy Secretary Norquist laid out in the previous 
administration, and almost every administration prior to that. 
Again, to do that we must have resources.
    I will offer one other option which I think you have heard 
all three of us touch on briefly. Every single patient in the 
Veteran Health Administration started in DOD. I had the great 
privilege of commanding the DOD/VA joint venture facility in 
Anchorage, and I can tell you that when the patient walked in 
the door, they were taken care of by a joint team. It was far 
more efficient than building duplicative adjacent facilities. 
Instead, we built integrated adjacent facilities.
    There is a $10 billion, unfunded recapitalization bill in 
the DOD, $100 billion, unfunded recapitalization bill in the 
VA. There are real opportunities to bring those higher acuity 
patients from the VA into the DOD facilities, or bring DOD 
medical personnel into the VA facilities, so that we are not 
wasting money on duplicative buildings and instead focusing our 
resources on the patients who need our care.
    Senator Reed. Thank you. And General Robb, or Dr. Robb, or 
both, do you think the Military Health System is adequately 
focused on the combat-related medical capabilities? I have 
heard comments by all the panel suggesting that they are 
diverted into things that are not effective in a combat 
situation.
    Dr. Robb. Well, I think, in fact, I would kind of like to 
challenge the misnomer that there is a separation between care 
beneficiaries and medical readiness. And I would argue, the way 
that we get our skills--primary care, specialty care, and just 
as important, our allied health, pharmacy, x-ray techs, 
logistics--we get that by taking care of our beneficiaries.
    So what I think is so, so, important is that we use--not 
use, but that we care for our patient population to best 
achieve medically ready, in a ready medical force. And what I 
think is really important is that, again, we have to create a 
capability. It has to be an enterprise approach. And when we 
talked about it, again, I will go back to the point of follow 
the casualty flow, and you look at those critical hospitals 
that we believe are important, we must staff those. And we must 
staff those to the fullest extent possible.
    You cannot reattract patient care into our MTFs unless you 
staff them, and I think that is what is key. If I cannot get an 
appointment, then I cannot get an appointment. So that is what 
is key.
    So if you talked with Walter Reed, for example, they may 
have enough surgeons, but for various reasons the support staff 
does not exist, so they do not have the throughput that they 
need for surgical cases. The case load is there.
    So what I think we need is an enterprise approach, and how 
do we resource, okay, the full spectrum of support for our 
critical care hospitals, and then make up the delta with our 
military VA partners and with our military-civilian 
partnerships.
    Senator Reed. Thank you. Dr. Cannon, your comments, please.
    Dr. Cannon. Senator, I think it is vitally important to 
have highly functioning, premier medical centers that we can be 
proud of, that our surgeons and other specialists and allied 
health members want to be a part of. Right now, many of these 
facilities are shells of what they used to be. You heard about 
Wilford Hall. That was an amazing facility that did so much 
good for so many decades.
    The new incarnation, Brooke Army Medical Center, the San 
Antonio Military Medical Center, is also amazing, but it is 
sort of out on the vanguard by itself. We need other premier 
flagship centers. And I think we can do it. We have got the 
pieces in place, but we have got to commit to keeping the 
combat casualty at the center of our focus, and make it happen.
    Senator Reed. Thank you. My time has just about expired, 
but a yes, no, or perhaps answer. I am concerned about the 
ability to mobilize medical professionals for an all-out fight. 
Is that a valid concern? Yes or no, please.
    Dr. Robb. Yes.
    Dr. Friedrichs. It is the billion-dollar concern. The 
Israelis have proved that. And we have a shell game right now 
with our Guard and Reserve and civilian facilities. We are 
going to pull them out, deploy them, and assume that civilian 
facilities, which during COVID required 70,000 military medics 
to take care of the surge in demand, instead lower their staff 
and then take care of a surge in demand. The math does not 
work, even for a Louisiana Public School grad.
    [Laughter.]
    Chairman Wicker. Dr. Cannon, go ahead and answer the 
question. Take the time.
    Dr. Cannon. Yes, I agree. It is a concern.
    Chairman Wicker. Thank you. Senator Fischer.
    Senator Fischer. Thank you, Mr. Chairman. Thank you all for 
being here today.
    I really appreciate the information that you are giving us, 
and also the concern you have with the direction that we are 
not headed yet. In the Fiscal Year 2020 NDAA, a pilot program 
was established to assess the National Disaster Medical System 
(NDMS) and hopefully that it would increase not just capability 
but also capacity within that. In a conflict, you know, we have 
touched on that already. We have to be able to quickly disperse 
and absorb casualties throughout the United States.
    Dr. Friedrichs, why is it so important for the NDMS to 
maintain this surge capacity?
    Dr. Friedrichs. Senator Fischer, first, thank you for the 
role that you and your colleagues from Nebraska played in 
championing this and highlighting this. It is important because 
the Military Health System does not have the capacity to care 
for every casualty coming back. We do not have the capacity to 
care for the people in peacetime right now. So to think that 
somehow we can do this on our own is another mistaken belief.
    During the cold war, we recognized that if our Nation went 
to war, we would go to war together, and that we would do it 
with an integrated system with DOD, the Veterans Health 
Administration, and civilian partners. We must rejuvenate the 
NDMS, not let it continue to atrophy.
    Senator Fischer. So what is the next step in this pilot 
program?
    Dr. Friedrichs. So the next step is to make this not a 
pilot program but to reiterate that this is, indeed, the intent 
of Congress, that the NDMS is the framework in which we 
integrate our ability to deal with either surges in military 
patients or, in the event of a natural disaster, surges in 
civilian patients. But that is the framework.
    A subset of that are the Respect Centers, which you are 
very familiar with, the regional Emerging Special Pathogen 
Centers that are designed to take care of patients exposed or 
infected with high-consequence infectious diseases. And another 
subset of that is the trauma system that Dr. Cannon so nicely 
described.
    We need your help to articulate in law that we must work as 
a nation and as a team. We are short 300,000 nurses nationally. 
The projections are we will be short 130,000 doctors by 2035. 
There is no way that we can do this individually. We must do it 
together, and I urge you to codify the NDMS pilot and make that 
the intent, moving forward.
    Senator Fischer. Dr. Cannon, Dr. Robb, anything to add on 
that?
    Dr. Cannon. Senator, I would just advocate for what my 
colleague, General Friedrichs, just said, but we need to put 
our foot on the gas. We do not have 5 years, 10 years, 20 
years. We need the solution really now.
    Senator Fischer. Dr. Robb?
    Dr. Robb. Yes, I concur with both their comments. And going 
back, the fact that we dual-purpose these assets, these 
expensive assets, to solve problems both in the military and 
civilian sector, but they are mutually synergistic. So 
absolutely, we need to press forward.
    Senator Fischer. Thank you. Dr. Friedrichs, you mentioned 
the University of Nebraska Medical Center and working with an 
academic institution. Can you explain to the Committee the 
benefits of those partnership with academic institutions in 
particular, and what that can yield for the Military Health 
System?
    Dr. Friedrichs. Thank you very much, Senator Fischer. The 
first benefit is we share and exchange information. University 
of Nebraska has established, without a doubt, one of the 
premier programs for treating casualties or patients who are 
exposed to highly contagious infectious diseases, and they have 
got remarkable onsite training, which they built in partnership 
with the United States Air Force. This is a great example of a 
military-civilian partnership in which the exchange of ideas 
improves care, both for military and civilian patients.
    But the other thing that we can learn from our civilian 
partners is something that I offer to the Committee to 
consider, the CHIP IN Act, which was originally passed to allow 
for blending of funding to build new VA facilities. It should 
be expanded to include the DOD. We cannot afford to keep 
building duplicative facilities, and the CHIP In Act was a 
great way to allow the blending of Federal, State, local, and 
philanthropic funds so that we can most efficiently care for 
this diverse patient population.
    Again, I commend the University of Nebraska for the 
pioneering work that they have done in showing what a good mil-
civ partnership looks like.
    Senator Fischer. Thank you for the shout-out on the CHIP IN 
Act. That bill was written in my office, so thank you very 
much.
    Dr. Cannon, as a professor of surgery, do you have anything 
to add on that?
    Dr. Cannon. I would just comment that these mil-civ 
partnership sites can be incredible assets for force 
generation, for building up that next generation of future 
leaders in surgery and other combat-relevant specialties. And 
these are epicenters of academic excellence where we can truly 
inspire that next generation.
    Senator Fischer. Thank you. Thank you, Mr. Chairman.
    Chairman Wicker. Thank you, gentlemen. It seems to me that 
the State of Nebraska must have excellent
    representation in the U.S. Congress.
    Senator Shaheen.
    Senator Shaheen. Thank you all very much for being here 
today.
    Dr. Robb, you discussed the impact of declining budgets on 
the Defense Health Agency. As a former director, can you talk 
about how late budgets and operating under continuing 
resolutions, continued budget uncertainty affects the readiness 
of the Military Health System?
    Dr. Robb. When I look back--in fact, I will go back in 
history, because I was part of that. When we initially stood up 
to the Defense Health Agency in response to the perception that 
we had 10 percent of the DOD's overall budget, and then fast-
forward to 12 years later and now we are actually less than 10 
percent. And we were meeting not quite but most of our demands 
back then. But as I watch, we have had increasing combatant 
command requirements with a decreasing defense health program.
    And what that has forced us to do is we have seen a couple 
of challenges, and there are multiple things going on. But the 
military departments, their end strength has gone down, and the 
way we man those hospitals is with a certain percentage of 
military members. And as Dr. Friedrichs said, you just cannot 
buy health care professionals off the streets.
    So when we cut the end strength then we apportion this care 
downtown, and then that increased TRICARE budget, but then we 
have to pay with bag one money, which is direct care money, to 
pay direct care. So now we actually have an internal shrinking 
of our budget. So it has been challenging for the Defense 
Health Agency to manage a set of Military Treatment Facilities 
with that to be the current business process.
    Senator Shaheen. And is it fair to say that budget 
uncertainty exacerbates that problem----
    Dr. Robb. Oh, absolutely.
    Senator Shaheen.--that continuing resolution exacerbates 
that problem?
    Dr. Robb. Absolutely. Yes, ma'am. Yes, ma'am.
    Senator Shaheen. Thank you. Dr. Friedrichs, you mentioned 
the National Guard, and one of the things I know, the National 
Guard, as we all know, is assuming a greater role in actual 
deployments and picking up work for the regular military. I 
could probably say that more eloquently, but they are taking on 
a much bigger role than they did 30 years ago. Yet the National 
Guard does not have the same coverage for health care that our 
regular military does. Despite the challenges that you all have 
identified, it is even a greater problem for the National 
Guard.
    Can you speak to what we ought to be thinking about as we 
are thinking about how do we ensure that the Guard actually has 
the health care they need so that they are ready to go if they 
are called to deploy or called into combat?
    Dr. Friedrichs. Thank you, Senator Shaheen, and I will 
start, if I may, first with your premise that there is an 
increasing demand signal. The decision to take down the United 
States Agency for International Development (USAID) and most of 
its capabilities is almost unquestionably going to drive more 
demand on the Department of Defense. USAID provided countless 
services for disaster response and for work with allies and 
partners around the world.
    Senator Shaheen. And for global health.
    Dr. Friedrichs. And for global health, and for 
biosurveillance, and many other roles. In the absence of USAID, 
we either agree that when Americans are caught in a disaster 
they are on their own, or we are going to turn to the only 
other organization that has those kinds of capabilities, and 
that is DOD. So we should, I am afraid, expect to see more 
demand on DOD as a result of those changes.
    To your point about health care preparedness, when we look 
back at why people, shortly after deployment, have to be pulled 
off the line, interestingly it is dental care primarily among 
the Guard and Reserve, who do not have ready access to that. I 
think if we are serious about a smaller force that must be 
ready on a moment's notice, we are going to have to address how 
to ensure that force is ready, when needed, to go forward, and 
that is medically ready, as well as ready and proficient with 
whatever their assigned task is.
    Senator Shaheen. And we are learning a lot of lessons on 
our industrial base side, from the war in Ukraine right now, 
and a lot of lessons about the conduct of war today. Are we 
learning anything about the health care system and what we 
ought to be thinking about from what is happening in the war in 
Ukraine? Anybody.
    Dr. Friedrichs. If I may, I will just quickly say, having 
just been with the Ukrainian Surgeon General, absolutely. What 
they have found, first and foremost, is they are in the kind of 
conflict we will likely be in, and in the absence of air 
superiority, contested logistics, you must have a functioning 
system that is integrated. And this gets back to Senator 
Fischer's question about the National Disaster Medical System.
    They are also learning the importance of supply chains. 
When we looked at this at the Joint Staff, we found that a 
significant percentage of the pharmaceuticals in our deployable 
assemblages actually rely on ingredients from countries that 
may or may not be willing to continue to provide those in the 
next conflict. Same song, next verse, with medical equipment.
    I urge you, as I said in my written statement, to require 
the Department to give you an accounting for our 
vulnerabilities in that area and a plan to address them. There 
are ways to do that. We need a strong push, I would submit, to 
actually accomplish that.
    Senator Shaheen. Thank you very much. Thank you all.
    Chairman Wicker. Thank you, Senator Shaheen.
    Dr. Cannon and Dr. Robb, do you want to elaborate on what 
Dr. Friedrichs said about USAID?
    Dr. Cannon. Sure. That is out of my domain so I do not have 
anything.
    Chairman Wicker. Very well, then. Yes.
    Dr. Robb. I would concur, one, with his comments, but 
number two, again it is mostly out of my domain currently.
    Chairman Wicker. All right. Thank you very much. Senator 
Cotton.
    Senator Cotton. General Friedrichs, I would like to 
continue with the answer you just gave to Senator Shaheen about 
our dependence on other countries for drugs and precursors, 
specifically Communist China. The United States relies heavily 
on Communist China for basic drugs and so-called Active 
Pharmaceutical Ingredients (APIs). Providers obviously need 
this, not just in the civilian world but in the military world, 
especially to treat combat casualties. China, for instance, has 
80 percent of the global supply chain of antibiotics.
    How could Communist China use this dependence of ours to 
its advantage if there were a major conflict in the Pacific?
    Dr. Friedrichs. Thank you very much, Senator Cotton, and I 
think we have seen examples of this with rare minerals and 
other things that China largely controls the supply chain for, 
in that they will choose to titrate that supply chain based on 
their satisfaction or dissatisfaction with those trying to 
purchase those items.
    I had the great privilege in my last role of working with 
India, the European Union (EU), Japan, and Korea on a 
consortium in which we began to identify ways to leverage new 
technologies to change and to broaden our supply chains. And I 
encourage this Committee to direct the Department of Defense, 
in partnership with the Department of Health and Human 
Services, to continue exploring those options.
    What we found was in many cases, as in the case of 
antibiotics that are based on penicillin, the Japanese have 
already made a tremendous investment in the ability to produce 
those APIs within Japan. We should be partnering with them and 
creating an environment in which at least the DOD and the VA 
purchase from Japan to help sustain that production base and 
ensure that we have the access that we need.
    There are many more examples. I touched on some of them in 
my written statement. But there are ways to mitigate this.
    Senator Cotton. And your answer to Senator Shaheen said 
that Congress should push the Department of Defense to catalog 
all of these dependencies. It sounds like you are saying we 
also need to push to eliminate, or at least significantly 
curtail, these dependencies, as well. Is that right?
    Dr. Friedrichs. Absolutely.
    Senator Cotton. And you mentioned four different sourcing 
options--South Korea, Japan, the EU, and India. Those first 
three are advanced industrial democracies, just like ours. If 
they can produce these items, like acetaminophen or ibuprofen 
or penicillin, at a reasonable cost, surely the United States 
could do so, as well, right?
    Dr. Friedrichs. I believe that is the case. And what we 
found is that particularly in these countries they have created 
an environment in which it was financially possible for 
companies to produce these items within their country. We have 
not done that here in the United States. But a thoughtful 
industrial policy that was focused on resilience and national 
security, as well as economic security and health security, 
could do that for us, as well.
    Senator Cotton. It is fair to say that between the two of 
them, the Department of Defense and the Department of Veterans 
Affairs, sure does have a lot of purchasing power to create a 
domestic market for the production of these fairly basic and 
longstanding medicines, right?
    Dr. Friedrichs. Absolutely. About 8 percent of the market--
and it get back to Senator Shaheen's point about continuing 
resolutions and predictability. If companies know that they 
have a predictable demand signal, they will build to it. If 
they have an episodic or random demand signal, they will let 
somebody else deal with that.
    Senator Cotton. General Robb, I have noticed you nodding 
your head vigorously, so please get off your chest everything 
you wanted to add to General Friedrichs' answers.
    Dr. Robb. Yes. Also, and I am sure you are aware, and this 
has been the direction from questions asked by our Congress, 
the Center for Health Services Research at the Uniformed 
Services University has been tasked, along with the Defense 
Logistics Agency, to catalog and specifically look at what, and 
define the problem what is, the Department of Defense's 
reliance on the medicines that we have talked about that are 
primarily sourced from China and from India, which would then 
help what I would call inform the decisions a way ahead of 
whether you, what I call it, ally shore, or near-shore, or on-
shore, as Dr. Friedrichs discussed, in looking at a way 
forward.
    But they are creating that, you know, what is the data to 
drive the decision and the investment. Thank you.
    Senator Cotton. Thank you, gentlemen, both, for your 
answers. It has long been the case that the Department of 
Defense, acting at congressional direction, has mandated the 
domestic purchase of many uniform items, so I think surely we 
should make sure that our troops have the medicines they need 
to stay healthy, or to recover, as needed.
    Chairman Wicker. Thank you, Senator Cotton. Senator Kaine.
    Senator Kaine. Thank you, Mr. Chairman. Thank you to the 
witnesses. I want to particularly recognize Dr. Cannon. I know 
you are very well-prepared for this hearing today because one 
of the leaders that is with you, Kristin Malloy, used to be on 
my staff, and she made sure I seemed a lot smarter than I was 
at any hearing that I attended.
    You know, I think I want to focus all of your attention on 
the workforce issues, because I am on the Health, Education, 
Labor, and Pension too, and if I go to my hospitals and health 
care providers they are singing the blues about workforce, 
tight labor market, difficulty hiring and retaining folks.
    I went to the grand opening of the new VA clinic in the 
Fredericksburg area two Fridays ago, and we built it to the 
tune of about $350 million. And we built this state-of-the-art 
clinic, with one step down from a hospital, because there were 
multiple clinics in the area, and veterans were having to go 
from pillar to post to get care rather than a single place.
    But when we opened it, and I was there for the opening, I 
had staff say, ``We are on a skeleton crew.'' The three VA 
hospitals in Virginia--Salem, Richmond, and Hampton--are laying 
people off. There are hiring freezes. There are plans for even 
more layoffs. So the estimates I was getting at that grand 
opening is they are probably 20 to 50 percent staffed. There is 
another sizable clinic similar that is going to open in 
Chesapeake, supposed to, on April 11th. If it does open on 
time, I am suspecting that it will be a similar thing. And you 
saw the announcements about more cuts coming in the VA.
    You have talked a little bit about the need to be more 
integrated between DOD facilities and VA facilities, but then 
also on the civilian side, what is your vision for how we equip 
our civilian system to provide a surge capacity or backup 
capacity when we need it, to perform well in combat situations?
    Please, Dr. Cannon.
    Dr. Cannon. Senator, thank you for your very insightful 
comments and questions. I am a veteran. I get my care at our VA 
in Philadelphia. My wife is a primary care physician and takes 
care of veterans. So I can speak to your comments about the VA 
from that perspective.
    I do have a role at Penn Medicine as the Assistant Dean for 
Veteran Affairs for Penn Medicine, but I am quite new in that 
role and still learning the ropes. So I will speak more from my 
end user experience.
    I would say that certainly there are opportunities for 
synergy. The partnerships between VA facilities and academic 
medical centers I think have been partially realized, but in 
this sort of urgent situation we find ourselves in, we need 
truly a whole-of-society approach, and where there can be 
market synergy, where there can be economies of scale we should 
aggressively pursue that.
    I know that our Chief Executive Officer (CEO), Kevin 
Mahoney, has made overtures to the VA, and there have been 
agreements signed between the VA. I do not have detailed 
knowledge about that and where that stands. But I think there 
is an opportunity, and we should push for that. And as a 
veteran who receives my care, I hope that we can continue to 
deliver excellent care through better synergy.
    Senator Kaine. How about Dr. Friedrichs and Dr. Robb?
    Dr. Friedrichs. Thank you, Senator Kaine, and that is a 
beautiful facility. It will be tragic if it sits there empty 
while veterans are unable to access care because of shortages 
of medical professionals in the VA, in the DOD, and in the 
civilian sector.
    We are in a less-than-zero-sum game right now, and that is 
both a health security issue but also a national security 
issue.
    The first recommendation I would make to this Committee, 
direct that the Department of Defense does not close any more 
of our military training programs. For decades, the military 
training programs have been one of the pipelines that, when 
people eventually left the military, which all of us do, they 
go to the civilian sector. We cannot afford to close any more 
training programs when we have so many shortages of doctors and 
nurses and dentists and other things.
    The second, I implore this Committee, in the NDAA, direct 
the DOD and in partnership with the appropriate VA oversight 
committees, the Veterans Administration, to come back with a 
plan, starting with the D.C. market, to integrate the two 
systems. We have talked about this since I was a Major. I moved 
here in 1997, and we were talking about this. It is time to 
stop talking and start doing it. We cannot afford to keep 
talking about this problem.
    That hospital in the VA here is ancient. It has got to be 
replaced. We just finished a billion-dollar upgrade at Walter 
Reed. Why in the world are you not demanding that we come back 
with a plan to do that? It is more efficient, and it helps to 
pool the resources.
    The third point, and the most important one in your Health 
Committee role, is we must address these pipelines as both a 
health security and an economic security and a national 
security concern. As long as the pipelines continue to be 
insufficient to need, there is no way that any of these 
problems are going to get fixed. And I think you have a unique 
opportunity to help bring that into both committees. Thank you, 
Senator.
    Senator Kaine. Thank you. And Dr. Robb, I will ask that 
question for the record because I am now out of time. I yield 
back to the Chair.
    Chairman Wicker. All right. Actually, these witnesses will 
not be taking questions for the record. I will let you followup 
for 45 seconds.
    Senator Kaine. Dr. Robb, then could you approach that 
workforce integration question too? Thanks.
    Dr. Robb. Yes, and I will go back to where we can share 
resources, and I will foot-stomp. We have very many successful 
joint DOD and VA partnerships. Travis Air Force Base is a great 
example, where the actual VA is inside of David Grant Medical 
Center, share staffs, but more importantly, share patients. We 
have others where we are co-located community-based outpatient 
centers that feed patients into like Anchorage, Alaska. We see 
that down there at Naval Pensacola.
    So those opportunities, because usually what happens is we 
want access to critical care patients for our proficiency, and 
the VA wants access to resources, which is either excess 
capacity on space or in staff. So I think that continued 
movement forward, not always one size fits all, but that is 
very, very important. Much like the VA is at all the academic 
health centers, I think the Department of Defense, especially 
six or eight strategic places, need to have strategic VA and 
strategic mil-civ partnerships, sharing staff.
    And I will quickly say, not only does the military learn 
from the civilian opportunities, during Operation Iraqi Freedom 
(OIF) and Operation Endurance Freedom (OEF), actually, the 
American College of Surgeons made sure that they were with us 
so they could learn, firsthand, real-time, on how we were 
treating. So it is a mutually synergistic relationship.
    Chairman Wicker. Thank you, Dr. Robb. Senator Rounds.
    Senator Rounds. Thank you, Mr. Chairman, and I am going to 
follow right along that same line because I think what you are 
laying out is basic common sense when it comes to the 
integration of these two systems.
    My question is, why is it that when we have what is 
considered to be excellent care with the military system, the 
MHS, involved, and then we have to transition these young men 
and women as they leave the armed service into a VA facility, 
in which we start all over again. And we have different ways of 
communicating, and, in fact, let me just ask this. In your 
experiences, how well do we integrate the transfer of 
information from the MHS back into the VA systems today?
    Dr. Cannon. Senator, I can take a crack at that. I believe 
you are spot on. My experience in transitioning from the DOD to 
the VA was more of a lukewarm handoff than a warm handoff. I 
had to sort of navigate my way to the VA. I now have closed 
that gap and I get my care there, as I mentioned. But it is not 
a smooth process.
    Why is it still the case that the two health care delivery 
systems are so partitioned? I think you have to go back to 
ancient history almost, in our country. And if you look at 
Secretary Gates' comment about his experience as Secretary of 
Defense, he said, ``The one department that gave me the most 
fits was the Department of the VA.''
    So there are historic challenges. The VA wants to do it 
their way. Understandably, most of us do want to do it our way. 
But I think there are clear opportunities and a clear demand 
signal to break down those barriers and realize opportunities 
for synergy. So I think we can do that.
    Senator Rounds. I think the focus should be on whether or 
not we are delivering for the veteran and not necessarily the 
survivability of the VA itself. And I think that sometimes gets 
mixed up.
    I am just curious, gentlemen. We have talked about trauma 
centers. We have talked about the reintegration, or integrated 
health care system, and so forth. We are not, right now, at the 
same degree of activity and intensity with regard to 
battlefield casualties as we were just a few years ago, and 
therefore the opportunity for these surgeons, these battlefield 
surgeons and others, to actually learn right now is probably 
not as great.
    How do we keep the intensity or the capabilities of the 
training, how do we keep that up to date when we do not have 
those opportunities? And I am not going to say that they are 
good opportunities. I am glad that we are not in them. But how 
do you allow that surgeon to keep those skills up to speed when 
you do not have the types of casualties that you have on a 
battlefield, that we were experiencing for a number of years?
    Dr. Friedrichs. Take care of sick patients, sir. I mean, 
there is an analog between taking care of a patient who has 
bladder cancer and needs to have their bladder removed and 
taking care of a patient who has just had a gunshot wound to 
the abdomen and needs to have their bladder reconstructed.
    We need our military medics taking care of sick patients. 
They do that at hospitals that are well-staffed and well-
resourced to take care of sick patients. And so that is what we 
have done historically to maintain the proficiency of surgeons 
or of critical care nurses or of medical logistics staff, is 
keep them busy during peacetime taking care of sick patients. 
It is not a perfect analog, but that is the best surrogate, and 
that requires resourcing the system, making sure that sick 
patients can get in the door and get the care they need.
    And to your point about the VA, I would just say I applaud 
the VA for accelerating moving forward with their electronic 
health record, because that is going to be the secret sauce 
that enables greater sharing between the two departments and 
will enable us to track patients from the day they join the 
military to the day they take their last breath, and really 
learn how to improve both systems.
    Senator Rounds. Is the current system that you use 
integratable with the VA's new proposed medical records health 
care system?
    Dr. Friedrichs. I am not an expert on the VA's system. When 
I left the movie they were looking at purchasing the same 
system that the DOD had purchased. I hope that those with 
oversight responsibilities will insist that the two systems are 
integratable, because technologically, there is nothing to 
prevent that. I mean, civilian health care system integrate 
Epic and Cerner all the time, or McKesson and Epic. There 
should be no technological reason why we cannot do that.
    Senator Rounds. Thank you. General Robb, anything to add to 
that?
    Dr. Robb. I would share what Dr. Friedrichs said. In fact, 
what I was excited about is I have had the opportunity for 
family members to be in civilian hospitals, and they are able 
to reach into it and see Genesis now. So they know the health 
care that my family members have been getting in the military.
    I know that has absolutely been the vision between the 
Department of Defense and the Department of VA, and I believe 
that is still what I would call the true north.
    Senator Rounds. Thank you. Thank you, Mr. Chairman.
    Chairman Wicker. Thank you, Senator Rounds. Senator King.
    Senator King. Thank you, Mr. Chairman. First, I want to 
thank you for having this hearing. Very timely and important. 
Second, I want to associate myself with Senator Cotton's 
comments about sort of Berry Amendment for drugs. The idea that 
we have to buy Made in America shirts for our troops but we are 
worried about the availability of crucial drugs, that seems to 
me that is something that should be pursued. We could even call 
it the King-Cotton Amendment, but I will pass on that.
    [Laughter.]
    Also, Mr. Chairman, before getting into the questions, and 
these witnesses would not have the answers, but I think in 
light of this hearing, the Committee should make an inquiry 
about whether there have been firings or early retirements 
encouraged within the medical facilities at the Defense 
Department, because we know there is a lot of that going 
around, and I would like to know whether that is happening in 
the Defense Health Agency.
    Second is the impact of the continuing resolution. That is 
certainly not going to help this situation in terms of 
maintaining demand signals, continuity, pilot programs--all of 
that is gone in a continuing resolution. For the first time in 
my knowledge, I think the first time in American history, we 
are faced with a year-long continuing resolution, which 
basically vitiates the entire budget process.
    Okay. What we are really talking about, it seems to me, is 
surge capacity. And it is impractical to maintain a capacity 
within the Defense Department, or even Defense plus VA, for the 
kind of casualties that would be generated in a significant 
conflict. Therefore, I see no other alternative than a 
cooperative surge agreement with the private sector. That is 
where capacity is, even though that is fairly limited.
    Dr. Friedrichs, isn't that really what we are talking about 
here is how do we deal with a conflict way beyond what we are 
seeing now, within the current capacity? Defense Health Agency 
could not do it. VA could not do it. It has got to be 
relationships, and should we not have those relationships in 
advance so this is not something that we scramble to do, as we 
did during COVID, for example?
    Dr. Friedrichs. Senator King, I could not agree more 
strongly----
    Senator King.
    [Inaudible.]
    Dr. Friedrichs. Thank you, sir. So in the cold war we had 
what was called the Integrated Continental United States 
(CONUS) Medical Operation Plan, which was essentially what you 
just described. It was our shared commitment, as a Nation, to 
care for our Nation's casualties, if and when our Nation went 
to war. That depended on the National Disaster Medical System 
as part of the integrating function between the Federal and the 
civilian health care system. The NDMS has been allowed to 
attrit.
    I echo the recommendations to reauthorize the Pandemic and 
All Hazards Preparedness Act, because that, in part, enables 
the NDMS. But I implore you to go further. The Integrated CONUS 
Medical Operation Plan needs to be updated, and we started that 
work when I was the Joint Staff Surgeon, and it is continuing 
today. Having the NDMS in name is not sufficient. We actually 
have to build out the numbers, by community, of what beds would 
be available----
    Senator King. With preexisting conditions and analysis of--
--
    Dr. Friedrichs. Yes.
    Senator King. I just wonder if the Pentagon has war-gamed 
this issue. They war-game everything else.
    Dr. Friedrichs. Absolutely, sir. We actually did a war game 
on this, that we hosted first when I was the Transportation 
Command Surgeon, and again when I was the Joint Staff Surgeon. 
And what we found was just as you said--it cannot be done 
unless it is a whole-of-the-nation effort. And the only way to 
get to that point is if we do much more detailed planning. 
Taking down funding for State and local readiness officials, 
for example, is not going to help them do more planning or 
preparing.
    We need to work together to build and flesh out that plan, 
and we must bring industry into that. The defense industrial 
base provides equipment. The health industrial base addresses 
the points that you bring up.
    Senator King. And we have an analog in United States 
Transportation Command (TRANSCOM), which has agreements with 
the private sector both in terms of airplanes and ships, in the 
case of an emergency. That is where our surge capacity is.
    So it seems to me, I mean, here we are talking about it, 
but I think there needs to be some very specific good, new 
looks at this relationship in order to be ready, so again we 
are not scrambling.
    Dr. Robb, you are nodding. I take it you agree?
    Dr. Robb. Yes. I would absolutely concur. And again, I keep 
going back to the same theme, is we have got to buildup those 6 
to 8 to 10 strategic Military Treatment Facilities, we have to 
resource them, and then you create the already established 
military-VA partnerships, and then you just keep expanding that 
ring. But you have to have those relationships codified and in 
place, and that is what Dr. Friedrichs is talking about. You 
cannot just, all of a sudden when it kicks off, pick up the 
phone and say, ``How is it going?''
    Senator King. You have got to have them in place before the 
crisis hits.
    Dr. Robb. Absolutely.
    Senator King. Thank you, gentlemen. I appreciate it. Thank 
you, Mr. Chairman.
    Chairman Wicker. Thank you very much, Senator King. Senator 
Budd. Catch your breath.
    Senator Budd. Thank you all for being here. Major General, 
in your opening statement, whether here or able to watch it on 
the closed circuit, you identified the importance of the 
relationship between the Military Health System and the defense 
logistics enterprise.
    So should deterrence fail and war break out in the Indo-
Pacific, there are undeniable logistics constraints, 
particularly given the geography of INDOPACOM. The logistics of 
replenishing medical supplies and evacuated wounded 
servicemembers could make all the difference in reducing 
servicemember casualties. You provide a number of 
recommendations in your opening statement to address these 
concerns, including a number of reports and studies, so thank 
you for that.
    What can our Military Health System do in the short term, 
like immediately, to address logistical constraints, and how 
can DOD leverage medical innovation to address some of those 
constraints?
    Dr. Friedrichs. Thank you very much, Senator. I think the 
most immediate recommendation that I included in my written 
statement was that whenever we contemplate an operation or we 
are updating plans, we do a medical feasibility assessment, 
very similar to the logistics feasibility assessment that the 
Joint Staff J4 does. We need to ensure that we are informing 
our combatant commanders about what is and is not possible. 
That is something that can be done very easily.
    The longer answer to your question gets back to the 
discussion that we were just having about partnering with 
industry, both on the equipment and pharmaceutical side and on 
the health care delivery side. We have the Civilian Reserve Air 
Fleet that allows us to commit money to ensure that we have 
industry partners willing to provide aircraft and support when 
we need it. We have no such analog in the health care space, 
even though we know, as multiple Senators pointed out this 
morning, that there is insufficient capacity in the DOD and in 
the VA to care for our casualties.
    The NDMS currently is a voluntary system in which hospitals 
can say, ``Yes, okay,'' and then when we call them, they say, 
``I'm busy today. I'm not going to participate.'' We actually 
need to codify a system, as we have done with other industrial 
partners, in which there is a commitment and an understanding 
of how the reimbursement would work.
    The last point that I would make on that going forward is 
in supplemental planning for future operations we have to build 
in that cost. There is no question, if we are bringing back 
thousands of casualties, as Colonel Cannon described, that that 
is going to displace care, and it is going to increase costs at 
hospitals. We have to plan for that. That is why this whole 
planning effort, the Integrated CONUS Medical Operations Plan, 
for which United States Northern Command (NORTHCOM) is the 
lead, in partnership with industry, State, local, and 
Department of Health and Human Services officials, is so 
important, so we can bring back the requirements for funding 
and the challenges that we will need congressional help to 
address.
    Senator Budd. Thank you. Following up on that, you said we 
need to codify that. Do you have the language ready, or has 
that been written in a way that we could review, either 
individually or as a Committee?
    Dr. Friedrichs. Senator, I took the liberty of including an 
attachment with suggested language, just in case anyone wanted 
to do that.
    Senator Budd. We will read it in a few moments. Thank you.
    Mr. Robb, as you know, the Department relies on a mix of 
military personnel, federal civilians, and contractors to carry 
out its mission. Talk to me about the roles of physician 
extenders such as registered nurses, and what role do physician 
extenders play in ensuring the readiness of the broader force, 
and what challenges do you see to retention of physician 
extenders?
    Dr. Robb. Thank you for that question, Senator. I think it 
is key that the same issues of what I call proficiency and 
currency that exists for physicians, exists for our physician 
extenders. And the Army does a great job, especially in the way 
they have manned and equipped their fighting forces, of using 
those physician extenders, all the way down to the corpsmen, to 
the fullest extent of their capabilities.
    And so I would argue, as we have these discussions about 
medical readiness and about our ability to care for what we 
call critical wartime specialties, we must remember, trauma is 
a small percentage of that, but the majority of the care that 
is applied to our fighting forces comes from our primary care 
providers, which would be Physician Assistants (PAs), nurse 
practitioners, general practitioners, family physicians. So we 
must ensure that they also have the critical thinking skills 
and the opportunity to practice at the top of their game.
    Senator Budd. Thank you all, to the whole panel. Chairman?
    Chairman Wicker. Senator Budd, yes indeed, in looking at 
the statements, which have all been admitted to the record, by 
unanimous consent, I see on page 14 of Dr. Friedrichs' prepared 
testimony Attachment 1, Suggested National Defense 
Authorization Act Language. So we do appreciate him acting as 
an uncompensated legislative staffer for this Committee. We 
appreciate that. And thanks for the question.
    Senator Kelly.
    Senator Kelly. Thank you, Mr. Chairman. General Friedrichs, 
good morning, and thank you, all of you, for being here today. 
General Friedrichs, in a recent war game brief to Congress in 
November 2024, a hypothetical conflict in the Indo-Pacific 
resulted in 3,000 U.S. casualties in 3 weeks, and 10,000 across 
the entire conflict. And I am kind of following up on Senator 
Budd's line of questioning here.
    These numbers are higher than anything we have seen since 
the Korean War. In a severely injured servicemember's 
transition through the care system and make their way back to 
the United States for treatment, I am concerned that the number 
of DOD providers capable of handling trauma will be grossly 
insufficient. So given that, we are going to need to surge 
capacity, potentially found in the U.S. hospital system and VA 
hospitals, meaning civilian hospitals, VA hospitals.
    What concerns do you have with relying on U.S. civilian and 
VA hospitals to provide this trauma care to our servicemembers?
    Dr. Friedrichs. Thank you very much, Senator Kelly, and I 
would start by saying even before we get patients back to the 
United States, in the past we have relied on our allies and 
partners to help care for our casualties. And I am deeply 
concerned if we sever or degrade those relationships we will 
need to rewrite our plans, and the demands on the U.S. health 
care system will be even greater.
    To your point about the U.S. health care system, the 
Integrated CONUS Medical Operation Plan that we updated in 
1998, and then did not look at until 2020, is the plan that 
describes how we will surge capacity. But a key part of that 
gets back to some of the discussions we have had earlier. There 
have to be doctors and nurses and pharmacists and all the other 
staff to do that, and I implore that we continue to look at the 
pipelines that produce those medics as well as the facilities 
in which they work.
    We had briefly chatted about the opportunity for a medical 
equivalent to the Civilian Reserve Air Fleet that we use to 
ensure access to civilian aircraft, when needed. I believe we 
need some similar construct in the health care system, where we 
partner with industry and recognized that during surge moments 
there is a plan, and there is money available, for us to be 
able to leverage their staff and their facilities.
    Senator Kelly. Is there a plan?
    Dr. Friedrichs. There is a plan. We wrote the first version 
of that before I retired, and they are working on an update to 
that. But it would benefit from additional congressional 
oversight to ensure that it is on track and it does not get 
diverted by bureaucratic buffoonery.
    Senator Kelly. Are there current efforts in the 
relationship building with these hospitals?
    Dr. Friedrichs. The Defense Health Agency is tasked to have 
that outreach, and as I have met with hospital CEOs and system 
owners, there is certainly an opportunity to do more in that 
space. We must view the health care industry the same way we 
view the aviation industry or the missile-producing industry, 
as our partners. We cannot take care of America's casualties 
without those partners.
    Senator Kelly. Can you talk to the value in the two Navy 
hospital ships--I do not know if anybody here is prepared to 
talk about it. Because I think there is an effort underway to 
replace those. There is also the training ships for the State 
maritime academies that I think also could serve a role. I 
visited one at the Philly Shipyard a few weeks ago, had an 
operating room on board. Is that part of the system, as you 
envision it?
    Dr. Friedrichs. Yes, absolutely. The hospital ships are 
integral to our plans for a large-scale combat operation, and 
the two ships we have are some of the oldest ships afloat. They 
have to be replaced.
    Senator Kelly. I think there is a plan to replace them now. 
Can you speak to how that is going, if you know?
    Dr. Friedrichs. I pushed incredibly hard for that plan as 
the Joint Staff Surgeon, against intense opposition that we 
should spend the money in other places. I would defer to the 
Navy for the latest update on it, because they can give you the 
most current plan. But my understanding is that we are still 
years away from having the replacement ships available.
    So we will have to extend the current ships, and I believe, 
the last update I received, which is dated, was through 2035. 
But we do need that additional replacement funding to replace 
those aged ships.
    Senator Kelly. All right. Thank you, and thank you, Mr. 
Chairman.
    Chairman Wicker. Thank you, Senator Kelly. Senator Warren.
    Senator Warren. Thank you, Mr. Chairman. So we need a 
medical health care system that works in wartime, but the one 
we have is failing us in peacetime. And I think we need to do 
better on this. Fixing TRICARE's prescription drug care benefit 
is part of that.
    Since 2009, TRICARE has outsourced to Express Scripts a 
massive Pharmacy Benefit Manager (PBM). The Defense Health 
Agency, DHA, pays Express Scripts to negotiate with pharmacies, 
deciding where servicemembers can pick up their prescriptions 
and what price they are going to pay. But Express Scripts also 
owns Accredo, a massive pharmacy that participates in TRICARE, 
and DHA has been allowing all kinds of self-dealing between 
these two entities.
    Here is one. DHA used to require Express Scripts to 
maintain a network of 50,000 pharmacies. But in 2021, Express 
Scripts negotiated that down to 35,000 pharmacies. Then they 
turned around and told thousands of pharmacies, that they do 
not own, either to take money-losing terms or get kicked out of 
TRICARE.
    General Robb, you used to oversee the TRICARE network 
before this gaming started. Do you have any idea how many 
pharmacies have left, just since 2022?
    Dr. Robb. And Senator Warren, I have been out of this since 
2016.
    Senator Warren. Okay. I just wondered if you happened to 
know how many had left. I will take a no.
    Dr. Robb. No, ma'am. No, ma'am, I do not.
    Senator Warren. Well, it is over 13,000 pharmacies have 
left this network, and most of them are independent pharmacies, 
community pharmacies. That has forced 400,000 servicemembers 
and their families to find new pharmacies, and many of them 
have been pushed to the Express Scripts-owned Accredo.
    Even worse, Express Scripts has set up Accredo as the 
primary off-base pharmacy where military families can fill 
specialty drug prescriptions. You know, these are the really 
expensive cancer drugs, rheumatoid arthritis drugs, that make 
up over half of the $8 billion in TRICARE prescription drug 
spending. So it is a lot of money here.
    It does not end there. As we speak, Express Scripts is 
facing a whistleblower lawsuit that alleges the company 
systematically overfilled TRICARE prescriptions at Accredo, 
saddling DOD with, quote, ``billions of dollars in excess 
dispensing fees and drug resupplies.'' And this is not a 
surprise. Express Scripts has been found to massively overfill 
and overpay for prescriptions at Accredo, which they own, in 
other government programs.
    So General Robb, since last year, an audit uncovered that 
Express Scripts was leveraging its contract with the West 
Virginia Public Employees System to send inflated payments to 
Accredo for expensive specialty drugs, in some cases inflating 
the price by 100fold more than the cost of dispensing exactly 
the same drug at a competing pharmacy.
    I imagine you think this kind of taxpayer overcharging is 
unacceptable. Is that fair, General Robb?
    Dr. Robb. I would agree with that, it would be unfair. Yes, 
ma'am.
    Senator Warren. Okay. DHA is supposed to audit Express 
Scripts' pharmacy data to make sure that that same thing is not 
happening at TRICARE, but DHA said it had not completed an 
audit because DHA had, quote, ``no concerns about data 
accuracy.''
    You know, talk about being asleep at the wheel here, in 
just the first quarter of 2023, Express Scripts dispensed 
70,000 specialty drug prescriptions at Accredo, but the company 
only reported about 40,000 to DHA. In other words, Accredo 
failed to report nearly half of the expensive specialty drugs 
dispensed at its own pharmacy, which were paid for by DHA. So 
they get the money, but they do not tell DHA what is going on 
here.
    General Robb, after completing their investigation, the 
Government Accountability Office (GAO) sensibly recommended 
that DHA periodically audit Express Scripts' reported data for 
accuracy, which, by the way, is already required in the 
contract. So this is telling them basically to follow through 
on the contract.
    Do you agree with GAO's recommendation?
    Dr. Robb. I would agree that they need to follow what is 
the business policy and what is the contractual requirements. 
Yes, ma'am.
    Senator Warren. All right. You know, I just want to say, 
and I will close up here, DHA is paying Express Scripts 
billions of taxpayer dollars to manage the TRICARE benefit and 
negotiate with itself, and DHA is not even bothering to check 
the books. I think that everyone in this room agrees that 
Express Scripts ought to pass an audit, and that ought to be 
required in this year's NDAA.
    Thank you, Mr. Chairman.
    Chairman Wicker. Thank you, Senator Warren.
    Dr. Friedrichs. Mr. Chairman, may I add a comment to that? 
Is there time?
    Chairman Wicker. You certainly may, yes.
    Dr. Friedrichs. Thank you very much. I would hold up the 
Veterans Health Administration's exemplary mail order program, 
which has worked for years, as an opportunity, again going back 
to this concept of how do we deliver better care, and where 
possible, do it more efficiently. There is a real opportunity 
for this Committee, in partnership with the appropriate 
oversight committees, to direct a comparison of the two systems 
and then bring back recommendations for the best practices 
between the two.
    Pharmaceuticals are growing in costs, and that is not going 
to change. But this is an area in which the Veterans Health 
Administration actually has done this well for years, with high 
patient satisfaction, and more importantly, the patients get 
the meds they need, when they need them. There is a real 
opportunity to learn from the VA here.
    Chairman Wicker. Thank you very much. Thank you, Senator 
Warren. Mr. Ranking Member, anything more?
    Senator Reed. Just let me commend the witnesses. You have 
given us lots to think about and lots to do, and so we 
appreciate that. Thank you very much.
    Chairman Wicker. We are indebted to you and grateful to all 
three of you. Thank you very much.
    This concludes the hearing.
    [Whereupon, at 11:04 a.m., the Committee adjourned.]

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