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i 

73–792 2012

[H.A.S.C. No. 112–120] 

HEARING 

ON

NATIONAL DEFENSE AUTHORIZATION ACT 

FOR FISCAL YEAR 2013 

AND

OVERSIGHT OF PREVIOUSLY AUTHORIZED 

PROGRAMS 

BEFORE THE

COMMITTEE ON ARMED SERVICES 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED TWELFTH CONGRESS 

SECOND SESSION 

SUBCOMMITTEE ON MILITARY PERSONNEL HEARING 

ON

DEFENSE HEALTH PROGRAM 

BUDGET OVERVIEW 

HEARING HELD 

MARCH 21, 2012 
(II) 

SUBCOMMITTEE ON MILITARY PERSONNEL 

JOE WILSON, South Carolina, Chairman 

WALTER B. JONES, North Carolina 

MIKE COFFMAN, Colorado 

TOM ROONEY, Florida 

JOE HECK, Nevada 

ALLEN B. WEST, Florida 

AUSTIN SCOTT, Georgia 

VICKY HARTZLER, Missouri 

SUSAN A. DAVIS, California 

ROBERT A. BRADY, Pennsylvania 

MADELEINE Z. BORDALLO, Guam 

DAVE LOEBSACK, Iowa 

NIKI TSONGAS, Massachusetts 

CHELLIE PINGREE, Maine 

JEANETTE JAMES, Professional Staff Member 

DEBRA WADA, Professional Staff Member 

JAMES WEISS, Staff Assistant 
(III) 

C O N T E N T S 

CHRONOLOGICAL LIST OF HEARINGS 

2012 

Page 

HEARING: 

Wednesday, March 21, 2012, Defense Health Program Budget Overview ......... 1 

APPENDIX: 

Wednesday, March 21, 2012 ................................................................................... 23 

WEDNESDAY, MARCH 21, 2012 

DEFENSE HEALTH PROGRAM BUDGET OVERVIEW 

STATEMENTS PRESENTED BY MEMBERS OF CONGRESS 

Davis, Hon. Susan A., a Representative from California, Ranking Member, 

Subcommittee on Military Personnel ................................................................. 2 

Wilson, Hon. Joe, a Representative from South Carolina, Chairman, Subcommittee on Military Personnel ........................................................................ 1 

WITNESSES 

Green, Lt Gen Charles B., USAF, Surgeon General, U.S. Air Force .................. 10 

Horoho, LTG Patricia D., USA, Surgeon General, U.S. Army ............................. 5 

Nathan, VADM Matthew L., USN, Surgeon General, U.S. Navy ....................... 7 

Strobridge, Col Steve, USAF (Ret.), Co–Chair, The Military Coalition .............. 11 

Woodson, Hon. Jonathan, M.D., Assistant Secretary of Defense for Health 

Affairs, U.S. Department of Defense .................................................................. 4 

APPENDIX 

PREPARED STATEMENTS: 

Davis, Hon. Susan A. ....................................................................................... 28 

Green, Lt Gen Charles B. ................................................................................ 109 

Horoho, LTG Patricia D. .................................................................................. 55 

Nathan, VADM Matthew L. ............................................................................ 83 

Strobridge, Col Steve ........................................................................................ 129 

Wilson, Hon. Joe ............................................................................................... 27 

Woodson, Hon. Jonathan ................................................................................. 29 

DOCUMENTS SUBMITTED FOR THE RECORD: 

Statement of the National Military Family Association ............................... 169 

Statement of the Reserve Officers Association of the United States and 

the Reserve Enlisted Association ................................................................. 161 

Statement of The Military Coalition ............................................................... 196 

WITNESS RESPONSES TO QUESTIONS ASKED DURING THE HEARING: 

Dr. Heck ............................................................................................................ 223 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING: 

Ms. Bordallo ...................................................................................................... 237 

Mrs. Davis ......................................................................................................... 227 

Mr. Jones ........................................................................................................... 237 
Page

IV 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING—Continued 

Mr. Loebsack ..................................................................................................... 241 
(1) 

DEFENSE HEALTH PROGRAM BUDGET OVERVIEW 

HOUSE OF REPRESENTATIVES, COMMITTEE ON ARMED SERVICES, SUBCOMMITTEE ON MILITARY PERSONNEL, Washington, DC, Wednesday, March 21, 2012. 

The subcommittee met, pursuant to call, at 3:10 p.m. in room 

2212, Rayburn House Office Building, Hon. Joe Wilson (chairman 

of the subcommittee) presiding. 

OPENING STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM SOUTH CAROLINA, CHAIRMAN, SUBCOMMITTEE 

ON MILITARY PERSONNEL 

Mr. WILSON. Ladies and gentlemen, good afternoon. I would like 

to welcome you to a meeting of the Military Personnel Subcommittee. This will be a hearing on the Defense Health Program 

budget overview. And I want to thank people for attending today 

and certainly thank our witnesses. 

Today the subcommittee meets to hear testimony on the Defense 

Health Program for fiscal year 2013. I would like to begin by acknowledging the remarkable military and civilian medical professionals who provide extraordinary care to our service members and 

their families and veterans here at home and around the world, 

often in some of the toughest and most austere environments. I 

have firsthand knowledge of their dedication and sacrifice from my 

son, Addison, who is an orthopedic resident in the Navy and who 

has served in Iraq. 

Even in this tight fiscal environment, the Military Health System must continue to provide world-class health care to beneficiaries and remain strong and viable and fully funded in order to 

maintain that commitment. The Department of Defense has proposed several measures aimed at reducing the cost of the Defense 

Health Program. Unfortunately, all of the proposals simply shift 

the cost burden to TRICARE fee and cost-share increases to not 

only our working-age retirees but, for the first time, to our most 

senior military retirees. 

The subcommittee has a number of concerns about the Department’s initiatives. To that end, we would expect the Department’s 

witnesses to address our concerns, including that: first, the proposed TRICARE Prime fee increases, which have been characterized by military leaders as modest, will raise fees in fiscal year 

2013 by 30 to 78 percent over the current rate. Over 5 years, the 

fees would increase by 94 to 345 percent. 

The proposed increases may be designed to cause military retirees to opt out of TRICARE, choose a TRICARE option that is less 

costly to DOD, or decrease their use of TRICARE. The proposal 
2 

would establish an annual enrollment fee for retirees who use 

TRICARE Standard and Extra and, for the first time, would require our most senior retirees to pay an enrollment fee for 

TRICARE For Life. 

What is not clear to me is why, aside from the revenue being 

generated from the fees, DOD believes enrolling these participants 

is necessary. What benefit can these individuals expect to receive 

from enrolling? 

And, finally, 60 percent of the estimated cost savings from 

TRICARE proposals is based on military retirees opting out of 

TRICARE or using it less. Frankly, I think this plan is wrongheaded. 

Finally, I would like to hear from the military surgeons about efforts they are taking within the military departments to increase 

the efficiency of the military healthcare system and reduce cost. I 

would also like the military surgeons’ views on areas where additional efficiencies can be gained across the DOD health system. I 

hope our witnesses will address these important issues as directly 

as possible in their oral statements and in response to Member 

questions. 

Before I introduce our panel, let me offer Ranking Member 

Susan Davis of California an opportunity to make her opening remarks. 

[The prepared statement of Mr. Wilson can be found in the Appendix on page 27.] 

STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE 

FROM CALIFORNIA, RANKING MEMBER, SUBCOMMITTEE ON 

MILITARY PERSONNEL 

Mrs. DAVIS. Thank you, Mr. Chairman. 

I look forward, as well, to hearing from Assistant Secretary 

Woodson on his views on the status of the military healthcare system, particularly the TRICARE system, and the Department’s efforts to improve the care that we are providing to our service men 

and women, retiree survivors, and their families. 

I am also looking forward to hearing from our Surgeon General, 

General Green. Welcome back, and thank you for your service. 

Admiral Nathan and General Horoho, welcome. I believe that 

this is your first testimony before the committee. We are happy to 

have you. Thank you for your service. I know that you will continue the laudable efforts of your predecessors. 

And, finally, Mr. Strobridge from The Military Coalition, welcome. We appreciate your joining us to share your views, as well. 

The last decade of conflict has been weathered on the backs of 

our remarkable forces, in particular those who serve in our military 

healthcare system. The constant demands borne by those in uniform and those in support of them have yielded incredible successes on our battlefields—our battlefields abroad and at home 

here in the States. 

While I suspect that much of this hearing will focus on the 

healthcare proposals of the Department of Defense, this hearing 

should also provide the members of the subcommittee an opportunity to understand and to examine some of the difficult challenges facing the military healthcare system, from our reductions 
3 

in resources to meeting the ever-increasing demand for mental 

health services. 

Our military personnel and their families consistently exceed expectations under tremendous strains and pressures. And their access to quality health care should not be added to their plights. I 

look forward to your testimony on how we are caring for our service 

members and their families, particularly our injured, ill, and 

wounded, and how we can continue to improve our healthcare system in the new fiscal environment that we will be facing. 

Thank you all. 

Thank you, Mr. Chairman. 

[The prepared statement of Mrs. Davis can be found in the Appendix on page 28.] 

Mr. WILSON. Thank you, Ms. Davis. 

We have five witnesses today. We would like to give each witness 

the opportunity to present his or her testimony and each Member 

an opportunity to question the witnesses. I would respectfully remind the witnesses that we desire you to summarize to the greatest extent possible the high points of your written testimony into 

3 minutes. I assure you your written comments and statements 

will be made part of the hearing record. 

At this time, without objection, I ask unanimous consent that additional statements from the Reserve Officers Association, the National Military Family Association, and The Military Coalition 

would be included in the record of this hearing. 

Without objection, so ordered. 

[The information referred to can be found in the Appendix on 

pages 161, 169, and 196, respectively.] 

Mr. WILSON. Let me welcome the panel. 

Welcome back, Dr. Jonathan Woodson—thank you—as Assistant 

Secretary of Defense for Health Affairs. And we have Lieutenant 

General Patricia D. Horoho, the Surgeon General of the Department of the Army—thank you for being here; and Vice Admiral 

Matthew L. Nathan, Surgeon General, Department of the Navy; 

and Lieutenant General Charles Bruce Green, Surgeon General, 

Department of the Air Force; and Colonel (Ret.) Steve Strobridge, 

co-chairman, The Military Coalition. 

Before we begin, I would like to recognize General Horoho and 

Admiral Nathan and extend a special welcome to them, as this is 

their first appearance before the subcommittee since becoming Surgeon Generals. Congratulations to both of you. 

And I want to join with a fellow nurse of General Horoho, and 

that is Jeanette James. She is so excited, rightfully so, of you being 

the first nurse to serve as Surgeon General. So congratulations, 

and I am very proud for you. 

General Green, I understand you are retiring—at an early age— 

this summer, so this may be your last DHP [Defense Health Program] hearing. Your leadership has been instrumental in the tremendous advances made in the aeromedical evacuation system that 

is key to the extraordinary survival rate of our wounded and injured around the world. Thank you, and best of luck to you. 

I also want to announce that, to ensure that Members have an 

opportunity to question our witnesses, we will use the 5-minute 

rule when recognizing Members for questions. 
4 

And we will now begin with the testimony from the witnesses. 

And we have Jeanette James keeping the time, and she is above 

reproach. So when she says time is up, we will all follow through. 

So thank you so much. 

Dr. Woodson. 

STATEMENT OF HON. JONATHAN WOODSON, M.D., ASSISTANT 

SECRETARY OF DEFENSE FOR HEALTH AFFAIRS, U.S. DEPARTMENT OF DEFENSE 

Secretary WOODSON. Thank you, Mr. Chairman, Ranking Member Davis, members of the committee. Thank you for the opportunity to appear before you today to discuss the future of the Military Health System, in particular our priorities for this coming 

year. 

Over the last 10 years, the men and women serving in the Military Health System have performed with great skill and undeniable courage in combat. Their contributions to advancing military 

and American medicine are immense. The Military Health System’s ability to perform this mission and be able to respond to humanitarian crises around the world is unique among all military 

and non-military organizations on this globe, and I am committed 

to sustaining this indispensable instrument of national security. 

One of the most critical elements of our strategy is to ensure the 

medical readiness of men and women in our Armed Forces. We are 

using every tool at our disposal to assess the service member’s 

health before, during, and following deployment from combat theaters. And for those who return with injuries and illnesses, we continue to provide comprehensive treatment and rehabilitation services supported by medical research and development portfolios appropriately focused on the visible and invisible wounds of war. 

Concurrent with our mission of maintaining a medically ready 

force is our mission of maintaining a ready medical force. This 

ready-medical-force concept has many interdependent parts. It requires our entire medical team to be well trained. It requires development of our physicians in active accredited graduate medical 

education programs. It requires our military hospitals and clinics 

to be operating at near-optimal capacity. And for our beneficiaries, 

it requires an active decision to choose military medicine as their 

preferred source of care. 

To meet these readiness imperatives means we need to compete 

with the rest of American medicine to recruit and retain top talent, 

to provide state-of-the-art medical facilities that attract both patients and medical staff, and to sustain a high-quality care system. 

The budget we have proposed provides the resources we need to 

sustain the system. As we maintain our readiness, we must also be 

responsible stewards of the taxpayers’ dollars. The 2011 Budget 

Control Act required the Department to identify $487 billion in 

budget reductions over the next 10 years. Healthcare costs could 

not be exempt from this effort. 

The Military Health System is undertaking four simultaneous 

actions to reduce costs: one, internal efficiencies to better organize 

our decisionmaking and execution arm; two, a continuation of our 

efforts to appropriately pay providers in the private sector; three, 

initiatives that promote health, reduce illness, injury, and hos-
5 

pitalization; and four, proposed changes to the beneficiary costsharing under TRICARE. 

The military and civilian leaders in the Department developed 

these proposals and have publicly communicated their support for 

these proposals to you in writing and in person. I want to identify 

the core principles to which we adhered to in developing these proposals. 

We believe the TRICARE benefit has always been one of the 

most comprehensive and generous health benefits in our country, 

and our proposals keep it that way. In 1996, military retirees were 

responsible for about 27 percent of overall TRICARE costs. In 2012, 

the percentage share of costs borne by beneficiaries has dropped to 

a little over 10 percent of overall costs. If these proposals we put 

forward are accepted, beneficiary out-of-pocket costs will rise to 14 

percent of costs by 2017. This is about half of what beneficiaries 

experienced in 1996. 

Second, we have exempted the most vulnerable populations from 

our cost-sharing changes. Medically retired service members and 

the families of service members who died on Active Duty are both 

protected under this principle. Additionally, we have introduced 

cost-sharing tiers based upon retirement pay, reducing the increases for those with lower retirement pays. And this was uniform 

and line-led. 

Mr. Chairman, we recognize the concerns the members of the 

committee and the beneficiary organizations have voiced regarding 

these proposals. I want to emphasize that these proposals are targeted to mitigate the burden on any one particular group of beneficiaries while simultaneously meeting our congressionally mandated cost-saving responsibilities under the Budget Control Act. 

We have also recently submitted to Congress the Secretary’s recommended path forward on how we reorganize the Military Health 

System. We have learned a great deal from our joint medical operations over the last 10 years, and we recognize that there is much 

opportunity for introducing even a more agile headquarters operation that shares services and institutes common business plans 

and clinical practices across our system of care. 

The budget we have put forward for 2013 is a responsible path 

forward to sustaining the Military Health System in a changing 

world and recognizes that the fiscal health of the country is a vital 

element in our national security. I am proud to be here with you 

today to represent the men and women who comprise the Military 

Health System, and I look forward to your questions. 

[The prepared statement of Secretary Woodson can be found in 

the Appendix on page 29.] 

Mr. WILSON. Thank you very much. 

And Dr. Horoho. 

STATEMENT OF LTG PATRICIA D. HOROHO, USA, SURGEON 

GENERAL, U.S. ARMY 

General HOROHO. Chairman Wilson, Ranking Member Davis, 

and distinguished members of the committee, thank you for providing me this opportunity to share with you today my thoughts on 

the future of Army Medicine and highlight some of the incredible 
6 

work being performed by dedicated men and women, with whom I 

am honored to serve alongside. 

We are American’s most trusted premier medical team, and our 

successful mission accomplishment over these past 10 years is testimony to the phenomenal resilience, dedication, and innovative 

spirit of soldier medics, civilians, and military families throughout 

the world. 

From July to October of 2011, I was privileged to serve as the 

International Security Assistance Force Joint Command’s special 

assistant for health affairs. My multidisciplinary team of 14 military health professionals conducted an extensive evaluation of theater health service support to critically assess how well we were 

providing health care from the point of injury to evacuation from 

theater. It cannot be overstated that the best trauma care in the 

world resides with the U.S. military in Afghanistan and Iraq. 

The AMEDD [United States Army Medical Department] is focused on building upon these successes on the battlefield as we perform our mission at home and is further cementing our commitment to working as a combined team anywhere, anytime. We are 

at our best when we operate as part of the joint team, and we need 

to proactively develop synergy with our partners as military medicine moves toward a joint operating environment. Continuity of 

care and continuity of information are key to the delivery as DOD 

[Department of Defense] and the VA [Department of Veterans Affairs] team provides care. 

There are significant health-related consequences over the 10 

years of war, including behavioral health needs, post-traumatic 

stress, intensive care of burns or disfiguring injuries, and chronic 

pain. A decade of war in Afghanistan and Iraq has led to tremendous advances in knowledge and care of combat-related physical 

and psychological problems. We have partnered with the Department of Veterans Affairs, the Defense and Veterans Brain Injury 

Center, and the Defense Centers of Excellence for Traumatic Brain 

Injury and Psychological Health in academia, as well as the National Football League, to improve our ability to diagnose, treat, 

and care for those affected by traumatic brain injury. 

Similar to our approach with concussive head injuries, Army 

Medicine has harvested the lessons of almost a decade of war and 

has approached the strengthening of our soldiers’ and families’ behavioral health and emotional resiliency through the comprehensive behavioral health system of care. It is a system of systems 

built around the need to support an Army engaged in repetitive deployments, often in intense combat, which then returns to home 

station to restore, reset the formation, and reestablish family and 

community bonds. The system is underpinned by the multiple 

touchpoints across the time, in which soldiers receive mandatory 

behavioral health assessments from pre-deployment to post-deployment and into garrison life. 

The warfighter does not stand alone in support of a nation in 

persistent conflict with the stresses resulting from 10 years of war. 

Army Medicine has a responsibility to all those who serve, to include our family members and our retirees who have already answered the call to our Nation. We are committed to ensuring the 

right capabilities are available to promote health and wellness and 
7 

are focused on decreasing variance, increasing standards and 

standardizations across Army Medicine. 

I am incredibly honored and proud to serve as the 43rd Surgeon 

General and the Army Commander of the U.S. Army Medical Command. There are miracles happening every day at our command 

outposts, forward operating bases, posts, camps, and stations every 

day because of the dedicated civilians and soldiers that make up 

the Army Medical Department. 

With the continued support of Congress, we will lead the Nation 

in health care and health, and our men and women in uniform will 

be ready when the Nation calls them to action. Army Medicine 

stands ready to accomplish any task in support of our warfighters 

and families. 

Thank you for the opportunity to talk with you today, and I look 

forward to your questions. 

[The prepared statement of General Horoho can be found in the 

Appendix on page 55.] 

Mr. WILSON. Thank you very much. 

And Admiral Nathan. 

STATEMENT OF VADM MATTHEW L. NATHAN, USN, SURGEON 

GENERAL, U.S. NAVY 

Admiral NATHAN. Thank you, Chairman Wilson, Ranking Member Davis, distinguished members of the subcommittee. I am 

pleased to be with you today to provide an update on Navy Medicine, including some of our collective strategic priorities, accomplishments, opportunities, and challenges. 

I want to thank the committee members for the tremendous confidence and support shown to Navy Medicine. 

I can report to you that Navy Medicine remains strong, capable, 

and mission-ready to deliver world-class care anywhere, anytime, 

as is our motto. The men and women of Navy Medicine are flexible; 

they are agile and resilient. They are meeting their operational and 

wartime commitments, including humanitarian assistance and disaster relief response, and concurrently delivering outstanding 

patient- and family-centered care to our beneficiaries. 

Force health protection is what we do. And we do it at the very 

foundation of our continuum of care in support of the warfighter, 

and optimizes our ability to promote, protect, and restore their 

health. 

One of my top priorities as I assumed my role as Surgeon General in November has been to ensure that Navy Medicine remains 

strategically aligned with the imperatives and priorities of the 

Commandant of the Marine Corps and the Chief of Naval Operations. Each day, we are fully focused on executing the operational 

missions and core capabilities of the Navy and Marine Corps, and 

we do this by maintaining warfighter health readiness, delivering 

the continuum of care from the battlefield to the bedside and from 

the bedside either back to the unit, to the family, or to transition. 

We are honored to be entrusted with the health care of all we 

serve. We are aligned with our Navy and Marine Corps leadership 

as we support the defense strategic guidance, ‘‘Sustaining U.S. 

Global Leadership: Priorities for the 21st Century,’’ issued by the 

President and Secretary of Defense earlier this year. 
8 

The Chief of Naval Operations, in his sailing directions to us, has 

articulated the Navy’s first principles, and these include: 

warfighting first, operate forward, be ready. Earlier this month, 

Secretary Mabus launched the 21st-Century Sailor and Marine 

Program, a new initiative focused on maximizing each sailor’s and 

marine’s personal readiness. This program includes comprehensive 

efforts in key areas such as reducing suicides, curbing alcohol 

abuse, and reinforcing zero tolerance on the use of designer drugs 

or synthetic chemical compounds. It also recognizes the vital role 

of safety and physical fitness in sustaining the force readiness. 

Navy Medicine is synchronized with those priorities and stands 

ready to move forward at this pivotal time in our history. We appreciate the committee’s strong support of resource requirements. 

The President’s budget for FY [fiscal year] 2013 adequately funds 

Navy Medicine to meet its medical mission for the Navy and Marine Corps. We recognize the significant investments made in supporting military medicine and providing a strong, equitable, and affordable healthcare benefit for beneficiaries. 

Moving forward, we must innovate, operate jointly, position our 

direct care system to recapture private-sector care, and deliver best 

value to our patients. Briefly, I will share with you a few specific 

areas of our attention. 

Combat casualty care: Navy Medicine, along with our Army and 

Air Force colleagues, are delivering outstanding combat casualty 

care. There is occasional discussion about what constitutes ‘‘worldclass,’’ and I can assure you that the remarkable skills and capabilities in places like the Role 3, a multinational medical unit in 

Kandahar, is, in fact, world-class trauma care, now even deploying 

MRI [magnetic resonance imaging] technology to investigate if this 

can be meaningful in changing the diagnosis and/or therapy in theater. 

Another area is TBI [traumatic brain injury] and PTSD [posttraumatic stress disorder]. Caring for our sailors and marines suffering with traumatic brain injury and post-traumatic stress and/ 

or PTSD remains a top priority. While we are making progress, we 

have much work ahead of us as we determine both the acute and 

the long-term impact on our service members. Military medicine 

cannot do this alone. We must continue active and expansive partnerships with the other services, our centers of excellence, the VA, 

and leading academic, medical, and private sectors. We wish to 

make the best care available to our warriors affected with TBI. I 

have been encouraged by our progress, but I am not yet satisfied. 

And, also, wounded warrior recovery: Our wounded, ill, and injured service members need to heal in body, mind, and spirit. And 

they deserve a seamless and comprehensive approach to their recover along that journey with their families. Moving forward, we 

must continue to connect our heroes to approved emerging and diagnostic therapeutic options, both within our medical treatment facilities and outside of military medicine through collaborations with 

major centers of reconstructive and regenerative medicine. Our 

commitment to these men and women will never waiver. 

And one last point on Medical Home Port, our adaptation of the 

successful civilian patient-centered medical home concept of care, 

which is transforming delivery of primary care across many man-
9 

aged care agencies in the country. We have completed our initial 

deployment of Medical Home Port throughout the Navy Medical 

Enterprise, and preliminary results in the first sites show better 

value, better health—preventative health, cost utilization of those 

enrolled. 

Also, our innovative research, including the critical overseas laboratories that not only provide world-class research but invaluable 

engagement with host and surrounding nations to strengthen theater security cooperation in places like Egypt, South America, 

Southeast Asia, along with excellent medical education and training programs ensure that we have the capabilities to deliver the 

state-of-the-art care now and in the future. They are truly force 

multipliers. 

We continue to welcome and leverage our joint relationships with 

the Army, the Air Force, the VA, as well as other Federal and civilian partners in these important areas. I believe this interoperability helps us create systemwide synergies and allows us to invest wisely in education, training, research, and information technology. 

None of these things would be possible without our dedicated 

workforce, a team of over 63,000 Active Component and Reserve 

Component personnel, Government civilians, as well as contract 

personnel, all working around the world to provide outstanding 

health care and support to their beneficiaries. I am continually inspired by their selfless service and sharp focus on protecting the 

health of sailors, marines, and their families. And I am particularly 

grateful for your support in helping us recruit and retain the best 

of these. 

In closing, let me briefly address the MHS [Military Health System] governance. We appreciate the opportunity to begin the dialogue with you a month ago, when there was a hearing held on this 

issue. The Deputy Secretary of Defense has submitted his report to 

Congress, required by Section 716 of the fiscal year 2012 National 

Defense Authorization Act. It addresses the Department’s plans, 

subject to review and concurrence by the GAO [Government Accountability Office], to move forward with governance changes. 

Throughout my remarks this morning and in my statement for 

the record, I referred to our jointness in theater, in our classrooms, 

our laboratories, and our common pursuit of solutions for challenges like TBI. I again stress our commitment to interoperability 

and cost-effective joint solutions in terms of overall governance. 

Navy Medicine looks forward to working on the next phase of the 

Deputy Secretary’s plan. We must proceed and deliver it in a measured manner to ensure that our readiness to support our service’s 

missions and our core warfighting capabilities will be maintained 

and our excellence in health care will be sustained. 

On behalf of the men and women of Navy Medicine, I want to 

thank the committee for your tremendous support, your confidence, 

and your leadership. It is my pleasure to testify before you today, 

and I look forward to your questions. 

[The prepared statement of Admiral Nathan can be found in the 

Appendix on page 83.] 

Mr. WILSON. Thank you very much, Admiral. 

General Green. 
10 

STATEMENT OF LT GEN CHARLES B. GREEN, USAF, SURGEON 

GENERAL, U.S. AIR FORCE 

General GREEN. Thank you. 

Chairman Wilson, Representative Davis, and distinguished members of the committee, thank you for inviting me here today. The 

Air Force Medical Service could not achieve our goals of readiness, 

better health, better care, and best value without your support, and 

we thank you. 

To meet these goals, the Air Force Medical Service is transforming deployable capability, building patient-centered care, and 

investing in education, training, and research to sustain worldclass health care. 

This year, we established 10 new expeditionary medical support 

health response teams. These 10-bed, deployable hospitals enable 

us to provide emergency care within 30 minutes of arrival at scene 

and perform surgery within 5 hours in any contingency. Light and 

lean, it is transportable in a single C–17, with full base operating 

support requiring only one additional C–17. The health response 

team was used successfully in the Trinidad humanitarian mission 

last May and is our new standard package for rapid battlefield care 

and humanitarian assistance. 

Critical care air transport teams and air evacuation continue to 

be a dominant factor in our unprecedented high survival rate. To 

close the gap and enter a critical care continuum, we applied the 

CCAT [critical care air transport] concept to tactical patient movement, delivering the same level of care during intratheater transports on rotary platforms. 

The Tactical Critical Care Evacuation Team was fielded in 2011, 

and five teams are now trained. Two teams are currently deployed 

to Afghanistan, and each team has an emergency physician, two 

nurse anesthetists. And we are able to move critical patients between level 2 and level 3 facilities even more safely. 

At home we enrolled 920,000 beneficiaries—actually, today it is 

940,000 beneficiaries—into team-based, patient-centered care at all 

Air Force medical treatment facilities. This care model reduced 

emergency room visits, is improving health indicators, and 

achieved unprecedented continuity of care for our military beneficiaries. 

The Air Force remains vigilant in safeguarding the wellbeing and 

mental health of our people. Post-deployment health reassessment 

completion rates are consistently above 80 percent for Active Duty, 

Guard, and Reserve personnel. The new Deployment Transition 

Center at Ramstein Air Base, Germany, provides an effective reintegration program for our deploying troops, and more than 3,000 

have been through to date. We focus on our highest-risk patients, 

our beneficiaries. And a study of the airmen who have attended 

showed significantly fewer systems of post-traumatic stress and 

lower levels of both alcohol use and conflict with family or coworkers upon their return home. 

By this summer, behavioral health providers will be embedded in 

every primary care clinic in the Air Force. And we reach our Guard 

and Reserve members through telemental health efforts and embedded psychological health directors, and we are further increasing mental health provider manning over the next 5 years. 
11 

New training to support air evacuation and expeditionary medical capability is now in place. Our training curriculums are continuously updated to capture the lessons from 10 years of war. And 

our partnerships with civilian trauma institutions have proved so 

successful in maintaining wartime skills that we have expanded 

the training sites to establish new programs with the University of 

Nevada–Las Vegas and Tampa General Hospital. 

We also shifted our initial nursing training for new Air Force 

nurses to three civilian medical centers. The Nurse Transition Program now at the University of Cincinnati, at Scottsdale, and in 

Tampa broaden our resuscitative skills and experience. 

Air Force graduate medical education continues to be the bedrock 

for recruiting our top-notch physicians. Our graduate programs are 

affiliated with Uniformed Services University and civilian universities. And these partnerships build credibility, both in the U.S. 

and international medical communities. 

One of our most significant partners is the Department of Veterans Affairs. And we are very proud of our 6 joint ventures, 59 

sharing agreements, and 63 joint incentive fund projects, which are 

improving services to all beneficiaries. 

We also note significant progress has been made toward the integrated electronic health record, to be shared by DOD and the Department of Veterans Affairs. 

In the coming year, we will work shoulder-to-shoulder with our 

Army, Navy, and DOD counterparts to be ready, to provide better 

health, better care, and best value to America’s heroes. Together, 

we will implement the right governance of our Military Health System. We will find efficiencies and provide even higher-quality care 

with the resources we are given. 

I thank this committee for your tremendous support to military 

medics. Our success, both at home and on the battlefield, would not 

be possible without your persistent and generous support. 

Thank you, and I look forward to answering your questions. 

[The prepared statement of General Green can be found in the 

Appendix on page 109.] 

Mr. WILSON. Thank you very much, General Green. 

And Mr. Strobridge. 

STATEMENT OF COL STEVE STROBRIDGE, USAF (RET.), CO– 

CHAIR, THE MILITARY COALITION 

Colonel STROBRIDGE. Thank you, Mr. Chairman, Ranking Member Davis, and distinguished members of the subcommittee. 

Less than 3 months ago, the fiscal year 2012 Defense Authorization Act became law, which let the Administration implement the 

TRICARE fee increases it recommended last year. Now, when the 

ink is hardly dry, the new proposal would impose far higher increases for TRICARE Standard, TRICARE Prime, and TRICARE 

For Life, plus a doubling and tripling of new pharmacy co-pays. 

It would raise health costs $1,000 to $2,000 a year or more for 

retirees, and the large pharmacy fee hikes would affect many currently serving people, as well—families, the family members. Defense leaders say they will keep faith with the currently serving on 

retirement reform, but thousands who retire in the next year would 

incur these new fees. If ‘‘keeping faith’’ means no changes for to-
12 

day’s troops on retirement, then it is breaking faith to raise their 

fees by $2,000. That is no different than a $2,000 retired pay cut. 

And if it is breaking faith to change the rules for someone with 1 

year of service, then it is doubly so to do that to those who have 

already completed 20 or 30 years. 

For generations, the Government has induced millions to complete arduous service careers in uniform with promises that, for 

rendering that sacrifice, they would earn the current retirement 

and healthcare package. In other words, their extended service and 

sacrifice constituted their prepaid premium. Now, after retirees 

have done their part, Pentagon leaders say their service isn’t worth 

so much anymore and they should pony up thousands more every 

year for the rest of their life. 

They blame the budget crunch but balk at changes to make the 

system significantly more efficient. Many studies document the inefficiencies of DOD’s fragmented healthcare systems, but the recent 

review made only minimal changes, in part because a key decision 

criterion was how hard the change would be. So the first choice 

was to make retirees pay more because it was easier. 

Another argument is that military programs should move toward 

market rates and be more like civilian plans. After all, they say, 

military retirees pay far less for health care than civilians do. 

Whenever somebody gives me that argument, I ask, ‘‘If the military 

deal is so great, are you willing to pay what they did to earn it? 

Would you sign up to spend the next 20 or 30 years being deployed 

to Iraq, Afghanistan, or any other garden spot the Government 

wanted to send you to?’’ 

Military people pay far steeper premiums for health coverage 

than any civilian ever has or ever will. That is why military coverage is supposed to be top-tier coverage, not just the civilian median. 

One example: Fifty-six percent of civilian employer plans charge $25 co-pays or less for brand-name medications. That puts the new 

$26 TRICARE proposal in the bottom half of civilian plans. Further, TRICARE’s $5 retail generic co-pay that was implemented 

last October is already more than civilians with no insurance at all 

pay at Wal-Mart and many other pharmacies. And they want to 

raise the military co-pay again. 

As for the plan to means-test retiree health fees, that is patent 

discrimination against the military. No other Federal retiree has 

service-earned health benefits means-tested, and it is rare in the 

civilian world. Under that perverse system, the longer and more 

successful you serve, the less benefit you earn. The Coalition believes strongly that the proposed rates are significantly too high for 

all military beneficiaries. 

Finally, the Coalition objects very strongly for tying TRICARE 

fee growth to any index of health-cost growth. On behalf of the 

MOAA [Military Officers Association of America] and 22 other associations, we strongly support the position you established in the 

fiscal year 2012 Defense Authorization Act: that the percent growth 

in TRICARE fees in any given year should not exceed the percentage growth in military retired pay. 

We are grateful for this opportunity to present our views, and I 

will be pleased to answer any questions. 
13 

[The prepared statement of Colonel Strobridge can be found in 

the Appendix on page 129.] 

Mr. WILSON. Thank you very much, Mr. Strobridge. 

And as we begin—and I am going to be on the 5-minute clock 

myself. But as we begin, I want to thank you. And I agree with 

General Horoho that miracles are performed every day. And as a 

military parent, as a veteran, I appreciate so much your service. It 

is so reassuring to know that the survival rate of our military is 

the highest in world history and, also, the technological advances 

for our wounded warriors is the best, again, in world history. And 

it is just reassuring as a parent. 

As we prepare today, Dr. Woodson, I am concerned—and I appreciate the points made by Mr. Strobridge. Based on your projections, 

60 percent of the savings from the TRICARE proposals will come 

from beneficiaries choosing not to use the benefit they earned by 

serving or by using it less. 

How did DOD calculate the estimated savings from beneficiaries 

opting out of TRICARE? 

Secretary WOODSON. Thank you, Mr. Chairman, for the question. 

I must admit I am a little perplexed at how those numbers are 

summed up. Our rationale going into deriving the fee adjustments 

were coming from the issue of what we needed to achieve in cost 

savings over 10 years. That is the $487 billion and, over the FYDP 

[Five-Year Defense Plan], of $269 [billion]. 

And although personnel benefits are a third of DOD’s costs, 90 

percent of the savings actually comes from reduction in weapons 

programs, force reductions, and the like. And, as I mentioned in my 

opening statement, healthcare costs could not be excluded and had 

been the subject of some review over a number of years, as the fees 

for TRICARE had not increased for some 15 or 16 years until the 

recent NDAA [National Defense Authorization Act]. 

And so we were left with about $29 billion to look at. And even 

with that $29-billion sort of assessment, we only took really less 

than half of that, $12.9 billion, really over the FYDP and applied 

those really to sort of the fee adjustments, and then spread it 

across all of the programs so, again, no one beneficiary group was 

unduly affected. 

So the real issue is about a rebalancing. And it is not even rebalancing to the original cost-share formula that Congress agreed to 

when we started the program. And the Secretary and the line leadership, who were heavily invested in both the adjustments and the 

tiering—remember, these are members in uniform, who spent the 

35 years in uniform and are going to retire and are going to be subjected to these fees—felt strongly—and this included the senior enlisted leadership—felt strongly that there should be tiering and 

that they were the right adjustments to make at this time. 

And I remind the committee also that we were guided by prior 

studies, such as the 2007 task force on the future of health care, 

which specifically, among other things, noted that these are one of 

the reforms that we should undertake. 

So that is how we arrived at it. It wasn’t an issue of trying to 

force people out of TRICARE. And, in fact, our numbers suggest 

that, considering the rise in premiums in the private sector and 

considering some of the other issues that affect health care, we 
14 

may have more people taking advantage of their TRICARE benefits, so quite the opposite. 

Now, the truth is that maybe some may want to switch to Standard, which has a different cost share, but there is no attempt, absolutely no attempt, to drive people away from their TRICARE benefit. 

Mr. WILSON. Well, I know of your personal commitment, but I 

am concerned about the formula, particularly with TRICARE fee 

increases, that an E–7 who served 28 years is going to pay more 

than an E–7 who served 20 years. And that doesn’t seem fair to 

me, that people who serve longer pay more. 

Secretary WOODSON. Well, you are speaking to the formula— 

again, line-driven, uniform-driven on this. I can’t emphasize that 

enough, that they took the mantle on this. The issue is that they 

felt strongly that those who make more should pay more. Their increases over the years, in fact, have been proportionally more because they come out with more retired pay. But for 16 years there 

has been no increase. So the issue is, they felt strongly that this 

was a fair way to go. 

Mr. WILSON. Thank you. 

We now proceed to Ms. Davis. 

Mrs. DAVIS. Thank you, Mr. Chairman. 

And I certainly can acknowledge that we are all probably going 

to dig in on this issue to a certain extent. But I think it is also very 

fair to ask what would happen if, in fact, approval of these changes 

did not go forward. 

Secretary WOODSON. Thanks again for that very important question because if—as I mentioned, 90 percent of the savings came 

from other areas, so planes, ships, people. If we don’t go forward 

with these TRICARE fee adjustments, we will have to look at 

planes, ships, and people again. 

And so the issue is that, if we look at people, we are looking at 

maybe a 50 percent more increase in the reduction of the force. 

And while I wouldn’t want to fix a number on this, we are talking 

about anywhere from, you know, 30,000 to 50,000 troops. 

Mrs. DAVIS. Okay. Well, thank you. I mean, we know we are in 

a very difficult space. 

And I guess, Mr. Strobridge, you probably have the most difficult 

job of anybody up there, in many ways. And I think in your comments you also were looking at ways that we could expand benefits 

while at the same time, I think quite eloquently, saying that, you 

know, this is not the place to increase these on the men and 

women who serve and sacrifice for our country. 

But, within that, of looking to expand and wanting to not change 

anything, where do you see any kind of wiggle room there? 

Colonel STROBRIDGE. Well, there are various views among the associations. And, as I said a little earlier, MOAA and 22 other associations have not taken the view that there should never be a single fee increase. We think that, you know, over time, as retired pay 

rises, there is an expectation that fees will rise. But we think that 

they have to be reasonable. And we think that the standard that 

the committee established last year, by tracking to the COLA [costof-living adjustment] percentage, is reasonable. 
15 

I would like to make one comment in terms of, you know, what 

are the alternatives. One of the things that we have said very consistently is that there are ways to make the system more efficient 

without raising beneficiary fees. We have talked to people who 

have done reviews in the last couple of years who have raised the 

figure of a potential savings of 30 percent if you reorganized the 

system, with no requirement to cut benefits and no increases in 

beneficiary fees. That entails significant reorganization of how 

health care is delivered in the military system. 

I was the defense implementation officer for the Goldwater-Nichols provisions, the jointness provisions. And I can tell you, at that 

time, all the hearings said it was too hard, we can’t do it. None of 

the Services wanted to do it. We did it, because Congress directed 

it. And I believe the same potential lies here. 

Mrs. DAVIS. Yeah. Thank you. 

You asked my next question for me. I appreciate that. Because 

I wanted to turn to Dr. Woodson, because we know that the Department of Defense has proposed another change in governance 

structure. In 2006, we saw a change to that. 

And I am just wondering, of the—I believe there were seven governance initiatives that were supposed to achieve some economies 

of scale and operational efficiencies, how many have projected any 

estimated savings? Do we see savings there? How much of the $200 

million annual savings has been realized that I think we were hoping for? And going back to Mr. Strobridge’s question—and I know 

I am running out of time—how does that improve jointness? 

Secretary WOODSON. Thank you very much for this important 

question. 

Clearly, it improves jointness, and I will return to that in just 

a minute. 

But just to put it in context, you know, when we talk about 30 

percent savings and what is achieved by reorganization, you are focusing really on the least costly part of the Military Health System—that is, the headquarters and sort of the administrative activities. And so that is about 2 percent of budget. The real area 

that you need to affect is in sort of the cost of delivery of care, so 

what we call Budget Area Group 1 and 2, which is the big balloons, 

you know, accounting for probably out of the DHP $25 billion or 

more in that situation. 

And so the thing that everyone needs to understand is that we 

are committed to restructuring the MHS to produce the most efficient administrative system. So we are already bought off on that, 

and that is why we made the proposal to the DHA [Defense Health 

Agency]. But it really is a leverage to produce the efficiencies and 

developing the strategies for delivering the care so that we improve 

access and quality at a lower cost, so a better value for the dollars 

that are spent. 

But to speak to what we have already done, clearly, you know, 

we have made amazing changes over the years in terms of the administrative structure to drive out that waste. We accepted, actually, MOAA’s suggestion some years ago about looking at our pharmacy approaches and going to Federal ceiling pricing, and we have 

already saved $3.4 billion in talking about administrative process; 

and fraud and recuperation of fees, $2.6 billion; medical acquisi-
16 

tions, $31 million a year. We have reduced headquarters already 

last year by 440 FTEs [Full Time Equivalents] and are on track to 

reducing it to the total of the 680 that we talked about with Congress last year. 

And so we have undertaken a lot of initiatives, some of which I 

won’t talk about now. So the issue is, we have really squeezed that 

lemon called an administrative process. And with the report to 

Congress, I think we are doing the right things in terms of reform. 

With the Defense Health Agency that is proposed, you know, we 

will be focusing on the issues of health IT [information technology], 

of medical education, of medical logistics, of sort of research and 

development, and being able to reduce an additional probable, at 

least, on the conservative side, 300 FTEs out of the administrative 

process. 

So I think we have worked diligently together to look forward 

and design a system that is responsive, not only to sort of our mission, to try and do our mission better, but to do it in a cost-efficient 

way. But the key is that that is only 2 percent of our budget. 

Mr. WILSON. Thank you, Ms. Davis. 

And we will now proceed by order of appearance. And Dr. Heck 

ran across the street. I saw him, so he was here first. 

Dr. Joe Heck from Nevada. 

Dr. HECK. Thank you, Mr. Chairman. 

And thank you all for being here, and thank you all for your 

service to our Nation, both in and out of uniform, and to the men 

and women that are still serving. 

We talk a lot about dollars, but to me it doesn’t make a difference, the dollar amount, if there is no access. And so, Dr. Woodson, primarily I have two questions regarding access that I would 

like to bring up, two issues. 

One is the contracting process by which the TRICARE contracts 

are awarded. As I am sure you are aware, there was recently an 

appeal in the TriWest region, in the west region, that resulted in 

a change of the contract provider. And that appeal occurred almost 

2 years after the contract was awarded and after the other entity 

lost an appeal in another region. 

And so I am wondering, what is the process that allows that to 

happen, where you are appealing in one region, you are not successful, and then you reserve the right to appeal in another region 

2 years later after the awardee has already, you know, been providing very good quality care? 

And in full disclosure, I say it as a former not only TriWest beneficiary but a TriWest provider. How does that—I mean, that whole 

acquisition and contracting process just doesn’t seem like it is 

something that should be working in that regard. 

Secretary WOODSON. Thank you very much for the question. And 

I think it is actually quite the reverse. The acquisition process is 

a difficult, somewhat cumbersome process, but it is carried out according to due process to ensure fairness. And some of the protests 

that have been raised have been protests about the process, and 

that is why you have to do it with all due diligence. 

We have, you know, in place the requirement that no one provider or group can operate in two different regions. And that has 

to do with making sure that if there was a serious problem in any 
17 

one provider, it would put at jeopardy too much of our network, if 

you will. 

And so what happens is that you just have to go through the 

rather laborious legal and regulatory steps in order to get to a final 

decision and give the competing entities the right to appeal. It is 

just part of the process. And we know it takes time. 

But one of the things that we have done is, we have actually reformed our acquisition process to ensure that there is fair adjudication of the individuals or the entities that are competing for these 

contracts. And it is understandable that they would protest. These 

are very large contracts, and it is important to their business. And 

it is just a process that needs to be played out. 

Dr. HECK. Well, I can appreciate that, but it would just seem odd 

that you can maintain a right of appeal in one region while you are 

being adjudicated on a protest in another region, and if that doesn’t 

work, then you can come back, you know, and protest another place 

after that original awardee has put together their care provisions. 

Is that a statutory, a regulatory, is that a DOD policy? Where 

does that fall, that process that is in use? 

Secretary WOODSON. Well, it is statutory, regulatory. It is all of 

those things, if you will. 

I am not sure that the two are necessarily tied, as suggested. 

Each of the regions went through their process of sort of looking 

at the proposals and adjudicating them and ranking them and 

making decisions by the source authority, basically, and it was 

played out. 

Dr. HECK. Well, I appreciate that. 

Secretary WOODSON. And it is a complicated process, but it is 

there for everybody’s protection. 

Dr. HECK. And just quickly in my last few remaining seconds 

here, I recently received a letter that the Department of Defense 

is considering not recognizing the accreditation of osteopathic residency programs. And when we talk about maintaining access to 

quality healthcare providers, I was wondering if you have had any 

visibility on that. We sent a letter off asking for further information, but we would certainly appreciate follow-up on that, as well. 

Secretary WOODSON. I had not heard about that as an issue, but 

I will take that for the record and I will respond to you. 

[The information referred to can be found in the Appendix on 

page 223.] 

Dr. HECK. Thank you. 

Thank you, Mr. Chair. I yield back. 

Mr. WILSON. Thank you very much, Doctor. 

And we now proceed to Congresswoman Madeleine Bordallo of 

Guam. 

Ms. BORDALLO. Thank you, Mr. Chairman. 

And to all of our witnesses, I thank you for your testimony today. 

Dr. Woodson, I have a question for you. Do you have any statistics in regards to the rise and/or fall of military healthcare costs 

as we drew down in Iraq? 

Secretary WOODSON. Thank you for the question, and it is a little 

bit of a complicated answer, and here is the reason why. 

Some of the costs of medical care are funded by OCO [Overseas 

Contingency Operations] funds. And if you look at probably the last 
18 

10 years of war, as best as we can dissect out sort of the relative 

cost, the increase in costs for the overall DHP is probably only in 

the range of about 6 percent. But I want you to understand that 

it depends on how you dissect out the cost. 

But the point I want to make is that most of the rise in costs 

is really parallel to what is experienced in the civilian sector in 

terms of health inflation costs, which has been relatively steep 

over—at least particularly in the first part of the first 5 years of 

the century. So the issue of the defense health costs are really driven by that equation, what we pay for care in the private sector and 

the cost of delivering care in our direct care setting, the medical 

treatment facilities. 

And that is why I pointed out before that, as much time as we 

spend talking about reorganizing and restructuring the administrative process, most of the money is in bag one and bag two, which 

is what we pay for care in the direct care system and in the purchased care system. 

So, to sum up, it is hard to answer your question. We haven’t 

seen a reduction in the cost coming out of Iraq. 

The other thing I would mention to you is that, just because the 

kinetic war stops today, we have a huge tail in terms of taking care 

of the wounded and injured. So we are not likely to see, even if 

there was a precipitous increase in cost due to the war, a drop-off. 

What is interesting, also, for the committee to know about is that 

last week we convened a 1-day conference looking at the long-term 

healthcare needs of wounded, ill, and injured. So we are talking 

about what they are going to need 10, 20 years down the pike or 

more. And we got a lot of interesting information about what that 

tail looks like and what we should be focusing on going forward. 

So the answer to your question is, no, we haven’t seen a reduction in the cost. The tail will be there for a long time. And there 

still are unknown factors that will affect those costs. 

Ms. BORDALLO. Thank you. 

Another question for you, Dr. Woodson. What efforts is the Department of Defense taking to find efficiencies within its overall 

medical system? 

For example, we may have moved to a joint medical facility up 

in Bethesda, but I am not certain we have a truly joint medical 

system that reduces redundancies between each of the Services’ 

healthcare providers. So I hope you can elaborate on what is being 

done to make a more joint healthcare delivery system and finding 

ways to reduce cost. 

Secretary WOODSON. Thanks again. And I think that speaks to 

the report to Congress and our proposal to develop a defense health 

agency. It is looking at all of those shared and common services 

that have redundancies within each of the Services, trying to move 

them into a single management agency, reduce the cost. We talked 

about probably saving 300 FTEs. And that is just one model of 

looking at how do you reduce costs. 

We really do believe that there are other efficiencies that will be 

driven, so that within the health IT we will be able to make some 

additional reductions. Within medical training, we will be able to 

make some reduction. Medical logistics, we will make some reductions. So the modest end of what we will achieve is represented by, 
19 

you know, the 300 FTE reduction, which equates to about $50 million to $100 million a year. 

Ms. BORDALLO. Fifty million to $100 million? 

Secretary WOODSON. Yes. 

Ms. BORDALLO. Great. Thank you very much, Doctor. 

And I yield back my time. Thank you, Mr. Chairman. 

Mr. WILSON. Thank you very much. 

We now proceed to Colonel Allen West of Florida. 

Mr. WEST. Thank you, Mr. Chairman and Ranking Member. 

And thanks to the panel for being here. 

And, look, I am going to be very honest. I didn’t go to law school, 

nursing school, medical school. I went to airborne school, so I am 

going to use a little paratrooper logic here. 

Mr. Strobridge, Dr. Woodson, did we have any consultation about 

this whole plan with military veteran organizations? 

Colonel STROBRIDGE. No. 

Secretary WOODSON. We had no direct consultation with the military organizations in putting this proposal together. What we did 

have is information that they had provided to us over years about 

their thoughts on these same issues, since this is not a new set of 

issues that has come up. 

Colonel STROBRIDGE. Well, I would say, no, there wasn’t any consultation. 

A couple of examples: You know, the one comment was made 

that we are talking about just the headquarters. The issue on reorganization isn’t the headquarters. The issue is consolidation of responsibility and accountability for the budget, which we don’t have 

right now. When a base wants to save money and they get ordered 

to cut their budgets, they can reduce the medications and the 

formularies, send people downtown, which costs more money but it 

doesn’t affect them because the charge goes to DOD. It is those 

kinds of inefficiencies that you have to eliminate by the reorganization in terms of how you deliver care, so that you get rid of that, 

you know, ‘‘I will just shift my expense over to somebody else.’’ 

The other example was the mail-order pharmacy, which Dr. 

Woodson is correct, we have pushed the Defense Department for 

several years to put more effort into promoting the mail-order 

pharmacy. We had a formal proposal to form a partnership with 

them by which the associations would go out and put out a common 

package developed by the Department of Defense that we would 

work with the Medicare supplement insurance companies, who also 

have an incentive to reduce their expenses if people reduce their 

drug expenses. After a year, we got one meeting for a half-hour. We 

have had nothing since. 

Mr. WEST. If I am correct, the population of the United States 

of America is about 350 million. Correct? Somewhere thereabout? 

And when I am reading through this, you provide to about 9.6 million beneficiaries. Are we supposed to believe that less than 1 percent are causing the fiscal woes of this country? That is something 

that really disturbs me. 

Furthermore, I read that in fiscal year 2013 we are looking at $452 million of savings; fiscal year 2013 to 2017, we are talking 

about $5.5 billion of savings. Last year, the GAO put out a report, 

February 2011, that said there is $200 billion to $300 billion of re-
20 

dundant and duplicative Government programs out there. Why 

don’t we look at that before we start penalizing the people that 

have, you know, given a lifetime of service to this country? 

The next question, is there any effect to DOD civilian healthcare 

plans, any changes to their plans? 

Secretary WOODSON. Let me address a couple of things. 

Your last question first: No. And in part because we don’t control 

that, but, more importantly, they already go through a yearly adjustment in fees and have done so over the last decade so that they 

pay about 30 percent of the cost. They already have had those adjustments, and civilians have had a pay freeze. But that is not 

within our line of authority, really, to address. 

In regards to your first point about the issue of military folks 

being responsible for the national debt crisis, I don’t think anyone 

is really saying that. What we are really saying is that—— 

Mr. WEST. I mean, let’s look at it. I mean, $487 billion, and now 

we are talking about another $600 billion, you know, through sequestration. I think that the message coming out of Washington, 

D.C., is that the military is going to be the bill payer for the fiscal 

irresponsibility of Washington, D.C. Furthermore, we are going to 

look at the men and women who have given a lifetime of service 

and say that you are on the cut line. That is the message. 

When I briefed this at a town hall meeting in south Florida, 

which has one of the highest percentages of the retirees, they were 

livid because no one is talking about this. 

So this is not about a dollar amount, this is really about a trust 

factor. And what are we saying to future generations of retirees 

and veterans? I mean, we already talked about the ink hadn’t dried 

off of fiscal year 2012 and we are doing this in 2013. What is going 

to happen in 2014? 

I am not upset with you all here, but I am telling you, that is 

the message that is getting out there and to friends of mine that 

are still in uniform. So, you know, I know my time has run out, 

but I have to tell you something. You have to tell Secretary Panetta this is FUBAR [fouled up beyond all recognition]. 

I yield back. 

Mr. WILSON. Thank you very much. 

We proceed to Colonel—Congressman Mike Coffman of Colorado. 

Mr. COFFMAN. Thank you, Mr. Chairman. I was a sergeant in the 

Army, a major in the Marines, so I didn’t get to that rank. 

Let me first say that, in visiting the wounded in Bethesda, how 

impressed I am with the care that they are receiving. And I want 

to commend you for that. 

I come from a military family. My father was in military medicine for the second half of his career. And I volunteered at 

Fitzsimons Army Medical Center in Aurora, Colorado, when I was 

a young person, 14, in 1969. And, you know, obviously, the technology, we have learned a lot about how to take care of particularly 

amputees, but I remember the morale just being terrible for those 

wounded. 

And I think as America became divided about the war in Vietnam, they became divided about support for our veterans. And they 

felt—that was an Army installation, and they felt completely disconnected once they were wounded, that they were no longer really 
21 

soldiers, where the wounded that I see in Bethesda are connected 

to their units. They feel that they are still a part of the military. 

And I like it that their rehabilitation is done in the military and 

they are not shuttered off to VA facilities. And that is a separate 

discussion, in terms of improving those. 

And I have tracked a double amputee coming out of my district, 

a lance corporal in the Marine Corps, who is able to not just walk 

but run on his prosthetics. He is competing in athletic events. He 

is at Balboa now, naval medical center. And I talked to him on the 

phone last week. He said he is in the best shape that he has ever 

been in. And so I am impressed with that. 

One thing, there is one gap that I want to ask you about in military medicine that I am concerned about, and that is post-traumatic stress disorder. And the reason why I am concerned about 

it is because I think that our approach is that we seem to have a 

disability-centric approach and not a treatment-centric approach. 

And I think that it would cost us more money in the short run but 

save money in the long run if we would shift to more of a treatment-centric approach. 

Those in the mental health profession that I talk to all feel that 

it could be brought—that the symptoms could be brought down to 

where they are not debilitating if given the proper modalities of 

treatment. So I wondered if any of you could respond to that issue. 

General HOROHO. Sure. I will take that first, if that is okay. 

Mr. COFFMAN. Yes. 

General HOROHO. What we have looked at is really shifting more 

toward prevention, and I believe that is what you are talking 

about. 

And so we have, over the last couple years, we have a comprehensive behavioral health system of care, where we have five 

touchpoints where our soldiers see a behavioral health specialist 

prior to deployment. In theater, we have increased our behavioral 

health assets. We are using tele-behavioral health, so that instead 

of waiting until they redeploy back to deal with some of the 

stressors and the symptoms associated with deployment, they are 

able to do that through tele-behavioral health in some of the remote areas in Afghanistan. And then we are also—we have overhired across each of our regions, using tele-behavioral health so we 

can shift that capability where the demand is. 

We are also looking, when you look at not just behavioral health, 

but it is looking at stress reduction, anger management, alcohol 

use. So the approach now is more toward that prevention and looking at incorporating mindfulness, yoga, acupressure, acupuncture, 

so that we really help with decreasing some of that stress. 

Because we agree with you. We have focused more on treatment, 

and over the last couple years it has been more toward prevention. 

And we have a ways to go, though. 

General GREEN. Sir, if I could add to that, the most recent of statistics is—we just went and looked at it. There was a perception 

that, because of the wounded warriors going through the IDES [Integrated Disability Evaluation System] system that so many of 

them, as high as 80, 85 percent, also had PTSD, that we were putting a lot of people out because they had PTSD. But the reality is, 
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of those diagnosed with PTSD, 75 percent are returned to duty. So 

our focus is on treatment. 

Obviously, I agree with General Horoho in terms of what we are 

doing to try and prevent this in the first place. But I do think that 

it is a bit of a misperception to think that we are not focused on 

treatment when we are bringing 75 percent back to duty. 

Mr. COFFMAN. Admiral. 

Admiral NATHAN. And if I may just add one caveat, sir, which 

is, my previous command role to this was the commander at Walter 

Reed Bethesda. And you talked about the two signature injuries in 

your question, one was amputations and limb loss, and the other 

is traumatic brain injury and post-traumatic stress. 

And what we have learned in PTS and PTSD is that it not only 

takes the individual or the patient with it, it takes the family 

along, too. In other words, it is a family illness and, basically, can 

be devastating not only to a single patient, such as loss of limb, but 

to family. And so we provide a much more holistic approach now 

across the military, engaging family care at the same time that we 

engage the patient. 

We actually created the national center of excellence for TBI at 

Bethesda, the National Intrepid Center of Excellence, NICoE, 

which is this avant-garde building there which is basically designed to be a prototypical facility to create and try innovative and 

new procedures, garnering the best academic, private, and military 

specialists available to look at new diagnostic and therapeutic techniques. 

And as they treat their cohorts of patients, they treat them at 

the same time as the families. The families are flown in, brought 

in. And the entire family, including children, are taken through diagnostic and therapeutic trials along with the patient. 

We are seeing some marvelous results from that. It is labor-intensive, it is personnel-intensive, and so it is going to be hard to 

replicate that across the entire spectrum. But we are starting to 

create satellite NICoEs in places like Camp Lejeune and Belvoir, 

and I think we will see more of those grow. 

Mr. COFFMAN. Thank you, Mr. Chairman. Just to say that I 

think that is a much cheaper approach than sending somebody a 

disability check for the rest of their life. 

With that, Mr. Chairman, I yield back. 

Mr. WILSON. Thank you all very much. 

And if there are no further questions—and Congressman Walter 

Jones of North Carolina had an appointment at the office, and so 

I have questions that he wanted submitted for the record for Dr. 

Woodson. And so, with unanimous consent, they shall be included. 

As we conclude, again, thank you for your sincere and genuine 

concern for our military personnel, military families, and veterans. 

And we look forward to working with you to provide the world-class 

health care that you are providing. 

Thank you, and we shall now be adjourned. 

[Whereupon, at 4:20 p.m., the subcommittee was adjourned.] 
A P P E N D I X 

MARCH 21, 2012 

PREPARED STATEMENTS SUBMITTED FOR THE RECORD 

MARCH 21, 2012 

(27) 

Statement of Hon. Joe Wilson 

Chairman, House Subcommittee on Military Personnel 

Hearing on 

Defense Health Program Budget Overview 

March 21, 2012 

Even in this tight fiscal environment, the Military Health System must continue to provide world-class health care to beneficiaries and remain strong and viable and fully funded in order to 

maintain that commitment. The Department of Defense has proposed several measures aimed at reducing the cost of the Defense 

Health Program. Unfortunately, all of the proposals simply shift 

the cost burden to TRICARE fee and cost-share increases to not 

only our working-age retirees but, for the first time, to our most 

senior military retirees. 

The subcommittee has a number of concerns about the Department’s initiatives. To that end, we would expect the Department’s 

witnesses to address our concerns, including that the proposed 

TRICARE Prime fee increases, which have been characterized by 

military leaders as modest, will raise fees in fiscal year 2013 by 30 

to 78 percent over the current rate. Over 5 years, the fees would 

increase by 94 to 345 percent. 

The proposed increases may be designed to cause military retirees to opt out of TRICARE, choose a TRICARE option that is less 

costly to DOD, or decrease their use of TRICARE. The proposal 

would establish an annual enrollment fee for retirees who use 

TRICARE Standard and Extra and, for the first time, would require our most senior retirees to pay an enrollment fee for 

TRICARE For Life. 

What is not clear to me is why, aside from the revenue being 

generated from the fees, DOD believes enrolling these participants 

is necessary. What benefit can these individuals expect to receive 

from enrolling? Sixty percent of the estimated cost savings from 

TRICARE proposals is based on military retirees opting out of 

TRICARE or using it less. Frankly, I think this plan is wrongheaded. 

Finally, I would like to hear from the military surgeons about efforts they are taking within the military departments to increase 

the efficiency of the military healthcare system and reduce cost. I 

would also like the military surgeons’ views on areas where additional efficiencies can be gained across the DOD health system. 
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Statement of Hon. Susan A. Davis 

Ranking Member, House Subcommittee on Military 

Personnel 

Hearing on 

Defense Health Program Budget Overview 

March 21, 2012 

The last decade of conflict has been weathered on the backs of 

our remarkable forces, in particular, those who serve in our military healthcare system. The constant demands borne by those in 

uniform and those in support of them have yielded incredible successes on our battlefields abroad and at home here in the States. 

While I suspect that much of this hearing will focus on the 

healthcare proposals of the Department of Defense, this hearing 

will also provide the members of this subcommittee an opportunity 

to understand and examine some of the difficult challenges facing 

the military healthcare system—from reductions in resources to 

meeting the ever-increasing demand for mental health services. 

Our military personnel and their families consistently exceed expectations under tremendous strains and pressures, and their access to quality health care should not be added to their plight. 

I look forward to your testimony on how we are caring for our 

service members and their families, particularly our injured, ill, 

and wounded, and how we can continue to improve our military 

healthcare system in the new fiscal environment we will be facing. 
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WITNESS RESPONSES TO QUESTIONS ASKED DURING 

THE HEARING 

MARCH 21, 2012 

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RESPONSE TO QUESTION SUBMITTED BY DR. HECK 

Secretary WOODSON. DOD considers Doctors of Osteopathy and Doctors of Medicine as equivalent. I am not aware of any effort or interest that would not recognize 

the American Osteopathic Association accredited osteopathic residency programs. 

[See page 17.] 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING 

MARCH 21, 2012 

(227) 

QUESTIONS SUBMITTED BY MRS. DAVIS 

Mrs. DAVIS. This year, the Department of Defense has proposed yet another 

change to its governance structure. In 2006, the Department approved a change to 

its medical governance structure. Of the seven governance initiatives that were supposed to achieve economies of scale and operational efficiencies to the tune of $200 

million, to date, how many have actually achieved any savings? 

Secretary WOODSON. The GAO has conducted a study to address this question. 

The findings from that study are poised for release in late April 2012. In the report, 

the GAO specifically assessed each of the seven governance initiatives with regard 

to savings achieved. The Department has reviewed the report and has concurred 

with the findings; however, the GAO has asked the department to refrain from 

quoting from the study entitled ‘‘Applying Key Management Practices Should Help 

Achieve Efficiencies within the Military Health System’’ until the formal release of 

the report. If additional changes to MHS governance are implemented, the Department is committed to a rigorous approach for measuring and monitoring costs and 

benefits of change. 

Mrs. DAVIS. Last year, this Congress directed the Comptroller General to conduct 

a review of women-specific health services and treatment. What is the Department 

and the Services doing to address the healthcare needs of female service members 

and dependents? 

Secretary WOODSON. The National Defense Authorization Act of 2012, Section 725 

directed the Comptroller General, as head of the Government Accountability Office 

(GAO), to conduct a review of women-specific health services and treatment for female members of the Armed Forces. This report is to be submitted by the Comptroller General to the congressional defense committees no later than December 31, 

2012. GAO has initiated two new engagements which are to be conducted by its Defense Capabilities and Management and Health Care teams. One engagement addresses DOD-wide, women-specific healthcare services ‘at home,’ while the other engagement pertains to deployment issues, and care for female sexual assault victims 

domestically and abroad. A May 2002 GAO Report of the adequacy and quality of 

the health care provided to women in DOD found that a full range of healthcare 

services for women are offered, and that members’ satisfaction with care was well 

above average. Some concern was noted in areas regarding healthcare services or 

availability of gender-specific supplies in austere environments. 

The provision of health care for women in the Armed Forces represents not only 

a clinical concern, but a tactical imperative in keeping DOD’s forces fit to fight. The 

Department provides a continuum of care ranging from preventive services (including contraception) to robust access to primary care; assessment and treatment of 

medical emergencies; referral to specialty care as indicated; care for chronic conditions; and rehabilitation and support for transition and disability for those whose 

illnesses or injuries do not permit return to full duty. Some medical services, such 

as Obstetrics and Gynecology, are focused on the medical needs of women, but most 

other adult medical services are designed and capable of assessing and treating 

medical conditions regardless of age or sex. When medical needs of any Service 

member exceed capabilities in their duty location, we also have the capacity to use 

medical evacuation to move the Service member to a location capable of meeting the 

specific medical need. The continuum of care includes both military and civilian 

treatment facilities, and we work especially closely with our VA colleagues when 

needs include transition from active to veteran status. 

Recent policy initiatives, research, and leadership focus have addressed some specific needs and illustrate our commitment to Service women. It is important to note 

that policies on management of sexual assault are equally applicable to both male 

and female victims. 

In FY11, the three new DOD policies augmented efforts to improve access to quality healthcare services for the victims of sexual assault and ensure continuity of 

medical care in both deployed and non-deployed environments: 

 In December 2011, a policy ‘‘Expedited Transfer of Military Service Members 

Who File Unrestricted Reports of Sexual Assault’’ was generated to affect ex-
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pedited transfer of Service members who file an unrestricted report of sexual 

assault. 

 Also in December 2011, Document Retention in Cases of Restricted and Unrestricted Reports of Sexual Assault, established comprehensive policy for the 

retention of sexual assault records. 

 The DOD Sexual Assault Prevention and Response (SAPR) Program policy 

was revised for reissuance and published in March 2012. Better policies for 

prevention, response and oversight of the SAPR program were promulgated. 

In 2008 and 2009, significant advances were made to evaluate and meet the medical needs of deploying and returning female Service members: 

 The Deputy Secretary of Defense convened a Scientific Oversight Committee 

meeting which specifically addressed Women Wounded Warrior Issues, appraised gender-specific foci in clinical and research studies, and reviewed 

compliance with the NDAA FY 2008 mandates. 

 In October 2009, the Armed Forces Health Surveillance Center published a 

monograph that focused on the unique health issues of women in combat environments and identified conditions with consistently high incidence rates 

among females, which served to highlight treatment essentials and inform clinicians’ diagnostic sensibilities and medical system requirements in theater. 

Mrs. DAVIS. There continues to be concern that diagnosis and treatment for PTS 

and TBI are still not at the levels needed to ensure that service members are getting the proper diagnosis and treatment for either PTS or TBI. Where is the Department and the individual Services on this issue? 

Secretary WOODSON. The Defense Department (DOD) and Military Healthcare 

System (MHS) remain committed to the delivery of high quality care by appropriately diagnosing and treating Service members (SMs) with posttraumatic stress 

disorder (PTSD) or traumatic brain injury (TBI). To address PTSD, the DOD has 

added over 2,000 behavioral health providers to military hospitals and clinics, and 

10,000 more to the care networks since 2009. There are currently many collaborative programs in the MHS, to include the Army Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT–Mil) and the USAF Behavioral 

Health Optimization Project (BHOP), that systematically coordinate care for SMs 

with psychological health (PH), TBI and other co-occurring conditions. The DOD is 

also highly invested in efforts to enhance psychological resilience/prevention, stigma 

reduction, and improved access to PH and TBI services. 

Further, the DOD has placed increased emphasis on PTSD and TBI screening in 

all individual Services to ensure that SMs are getting proper and timely diagnoses 

and treatment. The DOD has established enterprise wide screening and assessment 

procedures to identify both PH and TBI in SM at the earliest opportunity. For example, the Directive-Type Memorandum (DTM) 09–033: ‘‘Policy Guidance for the 

Management of Concussion/Mild Traumatic Brain Injury in the Deployed Setting,’’ 

requires the assessment of all SMs involved in potentially concussive events. Events 

requiring mandatory screening include any SM within 50 meters of a blast, involved 

in a vehicle collision or rollover, any SM who sustained a direct blow to the head 

or had loss of consciousness. All personnel with potentially concussive events are 

evaluated through evidence based clinical algorithms utilizing a mandatory standardized screening. Results are recorded for each screened individual, and submitted 

as part of the significant activities (SIGACT) report required for blast-related 

events. The DTM also outlines four clinical practice algorithms used by medical personnel. These were recently revised in 2012 by a DOD working group that included 

representatives from all Services. Additional efforts are underway at Military Treatment Facilities (MTFs) to identify SMs who are medically evacuated for any illness 

or injury, or are otherwise redeployed from theater for signs or symptoms of TBI. 

These additional screenings help to identify those SMs with a prior history of TBI 

or concussion exposure, are newly symptomatic, or those with poly-trauma whose 

injuries may have precluded an earlier evaluation for mild TBI. Receiving CONUS 

MTFs also rescreen wounded or ill SMs that are evacuated. 

Additional screening of all SMs for TBI and PTSD also occurs through DOD PostDeployment Health Assessments (PDHA) and Post-Deployment Health Reassessments (PDHRA). SMs who respond positively are referred for further clinical evaluation for mild TBI/concussion and/or PTSD. The DOD’s focus on TBI screening, diagnosis, and treatment has resulted in the development of over 60 TBI programs in 

MTFs in the non-deployed setting with varying levels of capabilities, and the establishment of 11 Concussion Restoration Care Centers in the deployed setting. There 

are over 377 programs available to help SMs with PH problems (including PTSD), 

in addition to clinical treatment available at MTF’s and locally through Tricare providers stateside, and through deployed providers in-theater. 
229 

Other initiatives to strengthen diagnosis and treatment efforts for PTSD and TBI 

involve the Joint Clinical Practice Guidelines (CPGs), which have been created by 

the DOD and VA to identify and promote effective PH and TBI care practices within 

and between the departments. Companion Clinical Support Tools for PTSD are in 

development and scheduled to be released in late summer of 2012. DOD has also 

developed Clinical Recommendations for managing neuroendocrine, visual and vestibular disturbances following mild TBI, scheduled to be released in 2012. Another 

cooperative effort between the DOD and VA, known as the ‘‘Integrated Mental 

Health Strategies’’ (IMHS), was developed to identify specific mutual goals that improve the quality, consistency, and continuity of PH and TBI health care for SMs, 

Veterans, and their families. All individual Services have representatives working 

on these initiatives. 

Finally, the DOD has made a strong financial commitment to continue to support 

research related to factors that inform the development of evidence based treatment 

for both PTSD and TBI. The DOD’s neurotrauma research portfolio through MRMC 

includes more than 600 clinical research studies encompassing novel treatment modalities to include nutraceuticals, complementary and alternative medicine, 

hyperbaric oxygen and other pharmacotherapies. The DOD also currently funds nine 

on-going additional studies to investigate the use of cognitive rehabilitation therapies in TBI. The DOD has made cognitive rehabilitation techniques available to SMs 

with cognitive and behavioral deficits subsequent to TBI. MRMC also supports DOD 

efforts to sustain a robust PTSD research program. The PTSD portfolio represents 

broad areas of study to include epidemiology, basic science, prevention and education, early screening and interventions, assessment, treatment, and recovery/return to duty. There are now over 300 PTSD studies funded and in progress. PTSD 

and TBI research results are used to inform and guide new clinical practices and 

these interventions are systematically taught to providers who treat SM’s with 

PTSD and TBI. DOD research efforts will continue to ensure that our SMs receive 

the greatest benefit, via accurate diagnosis and effective treatment derived from the 

most current scientific knowledge in the field. 

Mrs. DAVIS. What are the strategic issues that the subcommittee should be considering to ensure the success of the military healthcare system? 

Secretary WOODSON. The Military Health System has adopted the Quadruple Aim 

to describe our high level goals: improved readiness, better health, better care and 

lower costs. We have grouped the high level strategic issues according to the aim 

they most affect. 

Readiness: 

 Understanding and meeting the long term needs for medical care generated 

by 10 years of war  Integrating and optimizing psychological health programs to improve outcomes 

 Maintaining the skills and capabilities of the all-volunteer medical force that 

has performed so well in serving the warfighter 

Population Health: 

 Addressing the behaviors that influence the majority of health outcomes 

starting with obesity and tobacco use 

Experience of Care: 

 Improving safety and quality by implementing evidence based practices 

across the enterprise and making the MHS the safest health system in the 

world 

 Implementing the integrated Electronic Health Record (iEHR) with the VA to 

support better decisions, integrate patients into the care process and reduce 

waste 

Per Capita Cost: 

 Optimizing market management to bring care back to our Military Treatment 

Facilities to support readiness, strengthen Graduate Medical Education and 

reduce costs 

 Aligning incentives to pay for value 

 Rebalancing government and beneficiary cost shares 

Mrs. DAVIS. The Department of Defense has proposed cost increases for the health 

care of our military retirees. Why is the Department proposing such large fee increases for our military retirees? What was the rationale to begin a means testing 

for healthcare fees? 

Secretary WOODSON. Our proposed changes in the cost-sharing formula for health 

care will mostly affect retirees and, especially, retirees who are under the age of 65 

and are still in their working years. Since 2001, the cost of military pay and benefits 
230 

has grown by over 87 percent (30 percent more than inflation), while Active Duty 

end strength has grown by about three percent. We felt we had to review pay and 

benefits to avoid overly large reductions in forces and investments. 

The military and civilian leadership considered changes in pay and benefits based 

on several guiding principles. To begin with, the military compensation system must 

take into account the unique stress of military life. It should not simply be a copy 

of civilian systems. The system must also enable us to recruit and retain needed 

personnel. And we must keep faith with our military personnel. 

Changes affecting pay and compensation were designed to be disproportionately 

small when compared to the changes in forces and investments. While pay and benefits account for about one-third of the Defense budget, savings from the initiatives 

we are proposing will amount to about $29 billion over the FYDP, which is slightly 

more than 10 percent of our savings target. 

It is important to note that the proposed cost-sharing changes are still modest 

compared to the cost-shares, as a percentage of total healthcare costs, borne by 

beneficiaries as recently as 1996. In that year, we estimate that retiree beneficiaries 

were responsible for out-of-pocket costs representing 27 percent of the total 

healthcare costs. Due to the fact that virtually all beneficiary cost-shares were either frozen (or dropped further) since 1996, these out-of-pocket costs dropped to 10 

percent of the total healthcare costs. While cost-sharing is increasing, it is still well 

below 1996 levels, and will stabilize at approximately 14 percent of total health 

costs under this proposal. 

Where feasible, the proposed fee increases were tiered by military retirement pay, 

based on the principles of the FY 2007 Task Force on the Future of Military Medicine. In its deliberations, the Task Force recognized that military retirement is not 

like most civilian retirement systems and that the entire military compensation system differs from the typical civilian ‘‘salary’’ system because much of the compensation is ‘‘in-kind’’ or ‘‘deferred.’’ Thus, changes in the healthcare benefit were examined in the context of this unique system and its compensation laws, policies, and 

programs. The Task Force believes that, for equity reasons, military retirees who 

earn more military retired pay should pay a higher enrollment fee than those who 

earn less. While this ‘‘tiering’’ approach is not commonly used in the private sector 

for enrollment fees, the Task Force believed that it made sense in a military environment. 

Mrs. DAVIS. With your statements supporting the proposed changes to TRICARE, 

what is the impact to the DHP if Congress does not authorize the TRICARE fee increases? Even if Congress was to approve the fees, how will the Department cover 

unanticipated costs if the savings estimated from beneficiaries opting out of 

TRICARE do not materialize to the estimated levels? 

Secretary WOODSON. If Congress does not provide us with needed support for the 

health reform proposals, the Department will have to find about $12.9 billion, the 

projected savings from these proposals, from other Defense programs to meet its 

healthcare obligations. Such action would place the new defense strategy at risk. 

Without needed authority, the Department will face further cuts in forces and investment to be consistent with the Budget Control Act. The Department’s budget 

proposal already makes substantial reductions in the investment accounts so further 

cuts might fall mostly on forces. This could mean cutting additional Active Duty and 

Reserve Forces by FY17 at a magnitude that could jeopardize the Department’s ability to pursue the new defense strategy. 

If the assumptions on the behavioral changes projected in the Budget are overstated, savings will be reduced and the Department would have to review all requirements and resources available at that point in time. However, it is important 

to note that, if the behavior effect is not seen as modeled, the Department would 

still capture savings because those beneficiaries will still be subject to the higher 

fees. For example, if a beneficiary does not switch a prescription from retail to mail 

order, which results in some savings, they would still be subject to the higher copay 

in retail which would still result in some savings. However, since the proposals provide some incentive to motivate beneficiaries to use more cost-effective healthcare 

options, some behavioral effects will be inevitable. The Department will be able to 

refine its projections over time, based on actual experience. 

Mrs. DAVIS. Vision injuries have impacted 58,000 OIF and OEF service members 

according to DOD, hearing loss has been diagnosed in over 189,000 veterans from 

OIF and OEF according to VA, and male urological injuries from blasts have exceeded 1,670 and yet these battlefield wounds have not received the research funding 

that other types of defense medical research programs have in past budgets. Should 

additional funding be provided for these types of injuries given their traumatic impact on service members? 
231 

Secretary WOODSON. Research in vision injuries, hearing loss, and genitourinary 

injury are included in the Clinical and Rehabilitative Medicine Research Program 

(CRMRP). The CRMRP focuses on definitive and rehabilitative care innovations required to reset our wounded warriors, both in terms of duty performance and quality of life. Due to advances in trauma care, increasing numbers of service members 

are surviving with extreme trauma to the extremities and head. The program has 

multiple initiatives to achieve its goals, including improving prosthetic function, enhancing self-regenerative capacity, improving limb/organ transplant success, creating full functioning limbs/organs, repairing damaged eyes, treating visual dysfunction following injury, improving pain management, and enhancing rehabilitative 

care. These initiatives leverage research across the CRMRP to address dismounted 

complex blast injuries that include genitourinary injuries. 

Mrs. DAVIS. Where is the Army in implementing a confidential alcohol program? 

A pilot program was established in three bases. What is the current status of those 

programs, and what is the Army’s plan to address the increasing concern of alcohol 

abuse among soldiers? 

General HOROHO. In July 2009, the Army Center for Substance Abuse Programs 

(ACSAP) initiated the Confidential Alcohol Treatment and Education Pilot (CATEP) 

program at Fort Lewis, Fort Richardson, and Schofield Barracks. After conducting 

initial evaluations of the pilot, the Army expanded its implementation to Fort Carson, Fort Riley and Fort Leonard Wood in August 2010. In July 2011 the Army approved testing of CATEP procedural improvements, which included an enrollment 

contract in an effort to decrease the voluntary dropout rate and to ensure Soldiers 

with alcohol disorders receive the treatment their conditions require. As of August 

2012, CATEP participation at the six pilot sites is as follows: a total of 1310 Soldiers 

self-referred; of which 924 were screened and enrolled and 386 were screened, but 

not enrolled. A total of 253 Soldiers have successfully completed CATEP and another 127 are currently enrolled. In August 2012, the Deputy Chief of Staff, G–1 

will provide the Vice Chief of the Army with results of CATEP and recommendations for the way ahead on the expansion of CATEP Army-wide by Fiscal Year 2013. 

In addition to its efforts with CATEP, the Army recognizes the increasing role 

substance abuse plays in many high-risk behaviors, including suicide, and therefore 

is responding with comprehensive prevention resources, increased counselor hiring, 

and anti-stigma campaign efforts. 

To deliver substance abuse prevention services to Soldiers, the Army adopted 

Prime For Life (PFL) as its Alcohol and Drug Abuse Prevention Training (ADAPT). 

PFL, a classroom training platform developed over a 25-year time span, is delivered 

by certified Prevention Coordinator instructors. In April 2012, the Army began fielding a 4-hour standardized universal prevention training package for Soldiers. The 

Army will continue to define, develop and field leader-centric training for substance 

abuse, leveraging squad and platoon leaders. 

As of 25 July 2012, the Army has 481 substance abuse counselors, an increase 

of 57 since September 2011, providing education and treatment for Soldiers. We continue recruiting efforts to fill vacancies and put several initiatives in place to create 

a pipeline of resources that will be available to fill vacancies. 

The ACSAP completed a comprehensive study of stigma associated with substance 

abuse treatment and found stigma to be prevalent. As a result, the Army initiated 

a new campaign focusing on a more comprehensive view of stigma and developed 

messaging on a broader range of issues to encourage Soldiers to seek help for substance abuse, behavioral health, sexual assault and other personal challenges. 

ACSAP is currently rewriting Army Regulation 600–85, The Army Substance 

Abuse Program, to codify ASAP policies related to the fitness and combat readiness 

of Soldiers. 

Mrs. DAVIS. Last year, this Congress directed the Comptroller General to conduct 

a review of women-specific health services and treatment. What is the Department 

and the Services doing to address the healthcare needs of female service members 

and dependents? 

General HOROHO. The Women’s Health Campaign Plan focuses on standardized 

women’s health education and training, logistical support for women’s health items, 

fit and functionality of the Army uniform and protective gear for females, research 

and development into gynecologic issues during deployment, sexual assault case 

management, and the psychosocial effects of combat on women. 

Mrs. DAVIS. There continues to be concern that diagnosis and treatment for PTS 

and TBI are still not at the levels needed to ensure that service members are getting the proper diagnosis and treatment for either PTS or TBI. Where is the Department and the individual Services on this issue? 
232 

General HOROHO. The Army provides behavioral health care for all recognized behavioral health conditions as defined by the Diagnostic and Statistical Manual of 

Mental Disorders, 4th Edition, Text Revision. In February 2010 the Army launched 

the Behavioral Health System of Care Campaign Plan to standardize, synchronize, 

and coordinate behavioral health care, including PTSD, across the Army and 

throughout the Army Force Generation cycle. The Army has implemented a comprehensive TBI Action Plan based on the 2007 TBI Task Force Report and has hired 

over 460 providers since 2007 to evaluate and treat Soldiers with TBI. Providers at 

Army treatment facilities utilize the 2008 VA–DOD Clinical Practice Guidelines 

(CPGs) for the medical management of Service Members with concussion/mTBI. 

This set of CPGs was recently rated as the best of 8 CPGs for concussion/mTBI 

management and represent the highest level of scientific evidence. TBI care policy 

and medical algorithms in the deployed environment include special provisions for 

recurrent concussions within the previous 12 months. This proactive policy promotes 

early detection, medical management, and helps prevent subsequent concussion 

while the brain is still healing. In order to assist with the medical evaluation and 

advance TBI research, the Department of Defense deployed 3 MRI machines to Afghanistan in October 2011. 

The U.S. Army Medical Research and Material Command has invested over $633 

Million since 2007 to advance the science of TBI detection/screening, diagnosis, and 

treatment. While a definitive diagnostic biomarker for TBI is not available, Army 

Medicine is collaborating with academic and civilian scientists to evaluate tests that 

help identify TBI. The scientific community is also researching promising treatments to ensure that they are both safe and effective for TBI rehabilitation. 

Mrs. DAVIS. The Department of Defense has proposed cost increases for health 

care that not only will impact retirees, but they could also impact military dependents. Has your Service looked at the potential impact of these fee increases and its 

impact on retention of the force? 

General HOROHO. The Army Medical Department has not studied any impact of 

TRICARE fee proposals on retention of the force. 

Mrs. DAVIS. With your statements supporting the proposed changes to TRICARE, 

what is the impact to the DHP if Congress does not authorize the TRICARE fee increases? Even if Congress was to approve the fees, how will the Department cover 

unanticipated costs if the savings estimated from beneficiaries opting out of 

TRICARE do not materialize to the estimated levels? 

General HOROHO. If Congress does not support proposed reform, ASD(HA) has 

projected a Department deficit of $12.9 billion which will impact other Defense programs in order to meet healthcare obligations. Without needed authority, ASD(HA) 

states the Department will face further cuts to important programs and investments. If the assumptions on the behavioral changes projected in the Budget are 

overstated, savings will be reduced and the Department would have to review all 

requirements and resources available at that point in time. 

Mrs. DAVIS. There are anecdotal stories that service members are self-medicating 

themselves through alcohol consumption. What are your Services doing as well to 

address alcohol abuse among airmen, sailors, and marines as well? 

Admiral NATHAN. Navy Medicine has launched the MORE program (My Online 

Recovery Experience), a web- and phone-based recovery support program for Service 

members recovering from alcohol dependence. MORE offers individually tailored patient education and support over a secure web-based system with world-wide access, 

24 hour-day, seven-days a week. 

Additionally, the Navy has a long-standing and extensive Substance Abuse & Rehabilitation Program (SARP): 

—SARP has transitioned from an addiction-only treatment program to a dual diagnosis program that identifies and treats mental health illnesses in addition to 

identifying and treating substance use disorders. SARPs located at Naval Medical 

Center Portsmouth and Naval Medical Center San Diego also treat patients with 

dual diagnoses (substance use disorder and mental health illness). 

—SARP has established screening and treatment protocols for substance abuse 

and dependence, providing necessary treatment and rehabilitation with pre- and 

continuing after-care where appropriate. 

—All program activities comply with established DOD, DON, and Navy Medicine 

guidance or governance. 

—SARPs screen over 10,000 individuals a year, with an estimated 7,000 to 8,000 

enrolling as patients annually. 

—Fifty-two SARPs exist throughout the Navy Medicine enterprise, with a mix of 

Active Duty and civilians who provide screening, evaluation, and treatment. Treat-
233 

ments range from education with early intervention, to outpatient and intensive 

outpatient therapies, up to the highest level of inpatient care. 

Mrs. DAVIS. Last year, this Congress directed the Comptroller General to conduct 

a review of women-specific health services and treatment. What is the Department 

and the Services doing to address the healthcare needs of female service members 

and dependents? 

Admiral NATHAN. Navy Medicine is committed to delivering outstanding, patientcentered healthcare services to our female Sailors and Marines wherever and whenever needed. This support includes access to care in both operational settings and 

at our medical treatment facilities (MTFs). Navy Medicine continues to offer a full 

spectrum of services to address the unique healthcare needs of female service members and their family members. Referral processes are in place to provide services 

not available at local MTFs. 

In addition, Navy Medicine has Clinical Advisory Boards that provide current evidence-based practice guidance from subject matter experts throughout the Navy 

Medicine enterprise. Specifically, they recommend policy, evaluate clinical practice 

guidelines and provide an endorsement to support Navy-wide integration. At 18 

MTFs, there are peri-natal clinical advisory boards to guide the practice of maternal-child health. Town hall meetings, local forums and patient satisfaction surveys 

are used to gather feedback to ensure our patients have the required access to services. 

Mrs. DAVIS. There continues to be concern that diagnosis and treatment for PTS 

and TBI are still not at the levels needed to ensure that service members are getting the proper diagnosis and treatment for either PTS or TBI. Where is the Department and the individual Services on this issue? 

Admiral NATHAN. Post-Traumatic Stress Disorder (PTSD) is one of many psychological health conditions that adversely impacts operational readiness and quality 

of life. Navy Medicine has an umbrella of psychological health programs that target 

multiple, often co-occurring, mental health conditions including PTSD. These programs support prevention, diagnosis, mitigation, treatment, and rehabilitation of 

PTSD. Our efforts are also focused on appropriate staffing, meeting access standards, implementing recommended and standardized evidence-based practices, as 

well as reducing stigma and barriers to care. Priorities include: 

 Embedding psychological health providers in Navy and Marine Corps units, 

ensuring primary and secondary prevention efforts and appropriate mental 

health care are readily accessible for Sailors and Marines. 

 Embedding psychological health providers in the primary care setting where 

most service members and their families first seek assistance for mental 

health issues enhancing integrated treatment, early recognition and access to 

the appropriate level of psychological health care. The Behavioral Health Integration Program in the Medical Home Port is a new program that is actively being implemented across 69 Navy and Marine Corps sites. 

 Maintaining support to 17 Deployment Health Centers (DHCs) as non-stigmatizing portals of care for service members outside the traditional mental 

health setting. 

 Implementing innovative programs like Overcoming Adversity and Stress Injury Support (OASIS) at the Naval Medical Center San Diego is providing intensive mental health care for service members with combat-related mental 

health symptoms from posttraumatic stress disorder, as well as major depressive disorders, anxiety disorders and substance abuse problems. Care is provided seven days a week for 10–12 weeks, and service members reside within 

the facility while they receive treatment. 

 Providing active consultative subject matter expertise to Line Leaders, focusing on preventive measures, early pre-clinical recognition and intervention, as 

well as recommended treatment management. 

In addition, TBI care on the battlefield has improved significantly since 2007 

when it was labeled as a ‘‘signature injury’’ of the current conflicts. Most improvements have targeted early screening and diagnosis followed by definitive treatment. 

In 2010, Directive-type Memorandum 09–033 resulted in improved diagnosis and 

treatment of battlefield concussion. Policy highlights include mandatory screening 

by line commanders for any service member in a potentially concussive event, standardized medical screening with a 24 hour rest/recovery period regardless of diagnosis, rest and education (the only proven clinically effective treatments) for diagnosed concussion, and guidelines for evaluation, treatment and return to duty for 

symptom-free service members with 1, 2 or 3 concussions in a 12-month period. 

From 1 AUG 2010 to 30 AUG 2011 this policy resulted in the enhanced screening 

for 187 Sailors and 4684 Marines, resulting in diagnoses of concussion in 27 Sailors 
234 

and 803 Marines from that group. For the Navy and Marine Corps, the primary 

treatment site for concussed service members is the Concussion Care Restoration 

Center in Camp Leatherneck. 

Since opening in 2010, the Camp Leatherneck has treated over 930 service members with first-time concussions, resulting in a greater than 98% return to duty 

(RTD) rate, and an average of 10.1 days of duty lost from point of injury to symptom-free RTD. There is also a concussion clinic at the NATO Role III Hospital in 

Kandahar. Upon return from deployment, enhanced screening methods for TBI and 

mental health conditions are being piloted at several Navy and Marine Corps sites. 

This includes increasing use of the National Intrepid Center of Excellence (NICoE) 

along with development of NICoE satellite sites to provide state-of-the-art screening 

and treatment for those patients that do not improve with routine clinical care. 

We are also heavily engaged in active and expansive partnerships with the other 

Services, our Centers of Excellence, the VA, and leading academic medical and research centers to make the best care available to our warriors afflicted with PTSD 

and TBI. 

Mrs. DAVIS. The Department of Defense has proposed cost increases for health 

care that not only will impact retirees, but they could also impact military dependents. Has your Service looked at the potential impact of these fee increases and its 

impact on retention of the force? 

Admiral NATHAN. The Department of Navy supports these proposals and believes 

they are important for ensuring a sustainable and equitable benefit for all our beneficiaries. While the proposed increases will primarily impact our retired beneficiaries, military medicine provides one of the most comprehensive health benefits 

available. These changes will help us better manage costs, provide quality, accessible care and keep faith with our beneficiaries. 

Mrs. DAVIS. With your statements supporting the proposed changes to TRICARE, 

what is the impact to the DHP if Congress does not authorize the TRICARE fee increases? Even if Congress was to approve the fees, how will the Department cover 

unanticipated costs if the savings estimated from beneficiaries opting out of 

TRICARE do not materialize to the estimated levels? 

Admiral NATHAN. Based on information provided by the Assistant Secretary of 

Defense for Health Affairs, if Congress does not provide the needed support for the 

health reform proposals, the Department of Defense will have to find about $12.9 

billion, the projected five year savings from these proposals, from other Defense programs to meet its healthcare obligations. If the assumptions on the behavioral 

changes projected in the Budget are overstated, savings will be reduced and the Department of Defense would have to review all requirements and resources available 

at that point in time. 

Mrs. DAVIS. There are anecdotal stories that service members are self-medicating 

themselves through alcohol consumption. What are your Services doing as well to 

address alcohol abuse among airmen, sailors, and marines as well? 

General GREEN. As with any community, there are members of the Air Force who 

will use alcohol to self-medicate. Therefore, the Air Force has implemented processes to educate service members about the dangers of alcohol misuse, to recognize 

this when self-medication and other forms of alcohol misuse occurs, and to provide 

services when needed to treat both substance abuse and other problems that individuals may use alcohol to address. 

One means of addressing alcohol misuse is that Air Force medical professionals 

provide alcohol abuse prevention briefings to our first-term Airmen, at base Newcomers’ events, and annually to commanders, first sergeants, other senior enlisted 

personnel and medical professionals. Airmen involved with alcohol-related misconduct are provided individualized, focused education to prevent recurrence or 

worsening of alcohol related problems. 

Additionally, Air Force medical providers also provide screenings and treatment 

for alcohol abuse. Our medical providers screen patients from all Services for alcohol 

misuse at each visit to primary care medical home, and screen Air Force members 

during their annual health assessment. Service members are also screened for depression and Post Traumatic Stress Disorder and are provided effective mental 

health treatment when necessary so there is no need to self-medicate with alcohol. 

We also screen Airmen four different times as part of the pre- and post-deployment 

health assessments. Healthcare providers address concerns regarding a service 

member’s drinking behaviors as they arise. When further evaluation or treatment 

is necessary, a referral is made to an integrated behavioral health provider in the 

primary care clinic or to the specialty substance abuse providers. Our staff in the 

Specialty Substance Abuse Programs at each Air Force installation will assess service members and provide the appropriate education or treatment, including a refer-
235 

ral to a civilian program if a higher level of care is needed than can be provided 

on the installation. 

Mrs. DAVIS. Last year, this Congress directed the Comptroller General to conduct 

a review of women-specific health services and treatment. What is the Department 

and the Services doing to address the healthcare needs of female service members 

and dependents? 

General GREEN. The Air Force maintains a robust women’s healthcare program 

and provides women’s health services at all Air Force bases in the United States 

and overseas by either direct provision of care or through timely referral. Most of 

our 75 medical treatment facilities provide women’s healthcare services through separately established women’s health clinics. These clinics provide comprehensive 

women’s health services, including well exams, health teaching and screening, gynecological services, colposcopy, loop electrosurgical excision procedure (LEEP), birth 

control services, and hormone replacement therapy, to active duty, retired and dependent females. In addition to primary care physicians and obstetrician/gynecologists, the Air Force employs approximately 70 active duty Women’s Health 

Nurse Practitioners (WHNPs) and 14 civilian WHNPs. 

In 2008, the Air Force began promoting full-time clinical WHNPs to the rank of 

colonel with the specific goal of keeping these women’s health ‘‘master clinicians’’ 

at the bedside caring for women and running the women’s health clinics. Many of 

our WHNPs are trained as sexual assault forensic examiners and providers and in 

this capacity they perform the forensic/legal exams for victims of sexual assault. In 

addition, our WHNPS are deployed around the world to provide care for female airman, sailors, marines, and soldiers. 

Air Force Surgeon General obstetric modernization funds have been used to: establish an Obstetric Quality Forum to promote patient safety, quality outcomes and 

process improvement; provide lactation consultants for each Air Force site that delivers babies; create a prenatal care counseling and education video; host a national 

Patient Safety and Critical Care Obstetric conference; and lead a tri-service effort 

to create an evidence-based practice guideline for the management of pregnancy 

across the DOD and VA. 

The Air Force Medical Service is also involved in a number of ongoing women’s 

health research projects. The San Antonio Military Medical Health System 

(SAMMHS) Outcomes Coordinator and Pregnancy Coordinator completed a prospective randomized trial of 1800 women comparing routine one-on-one visits to a group 

prenatal care model. Preliminary results published as part of a collaborative nonrandomized study with the March of Dimes showed a 60% reduction in the risk of 

preterm birth. The results are being further analyzed and if sustained have the potential to change the format of prenatal care around the world. The Patient and 

Physician Radiotherapy Schedule Preferences for Breast Cancer treated with Breast 

Conservation Therapy study seeks to align of physician practice patterns with best 

evidence and patient preferences in order to enhance patient autonomy and improve 

cancer care. Recognizing that the pregnant spouses of deployed service members 

face unique challenges, the Air Force Medical Service is engaged in the Mentors Offering Maternal Support (M.O.M.S.) study to test the effectiveness specialized support services for pregnant spouses of deployed service members with the goal of promoting prenatal maternal adaptation. Other ongoing studies include a research collaboration on a FDA-promoted, multinational study involving 17–OH progesterone 

use for the reduction of preterm birth, a randomized controlled trial evaluating the 

use of lavender aromatherapy to reduce pain and anxiety during cervical colposcopy, 

and a study of post-breast lumpectomy reconstruction using cell-enriched fat grafting. 

Mrs. DAVIS. There continues to be concern that diagnosis and treatment for PTS 

and TBI are still not at the levels needed to ensure that service members are getting the proper diagnosis and treatment for either PTS or TBI. Where is the Department and the individual Services on this issue? 

General GREEN. Thank you for the opportunity to explain the Air Force’s approach for treating Service members who suffer from Traumatic Brain Injury (TBI) 

or Post-Traumatic Stress Disorder (PTSD). 

The Air Force’s goal is to identify and address PTSD and TBI symptoms as early 

as possible, before problems develop and to allow for full return to duty. This goal 

is pursued through a combination of programs aimed at screening, awareness education, and evidence-based treatment. 

Fortunately, despite Airmen deploying in roles involving combat or being involved 

in the rescue or treatment of those with severe injuries, the rate of both PTSD and 

TBI in Airmen has remained low. Per our recent report to Congress, for example, 

the average PTSD rate of new cases for active duty Airmen for 2003 through 2010 

was 2.0 per thousand (0.2%). The rate of TBI is about 10 per thousand (1%), nearly 
236 

90% of which are mild in severity. In mild TBI full recovery can be expected by the 

majority within weeks. 

The Air Force proactively screens for TBI, PTSD, and other mental health concerns on a recurrent basis. This is accomplished via annual Preventive Health Assessments and via Post-Deployment Health Assessments and Post-Deployment 

Health Re-Assessments. Additionally, Airmen are screened with the Automated 

Neuropsychological Assessment Metrics (ANAM) prior to deployment in order to establish a baseline measure of cognitive functioning. Deployed Service members who 

are involved in an event which may cause a TBI are screened for TBI and referred 

for further medical evaluation and treatment if the screening is positive. In addition 

to history and examination, the ANAM may be used post-injury in theater and compared to baseline pre-deployment ANAM results to aid in the medical evaluation. 

Airmen are provided with awareness education on PTSD and TBI and are offered 

multiple opportunities to identify symptoms and concerns. To ease access to mental 

health providers, many medical treatment facilities have one or more mental health 

providers working directly in the primary care clinics. 

Formal training has significantly increased for providers on assessment, diagnosis, and treatment of PTSD and TBI. The majority of Air Force mental health providers have attended formal training in evidence-based treatment of PTSD, and it 

is included in Air Force social work and psychology training programs to ensure providers appropriately recognize and treat affected individuals. Education on the 

causes, signs, and symptoms of TBI and PTSD are provided through new training 

modules in Self Aid and Buddy Care, an annually required computer based training 

for all Airmen. More advanced education on TBI and PTSD is provided in pre-deployment courses including Expeditionary Medical Support course and Combat Casualty Care Course, to include use of the Military Acute Concussion Evaluation and 

the Clinical Practice Guidelines for TBI in the Deployed Setting. VA/DOD clinical 

practice guidelines are also taught and used for the management of PTSD and TBI 

in post-deployment health throughout the Air Force. There has been increased emphasis on these topics during mental health and neurology internship and residency 

programs. Finally, the Defense and Veterans Brain Injury Center hosts an annual 

TBI Training Program to educate DOD and VA healthcare providers. The formal 

training emphasizes the use of evidence-based practices for the treatment of PTSD 

and/or TBI, to include exposure-based therapies (with or without virtual reality enhancement), medication management, and combinations of treatments. 

Mrs. DAVIS. The Department of Defense has proposed cost increases for health 

care that not only will impact retirees, but they could also impact military dependents. Has your Service looked at the potential impact of these fee increases and its 

impact on retention of the force? 

General GREEN. Our retiree population actively shapes perceptions of the value 

of military service. Any action that discourages our retiree population can adversely 

impact recruiting activities. Healthcare benefits for active duty military personnel 

are not impacted under the current proposal. TRICARE standard caps affect the 

small number of active duty family members not enrolled in Prime. The pharmacy 

co-pay increases only affect those who do not get their prescription filled at an Military Treatment Facility. Although increases in healthcare fees may be perceived as 

a loss of benefit to our retiree population, the increases are not expected to negatively influence retention of active duty military personnel. 

Mrs. DAVIS. With your statements supporting the proposed changes to TRICARE, 

what is the impact to the DHP if Congress does not authorize the TRICARE fee increases? Even if Congress was to approve the fees, how will the Department cover 

unanticipated costs if the savings estimated from beneficiaries opting out of 

TRICARE do not materialize to the estimated levels? 

General GREEN. If Congress does not provide us with needed support for these 

proposals, the Department will have to find about $12.9 billion, the projected five 

year savings from these proposals, from other Defense programs to meet its 

healthcare obligations. Without needed authority, we will face further cuts in forces 

and investment to be consistent with the Budget Control Act. Because our budget 

proposal already makes substantial reductions in the investment accounts, further 

cuts may impact end strength. If, for example, Congress did not support any of our 

proposed TRICARE changes, the Department would have to make very difficult 

choices between further cuts to weapons systems or reducing end strength to cover 

the $12B hole in the budget. Cuts of this magnitude would jeopardize our ability 

to pursue some priorities as planned the new defense strategy and force potential 

cutbacks in both direct and private sector care. 
237 

QUESTIONS SUBMITTED BY MR. JONES 

Mr. JONES. Medicare pays about 60% and DOD pays 40% of the overall TRICARE 

For Life (TFL) beneficiary costs, does your office have any ideas on how to reduce 

the cost? Have you considered looking at a management option for TFL beneficiaries? 

Secretary WOODSON. TRICARE for Life provides Medicare wrap-around coverage 

when health care is a benefit under both programs, as long as the beneficiary is 

enrolled in Medicare Part B. Medicare pays 80 percent of their allowed amount, and 

claims automatically cross over to TRICARE where TRICARE processes the remainder for payment. 

Recently, TRICARE Management Activity staff met with representatives from the 

Centers for Medicare and Medicaid Services’ (CMS) Innovation Center to discuss the 

Comprehensive Primary Care Initiative that CMS is developing. This initiative will 

use a managed care approach to providing preventive care and disease management 

for Medicare and other patients. It will reward providers when costs are reduced 

as participants in the initiative achieve desired health outcomes. Many TFL beneficiaries are likely participants in the initiative, and TRICARE intends to monitor 

progress and results of the initiative to assess how and whether to apply the care 

approach to a broader segment of our TFL population. 

We have also instituted new management controls that are applicable when 

TRICARE becomes primary payer for a TFL beneficiary’s stay in a skilled nursing 

facility (SNF). This occurs after exhaustion of the 100-day SNF care coverage provided by Medicare. We have found that bills for SNF care are among the largest 

of any that TFL must cover. Now we require that SNF care beyond 100 days be 

preauthorized, and base the decision upon review of medical records to ensure (a) 

that skilled care truly is required and (b) if skilled care is required, that it is of 

such intensity that it cannot be safely provided at a lower, less expensive level, than 

in a SNF. 

Mr. JONES. It is my understanding that DOD proposes to tie the cost that the 

military retiree will pay to a ‘‘means test’’ system, meaning the greater the annuity 

that a retiree receives, the more they will pay for their health care. As you know, 

no other Federal retired employee healthcare cost is ‘‘means tested.’’ Don’t you think 

that this proposed system is unfair to our service members and their families who 

have sacrificed so much, especially this last decade? 

Secretary WOODSON. Where feasible, the proposed fee increases were tiered by 

military retirement pay, based on the principles of the FY 2007 Task Force on the 

Future of Military Medicine. In its deliberations, the Task Force recognized that 

military retirement is not like most civilian retirement systems and that the entire 

military compensation system differs from the typical civilian ‘‘salary’’ system because much of the compensation is ‘‘in-kind’’ or ‘‘deferred.’’ Thus, changes in the 

healthcare benefit were examined in the context of this unique system and its compensation laws, policies, and programs. The Task Force believed that, for equity reasons, military retirees who earn more military retired pay should pay a higher enrollment fee than those who earn less. While this ‘‘tiering’’ approach is not commonly used in the private sector for enrollment fees, the Task Force believed that 

it made sense in a military environment. 

QUESTIONS SUBMITTED BY MS. BORDALLO 

Ms. BORDALLO. Do you believe that in this era of declining budgets and military 

end-strength, that the prohibition on converting medical military personnel to civilian personnel should be continued? 

Secretary WOODSON. No, I do not believe that the prohibition should be continued. 

Given the fiscal and budgetary pressures facing the Department and nation, the Department can achieve savings from pursuing such conversions. Additionally, with 

declining end-strengths and changing force structures, the Department must do everything it can to minimize the utilization of uniformed military personnel in positions that are not military essential, or do not require military unique knowledge 

and skills to support readiness or career progression. A significant portion of the 

current medical positions filled by military personnel do not meet these criteria and 

could, and should, be considered for conversion to civilian performance (or in certain 

circumstances, private sector performance if appropriate and in accordance with 

statutes). Doing so will not only achieve savings associated with lower civilian personnel costs but also free military personnel for more pressing needs of the Services 

and Combatant Commanders. 
238 

Ms. BORDALLO. How many military medical positions does the Department currently have that could potentially be converted to civilian performance because military incumbency is not essential? 

Secretary WOODSON. The Military Readiness Review (MRR) mandates the number 

of uniformed men and women necessary to deliver military medical and health care, 

and is established to meet service wartime requirements and to provide adequate 

rotational and training opportunities in order to maintain required skill levels for 

deployment. The number of military providers above the level dictated by the MRR 

could, and should, be converted to civilian positions (or contract if appropriate and 

in accordance with policies and statutes) without degrading either unit readiness or 

the training and deployability of the military member. Prior to the prohibition on 

conversion of such billets, the Department had estimated nearly 17,000 positions for 

conversion. Current data points to at least 6,000 medical military positions that 

could potentially be converted to civilian performance, at significant savings to the 

Department and in support of the end-strength reductions. 

Ms. BORDALLO. Given the opportunity, could the Department save money by converting medical military positions to civilian positions? 

Secretary WOODSON. Yes, the Department can save money by converting medical 

military positions to civilian performance, or, in certain circumstances, private sector performance (if appropriate and in accordance with statutes). The Department 

estimates it could potentially save in excess of $1.5 billion over a five year period 

(with savings continuing annually beyond that) by converting military medical positions to civilian performance, with no degradation to quality of care. This is based 

on approximately 16,000 military medical positions that were slated to be converted 

prior to the prohibition and annual savings of approximately $22,000 per position. 

In addition to these direct savings to the Department, additional government and 

taxpayer savings would be realized by the Departments of Veterans Affairs and 

Treasury by avoiding long-term deferred costs associated with military incumbency. 

Ms. BORDALLO. Notwithstanding the current congressionally imposed prohibition, 

how could the Department convert medical military personnel to civilians given the 

current mandate across DOD to maintain FY10 civilian levels? 

Secretary WOODSON. Absent the congressionally mandated prohibition, medical 

military personnel could be converted to civilian personnel by absorbing work into 

existing government positions by refining duties or requirements; establishing new 

positions to perform these medical duties by eliminating or shifting equivalent existing manpower resources (personnel) from lower priority activities; or requesting an 

exception. Any large-scale conversion of medical military manpower to civilian, as 

originally programmed prior to the congressional prohibition on such conversions, 

would require deviation and an exception from the fiscal year 2010 civilian personnel levels the Services have been directed to maintain. 

Ms. BORDALLO. What instances and requirements would justify military incumbency for medical requirements instead of civilian performance? 

Secretary WOODSON. The primary instance or requirement for military incumbency is predicated on the fact that military members have an obligation to deploy 

and medical personnel are a key element of the operating forces. They are responsible for providing world class medical and health care on the battlefield, referred 

to as ‘‘Service Wartime Requirements’’. Additionally, career progression, overseas rotation, and military unique skills/knowledge requirements necessitate military incumbency outside of these ‘‘Service Wartime Requirements’’. In order to maintain 

the necessary level of skills to meet operational, mobilization, and wartime requirements, it is critical that military medical professionals receive the training and patient load necessary to provide experience with current medical scenarios, diagnoses 

and treatments. Maintaining training and rotational practice opportunities for military providers is critical to the continued health of the Military Health System. 

Ms. BORDALLO. How many medical military positions were originally slated to be 

converted to civilian positions prior to the prohibition on such? 

Secretary WOODSON. The number of medical military positions originally slated to 

be converted, prior to the implementation of the congressional mandated prohibition, between fiscal years 2005 and 2013 was 16,876. 

Ms. BORDALLO. Do you believe that medical care for our uniformed men and 

women and unit readiness would suffer if delivered by civilian personnel instead of 

military personnel? 

Secretary WOODSON. The Military Readiness Review (MRR) mandates the number 

of uniformed men and women necessary to deliver military medical and health care. 

This number is established to meet service wartime requirements and to provide 

adequate rotational and training opportunities in order to maintain required skill 

levels for deployment. I believe that any military medical billets above the level dictated by the MRR could, and should, be converted to civilian positions (or contract 
239 

if appropriate and in accordance with policies and statutes) without degrading medical care, unit readiness, or the training and deployability of the military medical 

providers. 

Ms. BORDALLO. What impact has the civilian cap had on the Defense Health Program and ability to deliver care? 

Secretary WOODSON. The Military Health System (MHS) draws healthcare providers from three different labor sources: active and reserve military, government 

civilian employees, and contracted support. Any arbitrary personnel ceiling that limits the Department’s potential ability to hire civilian employees forces the MHS to 

increase contracted support, both within the military treatment facilities and in the 

local economy. The Department is committed to providing world class healthcare to 

Service members, and that level of healthcare will continue regardless of any 

constrants, but will come a significantly higher cost if the MHS is forced to utilize 

contracted support in lieu of government civilians. Such increased costs will impact 

availability of care and the patient share of the cost, and take funding away from 

other pressing medical and health needs of the force, as well as reducing available 

funding for other compelling needs across the Department. 

Ms. BORDALLO. Do you believe that in this era of declining budgets and Army endstrength, that the prohibition on converting medical military personnel to civilian 

personnel should be continued? 

General HOROHO. The current congressional prohibition has effectively reduced 

programmatic and operational turmoil to our complex medical workforce. Previous 

rounds of medical military to civilian conversion directly impacted Army Medical 

Department mission capabilities to the detriment of medical support to our Soldiers 

and their Families. The inability to backfill military conversions with qualified civilians in a timely basis generated shortfalls in the delivery of health care, especially 

in the ancillary workforce required to support our physicians and nurses. The Army 

restored military billets converted between FY07–FY11, recognizing the negative effects of reduced support staff and resulting decreased clinician efficiency and effectiveness which directly impacted quality and access to care. 

Ms. BORDALLO. How many military medical positions does the Army currently 

have that could potentially be converted to civilian performance because military incumbency is not essential? 

General HOROHO. An assessment of military medical billets, potential readiness 

impact, cost, and local market availability is necessary to determine if any medical 

positions could be converted to civilian performance. Military to civilian conversion 

would require the programming of additional funding for the required civilian medical workforce. 

Ms. BORDALLO. Do you believe that medical care for your soldiers and unit readiness would suffer if delivered by civilian personnel instead of military personnel? 

General HOROHO. The Army Medicine Team is composed of a symbiotic core of 

military, civilian and contract healthcare personnel. As an Army in persistent conflict for over a decade, we stand shoulder-to-shoulder with the Warfighter, both on 

the battlefield and at home. Our military healthcare personnel are the critical link 

between care in the garrison environment and on remote battlefields. The combined 

Army Medicine team leverages the strengths, competencies, Duty and Selfless Service necessary to ensure a fit and medically ready force. 

Ms. BORDALLO. Do you believe that in this era of declining budgets and Navy/Marine Corps end-strength, that the prohibition on converting medical military personnel to civilian personnel should be continued? 

Admiral NATHAN. Military to civilian conversions in the Medical Department are 

often independent of declining budgets and end strength reductions. The ideal mix 

of personnel; active duty, civilians, contractors, is established first and foremost to 

meet operational requirements, and then to appropriately augment the team with 

civilian and contractor staff; as is currently done. Uniformed staffing requirements 

are directly linked to the operational needs of the Fleet and Fleet Marine Forces. 

Active duty personnel directly support and mobilize, when needed, to meet Combatant Commanders’ requirements. Civilian and contract staff augment and complete 

the staffing at our fixed military treatment facilities, providing much needed continuity of care delivery. As was learned during the last effort of Military-to-Civilian 

conversions, ending the prohibition on converting military personnel to civilian personnel will not necessarily lead to lower costs. 

Ms. BORDALLO. How many military medical positions does the Navy/Marine Corps 

currently have that could potentially be converted to civilian performance because 

military incumbency is not essential? 

Admiral NATHAN. Navy Medicine uses an operational requirements model, based 

on the Combatant Commanders’ needs, to determine the appropriate, number of 
240 

uniformed medical department personnel needed to ensure that the Navy and Marine Corps missions are met. The total number of uniformed personnel within Navy 

Medicine today is adequate to meet currently identified operational requirements. 

Uniformed personnel are allocated to operational units and, when not deployed, are 

assigned to our fixed military treatment facilities. There they hone and sustain their 

needed clinical and ancillary skills in order to prepare for their mobilization assignments. The number of medical professionals needed to staff these Medical Treatment Facilities, in excess of active duty requirements, may be supported by any personnel category (military, civilian, or contractor). Navy Medicine’s complement of 

total staff, comprising all of these categories is approximately 63,000 men and 

women supporting Navy’s healthcare missions. 

Ms. BORDALLO. Do you believe that medical care for sailors and marines, and unit 

readiness would suffer if delivered by civilian personnel instead of military personnel? 

Admiral NATHAN. Navy maintains one high standard of health care, whether that 

care is delivered by military or civilian providers. Military or civilian providers 

maintain the same qualifications and credentialing standards. Navy Medicine meets 

the unit readiness and the beneficiary peacetime missions while in-garrison, by employing available uniformed staff, augmented by civilian and contract providers and 

support staff at our fixed facilities. Civilians delivering care to our deployable forces 

in our fixed Medical Treatment Facilities would not degrade unit readiness, so long 

as a uniformed force is maintained at the appropriate levels required to support our 

operational missions. 

Ms. BORDALLO. Do you believe that in this era of declining budgets and Air Force 

end-strength, that the prohibition on converting medical military personnel to civilian personnel should be continued? 

General GREEN. In certain locations, and for certain Air Force Specialty Codes, 

military-to-civilian conversions provide an effective option to the Air Force Medical 

Service for managing costs while continuing to deliver outstanding healthcare. The 

NDAA prohibition inhibits the ability to optimize force structure for emerging and 

changing missions and operations tempo by eliminating military to civilian/contract 

conversion options when conversion is deemed the most effective and efficient funding source. However, we need to ensure that the conversions are in the appropriate 

market due to the availability of civilians with the required skills/training and the 

potential competition and pay disparities with the civilian sector. 

Ms. BORDALLO. How many military medical positions does the Air Force currently 

have that could potentially be converted to civilian performance because military incumbency is not essential? 

General GREEN. The Air Force Defense Health Program current Critical Operational Readiness Requirement is 25,284 and current active duty Defense Health 

Program end-strength is 31,544. In theory, the Air Force could potentially convert 

approximately 6,200 positions from Military to Civilian across the Future Year Defense Plan (Fiscal Year 14–18) at an estimated rate of 1,240 positions per year. 

Three very important issues that would impact the number of conversions would 

be: 1. In theory, we could covert 6,200 Military to Civilian positions; however, we 

may not be able to execute because of the availability of civilians with the required 

skills/training and the potential competition and pay disparities with the civilian 

sector. 2. Currently there are ongoing discussions with Health Affairs and the Service Surgeon Generals to develop strategies for determining medical requirements 

and medical force sizing for future contingencies. 3. There needs to be consistent civilian pay categories across all government pay systems (e.g. DOD, VA, Public 

Health Service) to simplify recruiting and retention of civilians. 

Ms. BORDALLO. Do you believe that medical care for airmen and unit readiness 

would suffer if delivered by civilian personnel instead of military personnel? 

General GREEN. The Air Force does not believe that medical care for Airmen 

would suffer if delivered by civilian personnel. The Air Force has successfully utilized Active Duty, civilian and contract personnel to provide medical care to our active duty population in our Medical Treatment Facilities. Unit readiness requires 

a health system to assist commanders’ track and resolve health related readiness 

concerns. Any Shift that eliminated the health system from assisting commanders 

could impact readiness. 
241 

QUESTION SUBMITTED BY MR. LOEBSACK 

Mr. LOEBSACK. My understanding is that an announcement was recently made 

about the TRICARE program in the TRICARE West Region. Can you tell me what 

the Department has done to ensure that there will be no disruption in care for my 

constituents or for any TRICARE beneficiaries in the region? What has been done 

to ensure that any changes in the TRICARE West Region will not result in a reduction of healthcare services available in rural states like Iowa for our service members (including in the Reserve Component), retirees, and military families? 

Secretary WOODSON. The West contract is under protest and services will continue 

under the old contract until the protest is resolved. However, all TRICARE Regional 

contracts have transition periods as required by statute and those transition periods 

address the transfer of responsibility in a timely and orderly fashion. The contracts 

also contain required access standards and networks of adequate size and composition to cover all needed services in the Regions. While it cannot be guaranteed that 

all providers currently in the TRIWEST network will continue as providers under 

the new contractor, most will be likely retained and beneficiaries will not be without 

services nor should they experience any disruption of service as a result of the transition, regardless of the area they live in. 

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