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i 

58–309 2010

[H.A.S.C. No. 111–156] 

DEFENSE HEALTH PROGRAM 

HEARING 

BEFORE THE

SUBCOMMITTEE ON MILITARY PERSONNEL 

OF THE

COMMITTEE ON ARMED SERVICES 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED ELEVENTH CONGRESS 

SECOND SESSION 

HEARING HELD 

APRIL 21, 2010 
(II) 

SUBCOMMITTEE ON MILITARY PERSONNEL 

SUSAN A. DAVIS, California, Chairwoman 

VIC SNYDER, Arkansas 

LORETTA SANCHEZ, California 

MADELEINE Z. BORDALLO, Guam 

PATRICK J. MURPHY, Pennsylvania 

HANK JOHNSON, Georgia 

CAROL SHEA-PORTER, New Hampshire 

DAVID LOEBSACK, Iowa 

NIKI TSONGAS, Massachusetts 

JOE WILSON, South Carolina 

WALTER B. JONES, North Carolina 

JOHN KLINE, Minnesota 

THOMAS J. ROONEY, Florida 

MARY FALLIN, Oklahoma 

JOHN C. FLEMING, Louisiana 

DAVE KILDEE, Professional Staff Member 

JEANETTE JAMES, Professional Staff Member 

JAMES WEISS, Staff Assistant 
(III) 

C O N T E N T S 

CHRONOLOGICAL LIST OF HEARINGS 

2010 

Page 

HEARING: 

Wednesday, April 21, 2010, Defense Health Program .......................................... 1 

APPENDIX: 

Wednesday, April 21, 2010 ..................................................................................... 31 

WEDNESDAY, APRIL 21, 2010 

DEFENSE HEALTH PROGRAM 

STATEMENTS PRESENTED BY MEMBERS OF CONGRESS 

Davis, Hon. Susan A., a Representative from California, Chairwoman, Subcommittee on Military Personnel ........................................................................ 1 

Wilson, Hon. Joe, a Representative from South Carolina, Ranking Member, 

Subcommittee on Military Personnel ................................................................. 3 

WITNESSES 

Green, Lt. Gen. Charles B., USAF, Surgeon General, U.S. Air Force ................ 11 

Rice, Charles L., M.D., Performing the Duties of the Assistant Secretary 

of Defense for Health Affairs, and President, Uniformed Services University 

of Health Sciences, U.S. Department of Defense ............................................... 5 

Robinson, Vice Adm. Adam M., USN, Surgeon General, U.S. Navy ................... 8 

Schoomaker, Lt. Gen. Eric B., USA, Surgeon General, U.S. Army ..................... 6 

APPENDIX 

PREPARED STATEMENTS: 

Davis, Hon. Susan A. ....................................................................................... 35 

Green, Lt. Gen. Charles B. .............................................................................. 96 

Rice, Charles L., M.D. ...................................................................................... 42 

Robinson, Vice Adm. Adam M. ........................................................................ 77 

Schoomaker, Lt. Gen. Eric B. .......................................................................... 61 

Wilson, Hon. Joe ............................................................................................... 39 

DOCUMENTS SUBMITTED FOR THE RECORD: 

[There were no Documents submitted.] 

WITNESS RESPONSES TO QUESTIONS ASKED DURING THE HEARING: 

Mrs. Davis ......................................................................................................... 117 

Dr. Fleming ....................................................................................................... 117 

Ms. Shea-Porter ................................................................................................ 117 

Ms. Tsongas ...................................................................................................... 118 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING: 

[There were no Questions submitted post hearing.] 

(1) 

DEFENSE HEALTH PROGRAM 

HOUSE OF REPRESENTATIVES, COMMITTEE ON ARMED SERVICES, SUBCOMMITTEE ON MILITARY PERSONNEL, Washington, DC, Wednesday, April 21, 2010. 

The subcommittee met, pursuant to call, at 1:40 p.m., in room 

2118, Rayburn House Office Building, Hon. Susan A. Davis (chairwoman of the subcommittee) presiding. 

OPENING STATEMENT OF HON. SUSAN A. DAVIS, A REPRESENTATIVE FROM CALIFORNIA, CHAIRWOMAN, SUBCOMMITTEE ON MILITARY PERSONNEL 

Mrs. DAVIS. Good afternoon. Today the Military Personnel Subcommittee will hold a hearing on the President’s fiscal year 2011 

budget request for the Defense Health Program (DHP). 

Testifying before us are the senior medical leaders of the Department of Defense (DOD). Dr. Charles Rice is the President of the 

Uniformed Services University of Health Sciences, and is currently 

performing the duties of the Assistant Secretary of Defense for 

Health Affairs. This office is responsible for the preparation and 

oversight of the Defense health budget, as well as the execution of 

private sector care. 

We also have with us the service surgeons general, Lieutenant 

General Eric Schoomaker from the Army, Vice Admiral Adam Robinson from the Navy, and Lieutenant General Bruce Green from 

the Air Force, who are responsible for the provision of care in military hospitals and clinics. Thank you all for being here. Welcome. 

This year’s budget request, much like last year’s, lacks many of 

the objectionable proposals of years past. For example, there are no 

onerous TRICARE fee increases that seek to place a burden of improving the system on beneficiaries instead of on the Department 

of Defense. There are no ‘‘efficiency wedges,’’ an interesting term 

that meant ‘‘We think the services are spending too much, but we 

don’t know exactly where, so we are just going to cut their budgets 

and let them figure it out.’’ There are no proposed conversions of 

military medical positions to civilian medical positions. And the absence of all of these things from the proposed budget is a very good 

start. 

However this budget request, while devoid of these negatives, 

doesn’t have so many positives that are forward-looking. We continue to see little if any evidence of a comprehensive, multifaceted 

strategy for moving the Military Health System (MHS) forward. 

For the past few years Congress has been pushing the Department 

of Defense to improve the health status of the beneficiary population and improve cost-effectiveness of the care provided to our 
2 

beneficiaries by adopting proven practices, the fiscal year 2009 National Defense Authorization Act contains many initiatives to improve preventive and wellness care. But 18 months, now, after it 

was signed into law, we are still waiting for most of them to be 

fully implemented. 

That same bill also gave the Department great latitude and authority to conduct demonstration projects to test other methods of 

improving health while reducing costs. We would like to hear today 

how the Department plans to take advantage of that authority. 

Further, the 2010 National Defense Authorization Act contained 

a requirement for the Department to undertake actions to enhance 

the capability of the Military Health System and improve the 

TRICARE program. Congress felt that such action was needed because private sector care, which was originally intended to be and 

is still described by the Department as a program to fill gaps in 

the direct care system, is projected to account for about 67 percent 

of the Department of Defense health-care expenditures in fiscal 

year 2011 versus 65 percent this year. It is strange logic to characterize something that accounts for almost 70 percent of a program 

as a gap-filler. 

We recognize that several factors have contributed to the unintentional growth in private sector care, such as two wars, staffing 

shortages, and broad reserve globalization. 

With that said, without appropriate planning, the effect of these 

factors could be an irreversible trend, placing medical readiness in 

future contingencies in jeopardy. Congress clearly believed the Department must develop a long-term plan to maximize the capabilities of the direct care system, and we would like to hear from our 

witnesses today any ideas they may have. 

This has been a momentous year for health care in this country. 

Last month the Patient Protection and Affordable Care Act and the 

companion improvements bill were signed into law. Further, just 

last week, the Senate unanimously passed the TRICARE Affirmation Act introduced by the chairman of this committee, Ike Skelton, 

which had previously passed unanimously in the House. 

The TRICARE Affirmation Act explicitly states that TRICARE 

and nonappropriated fund, NAF, health plans meet all of the 

health-care requirements for individual health insurance under the 

newly enacted health-care reform law. TRICARE and the NAF 

health plans already meet the minimum requirements for individual health insurance coverage in the recently enacted healthcare bill, and no TRICARE or NAF nonappropriated fund health 

plan beneficiary will be required to purchase additional coverage 

beyond what they already have. 

However, to reassure our military service members and their 

families and make it perfectly clear that they will not be negatively 

affected by the health-care reform law, the TRICARE Affirmation 

Act explicitly states that TRICARE and the NAF health plans meet 

the minimum requirements for individual health insurance. 

Now that the bills are law, parents across the country will now 

be able to extend their health coverage to their dependent children 

up to age 26. Being true to their word, congressional Democratic 

leadership ensured that the health reform bills do not involve 

TRICARE in any way. But since care was taken to guarantee that 
3 

the Department of Defense health programs under Title 10, U.S. 

Code, were not touched by the health reform bills, this means that 

the new law does not allow TRICARE beneficiaries to extend their 

health coverage to their dependent children. 

Fortunately, a member of this committee, Mr. Heinrich of New 

Mexico, quickly crafted and introduced a bill, H.R. 4923, the 

TRICARE Dependent Coverage Extension Act, that would amend 

Title 10 to precisely match the health reform law to allow 

TRICARE beneficiaries to extend their health coverage to their dependent children up to age 26. I want to thank Mr. Heinrich for 

introducing this important legislation and I want to let everyone 

know that I certainly intend to include that bill in this subcommittee’s mark for this year’s National Defense Authorization Act in a 

few weeks. 

Since Mr. Heinrich is not a member of the subcommittee, I would 

ask unanimous consent that he be allowed to participate in today’s 

hearing and be allowed to ask questions after all the members of 

the subcommittee. 

Hearing no objection, thank you for being here. 

Mr. Wilson, we welcome you. We are sorry we got underway because we just had everybody ready to go here and we appreciate 

the fact that you were trying to get here as well. 

Please, we are happy to have any of your comments. 

[The prepared statement of Mrs. Davis can be found in the Appendix on page 35.] 

STATEMENT OF HON. JOE WILSON, A REPRESENTATIVE FROM 

SOUTH CAROLINA, RANKING MEMBER, SUBCOMMITTEE ON 

MILITARY PERSONNEL 

Mr. WILSON. Thank you, Chairwoman Davis. Today the subcommittee meets to hear testimony on the Defense Health Program 

for fiscal year 2011. Although we routinely have an annual hearing 

on the Defense Health Program, I believe there is nothing routine 

about the Military Health System and the extraordinary care it 

provides to our service members and their families. I have firsthand knowledge of these remarkable military and civilian medical 

professions from my second son, who is an orthopedic resident in 

the Navy, and my other three sons who are current members of the 

Army National Guard. 

The subcommittee remains committed to ensuring that the men 

and women who are entrusted with the lives of our troops have the 

resources to continue their work for future generations of our most 

deserving military beneficiaries. 

I would like to express my deep appreciation to all the Military 

Health System leadership and personnel who are responsible for 

delivering the highest quality health care during these most challenging times. 

To begin, I want to commend the Department of Defense for 

sending us a budget that does not rely on raising TRICARE fees 

to help finance the Defense Health Program. It appears the Defense Health Program is fully funded. However, I remain concerned 

a portion of the funding is based on projected savings from several 

programs that may not be fully realized. 
4 

I would like to know how the Department of Defense plans to 

cover any unexpected shortfalls in the Defense Health Program if 

the savings from initiatives such as the Federal Pricing for Pharmaceuticals doesn’t materialize. 

With that, I am anxious to hear from our witnesses today about 

the progress the Department has made in developing a comprehensive approach to providing world-class health care to our beneficiaries while at the same time controlling cost. I would like to 

know how the Military Health System is meeting the medical 

needs of our beneficiaries today and what process you use for determining the medical requirements of future beneficiaries. I am interested in knowing how you have included the stakeholders in 

military health care and the discussions about providing worldclass health care in the future of the Military Health System. Further, I would like to hear from the witnesses on how the Defense 

Health Program supports the critical mental health services needed 

by our service members and their families, particularly the National Guard and Reserve members who rely primarily on 

TRICARE standard. 

I would also like to better understand from our military Surgeons General whether the Defense Health Program will fully support their responsibility to maintain medical readiness, provide 

health care to eligible beneficiaries, provide battlefield medicine to 

our brave men and women in Iraq and Afghanistan, care for combat veterans through the long recovery process when they become 

injured and wounded. 

Finally, with regard to TRICARE, which is now regarded as a 

health-care delivery system worthy of emulation, I quite frankly 

don’t understand why the Department of Defense would not want 

to explicitly protect it from any unintended consequence that may 

arise from the health-care takeover. 

Congress has already acted to make clear, explicit, that the recent health-care bill did not, that TRICARE meets the statutory requirement for minimal essential health care. The Department of 

Defense did not object to that recent congressional action. Now it 

is time to make explicit in the law what has been promised that 

would be explicit in the health-care reform. 

The Secretary of Defense would remain in control of the DOD 

Health Care Program. No one should object to Congress making 

that control explicit in the law. While some may feel that this is 

an unnecessary precaution, we owe our military that clearly stated 

protection. 

With that, I would like to welcome our witnesses and thank them 

for participating in the hearing today. I look forward to your testimony. 

Mrs. DAVIS. Thank you, Mr. Wilson. 

[The prepared statement of Mr. Wilson can be found in the Appendix on page 39.] 

Mrs. DAVIS. Dr. Rice, please begin. 
5 

STATEMENT OF CHARLES L. RICE, M.D., PERFORMING THE 

DUTIES OF THE ASSISTANT SECRETARY OF DEFENSE FOR 

HEALTH AFFAIRS, AND PRESIDENT, UNIFORMED SERVICES 

UNIVERSITY OF HEALTH SCIENCES, U.S. DEPARTMENT OF 

DEFENSE 

Dr. RICE. Madam Chair, members of the committee, thank you 

for the opportunity to discuss the military health care system’s priorities and our budget submission for fiscal year 2011. It is a privilege to be here with my colleagues, the Surgeons General of the 

three military services. 

We have enduring obligations to the men and women of our 

armed forces, as you have observed, and to their families who serve 

with them, and to the millions of retired personnel who have 

served us in the past. This obligation begins the moment a recruit 

walks through our doors. In our budget for the coming year we acknowledge that lifetime commitment we have to those who serve 

today, or who have served in the past, and to their families. For 

those service members who honorably conclude their service before 

reaching military retirement, we have an obligation to ensure that 

their medical experience is fully captured and easily shared with 

the Department of Veterans Affairs (VA) or with their own private 

physician. 

For those who retire from military service, our obligation to them 

and to their families often extends for a lifetime. And for those who 

have borne the greatest burden through injury or disease suffered 

in our nation’s conflicts, we have an even higher obligation to the 

wounded and to their families. 

As Secretary Gates stated with the introduction of the Defense 

budget, ‘‘Recognizing the strain that post-9/11 wars have put on so 

many troops and their families, the Department will spend more 

than $2 billion for wounded warrior initiatives, with a special focus 

on signature ailments of the current conflict, such as post-traumatic stress disorder and traumatic brain injury (TBI), manifestations of the last injury. 

‘‘We will sustain health benefits and enlarge the pool of medical 

professionals. We will broaden electronic information sharing between the Department of Defense and the VA for wounded warriors 

making the transition out of military service.’’ 

The budget we are putting forward reflects our commitment to 

the broad range of responsibilities of the military health care system; the medical readiness requirements needed for success on today’s battlefield; the medical research and development necessary 

for success on tomorrow’s; the patient-centered approach to care 

that is being woven through the fabric of the military health care 

system; the transformative focus we have placed on the health of 

our population; the public health role we play in our military community and in the broader American community; the reliance we 

have on our private sector health-care partners who provide indispensable service to our service members and their families; and our 

responsibility to deliver all of those services with extraordinary 

quality and care. 

The Defense Health Program, the appropriation that supports 

the MHS, is under mounting financial pressure. The DHP has 

more than doubled since 2001 from 19 billion to 50.7 billion in 
6 

2011. The majority of DOD health spending supports health-care 

benefits for military retirees and their dependents, not the active 

force. We projected up to 65 percent of DOD health-care spending 

will be going towards retirees in fiscal year 2011, up from 45 percent in 2001. 

As civilian employers’ health costs are shifted to their military 

retiree employees, TRICARE is seen as a better, less costly option, 

and they are likely to drop their employer’s insurance. 

These costs are expected to grow from 6 percent of the Department’s total budget in 2001 to more than 10 percent in 2015. Despite these financial challenges, however, the fiscal year 2011 

budget request provides realistic funding for projected health-care 

requirements, and we are grateful to this committee and to the 

Congress for affirming TRICARE as a qualifying plan under the 

health reform act. 

The unified medical budget, the Department’s total request for 2011 is $50.7 billion. This includes the DHP appropriation, including wounded, ill, and injured care and rehabilitation, military personnel, military construction, and normal cost contributions for 

Medicare-eligible retiree health care. 

For military personnel, the unified budget includes 7.9 billion to 

support the more than 84,000 military personnel who provide 

health-care services in military theaters of operations in fixed 

health-care facilities around the world. These services include medical and dental care, global aeromedical evacuation, shipboard and 

undersea medicine, and global humanitarian assistance and response as we recently saw in Haiti. 

Funding for the military construction (MILCON) includes a billion dollars to improve our medical infrastructure. We are committed to building new hospitals, using the principles of evidencebased design, and excited to be able to open a national showcase 

in evidence-based design, the new Fort Belvoir Community Hospital, in 2011. 

MILCON funding will also be directed toward infrastructure enhancements at the interagency biodefense campus at Fort Detrick. 

Madam Chair, the military health care system continues to provide world-class medical care for a population that demands and 

deserves the best care anywhere. I am proud to be here on behalf 

of the men and women who comprise the military health care system, proud to submit to you and your colleagues a budget that is 

fully funded and that we can successfully execute in the coming 

year. I look forward to your questions. 

Mrs. DAVIS. Thank you. 

[The prepared statement of Dr. Rice can be found in the Appendix on page 42.] 

Mrs. DAVIS. General. 

STATEMENT OF LT. GEN. ERIC B. SCHOOMAKER, USA, 

SURGEON GENERAL, U.S. ARMY 

General SCHOOMAKER. Chairwoman Davis and Representative 

Wilson, distinguished members of the Military Personnel Subcommittee and the full committee, thank you for inviting us to discuss the Defense Health Program and our respective medical service programs. 
7 

Now in my third hearing cycle as the Army Surgeon General and 

the Commanding General of the United States Army’s Medical 

Command, or MEDCOM, I can tell you that these hearings are valuable opportunities for me to talk about the accomplishments and 

challenges of Army Medicine and to hear your collective perspectives regarding military health promotion and health care. And for 

the reasons, ma’am, that you mentioned in your opening comments, 

although closely interrelated, I keep military health promotion and 

health care somewhat separate issues. 

I am pleased to tell you that the President’s budget submission 

for fiscal year 2011 fully funds the Army Medical Department’s 

needs. Your support of the President’s proposed budget will be 

greatly appreciated. 

One particular area of special interest to this subcommittee is 

our comprehensive effort to improve warrior care from the point of 

injury through evacuation and inpatient treatment to rehabilitation 

and return to duty. There is nothing more gratifying than to care 

for these wounded, ill, and injured heroes. We in Army Medicine 

continue to focus our efforts on our warriors in transition, which 

is our term for them. And I want to thank the Congress for your 

unwavering support of these efforts. 

The support of this committee especially has allowed us to hire 

additional providers to staff our warrior transition units, to conduct 

relevant medical research, and to build healing campuses, the first 

of which will open in Fort Riley, Kansas very soon. 

I am convinced that the Army has made some lasting improvements. The most important improvement will be the change in 

mindset from a focus on disability to an emphasis on ability and 

achievement. Each of these warriors has the opportunity and resources to create their own future as soldiers or as productive private citizens. 

A second area of special interest for the subcommittee is psychological health. Army Medicine, under the direction of our new Deputy Surgeon General, Major General Patty Horoho who has just relinquished command of the Western Region and has traveled here 

and is replacing David Rubenstein who is headed to San Antonio, 

is finalizing a comprehensive behavioral health system of care campaign plan. This comprehensive behavioral health system of care is 

intended to standardize and synchronize the vast array of activities 

across the medical command and throughout the Army’s force generation cycle, this iterative three-cycle process by which we prepare 

soldiers and units for deployment, deploy them and support their 

families back in garrison, bring them back and redeploy them and 

reintegrate them. I look forward to sharing more information with 

you over the next few months as we roll out this exciting initiative. 

In keeping with our focus on preventing illness and injury, Army 

leadership is fully engaged in an all-out effort to change the military mindset regarding traumatic brain injury, especially the milder form, or a concussion. Our goal is nothing less than a cultural 

change in fighter management after potential concussive events. 

Every warrior requires appropriate treatment to minimize concussive injury and to maximize recovery. And to achieve this goal we 

are educating the force so that we have trained and prepared soldiers, leaders, medical personnel to provide early recognition, treat-
8 

ment, and tracking of concussive injuries from the moment of the 

injury on the battlefield, homeward. Ultimately this is designed to 

protect warrior health. This also further highlights strong efforts 

by the senior Army and DOD leadership to reduce the stigma associated with seeking help for these injuries and for behavioral 

health problems which might be present, separately or jointly. 

The Army is issuing very direct standards and protocols to commanders and health-care providers. Similar to aviation incident actions, automatic grounding and medical assessments are required 

for any soldiers meeting specified criteria. The end state of these 

efforts is that every service member sustaining a possible concussion will receive early detection, state-of-the-art treatment and a 

return-to-duty evaluation and a long-term digital health record 

tracking of their management. Treatment of concussive injury is an 

emerging science. The Army is leading the way, along with the 

DOD, in implementing these new treatment protocols both for the 

DOD, and the DOD is leading the nation. 

I brought here with me today a brain injury awareness kit that 

I will share with you and your staff. It contains patient information 

materials, as well as a very informative DVD, sort of a concussive 

injury 101. 

Mrs. DAVIS. Thank you General. I just ask that that be included 

in the record by unanimous consent. 

[The information referred to is retained in the subcommittee files 

and can be viewed upon request.] 

General SCHOOMAKER. Thank you. 

I truly believe our evidence-based directive approach to concussion management will change the military culture regarding head 

injuries and significantly impact the well-being of the force. 

Ma’am, in reference to your comments about cost containment 

and improvements and health outcomes, the Army Medicine is in 

its fourth year of the performance-based health-care budget program which incentivizes our commanders and our clinicians for 

practicing evidence-based medicine and improving individual and 

community health. It has been a very successful campaign. I am 

very eager to address any questions that you may have about it. 

In closing, I am very optimistic about the next two years. Logic 

would not predict that we would be doing as well as we are in attracting and obtaining and career-developing such a talented team 

of uniformed and civilian military medical professionals. I feel very 

privileged to serve with the men and women of Army Medicine, as 

soldiers, as Americans, and as global citizens. 

Thank you for holding this hearing and for your steadfast support of Army Medicine. I look forward to your questions. 

Mrs. DAVIS. Thank you. 

[The prepared statement of General Schoomaker can be found in 

the Appendix on page 61.] 

Mrs. DAVIS. Admiral Robinson. 

STATEMENT OF VICE ADM. ADAM M. ROBINSON, USN, 

SURGEON GENERAL, U.S. NAVY 

Admiral ROBINSON. Good afternoon. Thank you, Chairwoman 

Davis, Representative Wilson, distinguished members of the committee, Representative Heinrich, I want to thank you for your un-
9 

wavering support of Navy Medicine, particularly as we continue to 

care for those who go in harm’s way, their families and all beneficiaries. I am honored to be with you today to provide an update 

of Navy Medicine. 

Navy Medicine, world-class care anytime anywhere. This poignant phrase is arguably the most telling description of Navy Medicine’s accomplishment in 2009 and continues to drive our operational tempo and priorities for the coming year and beyond. 

Throughout the last year we saw challenges and opportunities, 

and moving forward I anticipate the pace of operations and demand will continue to increase. We have been stretched in our ability to meet increasing operational and humanitarian assistance requirements, as well as maintaining our commitment to provide 

care to a growing number of beneficiaries. However, I am proud to 

say that we are responding to this demand with more flexibility 

and agility than ever before. 

The foundation of Navy Medicine is force health protection, and 

nowhere is this more evident than in Iraq and Afghanistan. During 

my October 2009 trip to theater, I saw again the outstanding work 

of medical personnel. The Navy Medicine team is working side by 

side with Army and Air Force medical personnel and coalition 

forces to deliver outstanding health care to troops and civilians 

alike. 

As our wounded warriors return from combat and begin the healing process, they deserve a seamless and comprehensive approach 

to their recovery. We want them to mend in body, mind, and spirit. 

Our patient- and family-centered concept of care brings together 

medical treatment providers, social workers, case managers, behavioral health providers and chaplains. We are working closely with 

our aligned counterparts in Marine Corps wounded warrior regimens, and the Navy’s Safe Harbor Program to support the full 

spectrum recovery process for sailors, Marines, and their families. 

An important focus for all of us continues to be caring for our 

wounded warriors suffering with traumatic brain injury. We are 

expanding traumatic brain injury training to health-care providers 

throughout the fleet and Marine Corps. We are also implementing 

a new in-theater TBI surveillance system and conducting important research. Our strategy is both collaborative and integrated by 

actively partnering with other services, Defense Center of Excellence for Psychological Health and Traumatic Brain Injury, the Department of Veterans Affairs, and leading academic medical and 

research centers to make the best care available to our warriors. 

We must act with a sense of urgency to continue to help build 

resiliency among our sailors and Marines, as well as the caregivers 

who support them. We are aggressively working to reduce the stigma surrounding psychological health and operational stress concerns. 

Programs such as Navy Operational Stress Control, Marine 

Corps Combat Operational Stress Control Focus, Families Overcoming Under Stress, Caregiver Occupational Stress Control, and 

our Suicide Prevention Programs are in place and maturing to provide the support to personnel and their families. 

Mental health specialists are being placed in operational environments and forward deployed to provide service where and when 
10 

they are needed. The Marine Corps is sending more mental health 

teams to the front lines, and Operational Stress Control and Readiness team, also known as OSCAR, will soon be expanded to include 

the battalion level. 

A mobile care team of Navy Medicine mental health professionals 

is currently deployed to Afghanistan conducting mental health surveillance, consulting with command leadership, and coordinating 

mental health care for sailors throughout the area of responsibility 

(AOR). 

An integral part of the Navy’s maritime strategy is humanitarian 

assistance and disaster response. In support of Operation Unified 

Response Haiti, we deployed USNS Comfort from her homeport in 

Baltimore within 77 hours of the order, and ahead of schedule. She 

was on station in Port-au-Prince five days later. 

From the beginning, the operational tempo on board Comfort was 

high and our personnel were challenged professionally and personally. For many, this was a career defining experience, and I was 

proud to welcome the crew home last month and congratulate them 

for their outstanding performance. 

I am encouraged with our recruiting efforts within Navy Medicine, and we are starting to see the results of new incentive programs. But while overall manning levels for both officer and enlisted personnel are relatively high, ensuring we have the proper 

specialty mix continues to be a challenge in both active and reserve 

components. Several wartime critical specialties, as well as advance practice nursing and physician assistant, are undermanned. 

We also face shortfalls for general dentists, oral and maxillofacial 

surgeons, and many of our mental health specialists, including clinical psychologists and social workers. We continue to work hard to 

meet this demand but fulfilling the requirement among these specialties is expected to present a continuing challenge. 

Research and development is critical to Navy Medicine’s success 

and our ability to remain agile to meet the evolving needs of our 

warfighters. It is where we find solutions to our most challenging 

problems and, at the same time, provide some of medicine’s significant innovations and discoveries. Research efforts targeted at 

wound management, enhanced wound repair and reconstruction, as 

well as extremity and internal hemorrhage control, phantom limb 

pain in amputees present definitive benefit. These efforts support 

our emerging expeditionary medical operations in aid and support 

to our wounded warriors. 

Clearly, one of the most important priorities for leadership of all 

the service is the successful transition to the Walter Reed National 

Medical Center on board the campus of the National Naval Medical 

Center, Bethesda. We are working diligently with the lead DOD organization, Joint Task Force National Capital Region Medical, to 

ensure that this significant and ambitious project is executed properly and without any disruption of services to our sailors, Marines, 

their families, and all of our beneficiaries for whom we are privileged to serve. 

In summary, I believe we are an important crossroads for military medicine. Commitment to wounded warriors and their families 

must never waiver, and our programs of support and hope must be 

built and sustained for the long haul. And the long haul is the rest 
11 

of this century when the young, wounded warriors of today mature 

into our aging heroes in the years to come. They will need our care 

and support, as will their families, for a lifetime. 

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

thank the committee for your tremendous support and confidence 

and also for your leadership. It has been my pleasure to testify before you today and I look forward to your questions. Thank you. 

Mrs. DAVIS. Thank you. 

[The prepared statement of Admiral Robinson can be found in 

the Appendix on page 77.] 

Mrs. DAVIS. General Green. 

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

GENERAL, U.S. AIR FORCE 

General GREEN. Chairwoman Davis, Representative Wilson and 

distinguished members of the committee, thank you for this opportunity to join you today as we address common goals in serving our 

warriors and their families. 

The Air Force is all in to support the joint fight, providing global 

vigilance reaching power for America. The Air Force medical service does whatever it takes to get coalition wounded warriors home 

safely. 

I have previously shared the case of a British combatant with 

wounds requiring removal of a lung. It took three airplanes and 

nearly a thousand people coordinating his movement on heart-lung 

bypass to get him back to England. Today he is out of the hospital 

and back to a normal life in Birmingham, England. 

You may have seen or heard recent national news reports about 

an amazing operation that took place last month at the Craig Joint 

Theater Hospital at Bagram. Air Force Major Dr. John Bini is a 

seasoned theater hospital trauma surgeon, stationed in Wilfred 

Hall Medical Center, who is deployed to Bagram. When the radiologist discovered a live explosive round in an Afghan patient’s head, 

Major Bini and his anesthesiologist, Dr. Jeffrey Rengold, put on 

body armor and went to work. They evacuated the operating room 

(OR), leaving only themselves and a bomb technician with the patient, because any electrical equipment could detonate the round. 

They turned to manual blood pressure cuffs and battery-operated 

heart monitor. Counting drips per minute they administered anesthesia the old-fashioned way. Dr. Bini operated and, within 10 minutes, removed the live round. Miraculously, the patient has been 

discharged, and is recovering, able to walk, talk, and feed himself. 

Dr. Bini told the New York Times that technically it wasn’t a 

very complicated procedure; it is just something we train for, although it is a very uncommon event. 

In short, this is what Air Force and Army medics, along with 

Navy corpsmen, are all about. We are trained and ready as a team 

to meet the mission wherever, whenever, and however needed, with 

cutting-edge techniques and equipment, or the most basic of resources if this is our only option. We have the lowest died-ofwounds rate in history because of well-trained, highly skilled, and 

extraordinary people. 

Our country should be very proud of our men and women who 

put service before self and demonstrate excellence in all we do. We 
12 

deeply appreciate all you do to ensure we recruit and retain these 

very special medics who are devoted to providing trusted care anywhere. We could not achieve our goals of better readiness, better 

health, better care, and best value, for our heroes and their families, without your support. Thank you. 

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

Appendix on page 96.] 

Mrs. DAVIS. Thank you very much, to all of you, and for all the 

programs that you have highlighted. We know that there are men 

and women behind you that are really performing extraordinary 

feats and have used their education and their experience to work 

on behalf of the men and women who are serving, and we are certainly very grateful for that. 

I wanted Dr. Rice to just pick up with one of the provisions that 

the National Defense Authorizations Act (NDAA) from 2010, section 721, which basically spoke to the study, and a plan to improve 

military health-care requirement interim response by the end, actually, of this week. I am just wondering if you know what the status of that response is, whether it is being prepared, sort of what 

strategic evaluation and planning has gone into that report. 

Dr. RICE. Madam Chair, I would be happy to get back to you 

with the details. It is my understanding that the draft is well underway. Obviously we need to coordinate it with the services who 

deliver the care, but we anticipate having the report in very shortly. 

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

page 117.] 

Mrs. DAVIS. Thank you. We will be looking forward to that. 

In your remarks you mentioned transformative medical care. I 

wonder if you could—we have heard, certainly from all of you to 

some extent, on medical homes and more healing communities, 

issues of that sort, of that kind of transformative look that we are 

trying to gain, I think, some real progress in today. Is that something that you expect out of the report? And if you could detail for 

us a little bit more about what is that kind of transformative care 

that you have in mind, rather than perhaps something that I would 

think that we are talking about here. 

Dr. RICE. Well, as you are well aware from the discussions that 

the Congress has had for the past year, wrestling with the issues 

of the delivery of health care while controlling costs and ensuring 

quality is a challenge for the nation as a whole. The military health 

care system is not isolated or insulated from that. 

As you are aware, we are close to concluding the award of the 

third-generation TRICARE contracts. Working with Rear Admiral 

Hunter, the Deputy Director of the TRICARE Management Activity, we have begun discussions on what the fourth generation of 

TRICARE contracts should look like, so that we work with our purchase care contract support organizations to incentivize individual 

patients to take responsibility for maintaining and improving their 

own health and working both within the direct care system as well 

as in the purchase care system for making care more efficient, 

more patient-centered, and more successful. 

As you may be aware, the Department has adopted, with permission from the Institute for Health Care Improvement, who devel-
13 

oped what they refer to as the ‘‘triple aim,’’ we have modified that 

slightly for the ‘‘quadruple aim,’’ the four aims that are the experience of care, the quality and safety, an emphasis on population 

health, doing the very best you can to make care safe, efficient, and 

cost-effective and all of those surround our core mission which all 

three of the Surgeons General have alluded to, which is readiness—our responsibility to provide a medically ready force and a 

ready medical force. 

We have just begun those conversations on what the fourth-generation TRICARE contracts will entail, what the underlying philosophy is, and I look forward to coming back to report back to you 

and seek your guidance on ways that we should be thinking about. 

Mrs. DAVIS. When do you anticipate that the contracts would be 

awarded? 

Dr. RICE. We expect it to be imminent. As the committee is undoubtedly aware, there were protests in two of the regions that 

were upheld by the General Accounting Office (GAO). The contracting officer has agreed with the GAO’s findings, and we are 

now refining exactly how we will resolve those conflicts. The discussions of that are ongoing within the Department and we hope 

that we will have that issue resolved very shortly. 

Mrs. DAVIS. Thank you very much. 

I am going to come back later. I am just thinking about this split 

of direct cost and essentially bought care. Today we are looking at 

33 percent, 67 percent. Do you think that is the right mix? Where 

do we want to be in five years from now in terms of that breakdown? 

I will come back and let my colleague speak, but that would be 

something that I would like to explore. 

Mr. Wilson. 

Mr. WILSON. Thank you, Madam Chairwoman. Again, thank all 

of you for your service. All of us are concerned, facing an asymmetric enemy that seems to have zero morality in terms of attacking military civilians. We are so concerned about the post-traumatic stress disorder, mental health issues. And I want to thank 

you, General Schoomaker, for your information about traumatic 

brain injury. This is just so helpful and positive. 

Yesterday in a hearing we were discussing a concern that I know 

that you have, too, and what can be done; and that is to determine 

for pre-deployment neurocognitive baseline, and also then to have 

a post-deployment assessment. 

For any of who would like to answer that, what is being done 

and how effective do you feel this is? 

General SCHOOMAKER. Well, I will take that on, sir. I would say 

right now the screening for neurocognitive problems as a tool or as 

an instrument for getting both baselines and post-appointment is 

fraught with problems. One of the tools that we first turned to that 

was jointly developed between the University of Oklahoma and the 

Army was the Automated Neurocognitive Assessment Model, 

ANAM. ANAM was never designed as a screening tool. It is designed as a prospective ongoing evaluation of neurocognition to see 

improvements for people who have neurocognitive problems from 

all causes, not just concussive injury or more severe forms of brain 

injury. 
14 

And when we have looked at this—in fact I sent a team down 

range over a year ago to look in a very careful way at cohorts of 

known concussed soldiers in combat, non-concussed but ill soldiers 

from other causes, and then soldiers without any problems whatsoever either from concussion or from other illnesses, and discovered 

in that cohort controlled study, conducted by neurologists and scientists, that the ANAM as a screening tool was basically a coin 

flip. We would call it an insensitive and nonspecific test, both for 

non-concussed soldiers as well as for soldiers who received concussion. 

So we have turned away from ANAM as a simple screening tool. 

It still has utility for following longitudinally patients who might 

have, or soldiers who might have been concussed, but it is not a 

screen. What we have turned to is what we do every day on sports 

fields in this country, or following motor vehicle accidents or anything else. If we suspect a soldier, or Marine, or sailor, or airman 

has had a concussion, we evaluate them at the moment of the concussion, as quickly as we can, and safely. That is what is in that 

packet there, sir. 

Mr. WILSON. I looked at it, and this looks very positive, but it 

is just obviously is a concern that I have that was expressed yesterday. And you are right; whether it be sports or auto accidents, that 

is where military medicine is leading the way with prosthetics. I 

am counting on you all on what can be done for pre-deployment, 

post-deployment. 

Another concern I have has been with the Walter Reed National 

Medical Center, which is to be concluded September 2011; and that 

is, will the wounded warrior facilities be adequate and will they be 

contracted out? Are we really prepared? I know Admiral Robinson 

used to have a lot of hair until this issue came up, but what is the 

status of development? 

Admiral ROBINSON. Representative Wilson, the status of development is that the Navy, the Army, the Air Force, Joint Task Force 

(JTF) CapMed, are meeting and developing plans for wounded warriors. I will speak for the National Naval Medical Center—to become the Walter Reed National Military Medical Center. We have 

gone through a long series of discussions and talks. There will be 

350 wounded warriors coming to the National Naval Medical Center, Walter Reed National Naval Medical Center, with their requisite nonmedical attendants and family members, and also with 

the requisite staff of individuals that will help care for them in 

terms of all of the personnel and other issues that men and women 

in the military need to have. So that number will be 350-plus and 

there will be a tail with that number. 

I think that if you look at the average daily census of Walter 

Reed and Bethesda in terms of their outpatient wounded warriors 

now, I think you will note there is probably a deficit of some number, between the 350 that I know about and the rest in the National Capital Area. And with that in mind, I think that the JTF 

CapMed and the services need to make sure that we have a comprehensive plan for whatever that delta may be for those wounded 

warriors and how they may be in fact cared for in the NCA, National Capital Area. 
15 

I think that includes—and during discussions last week that will 

include several other bases in the area, such as Fort Meade. That 

may include Fort Belvoir. That will include other areas, and that 

may include also some reconnoitering of the spaces that we have 

at National Naval Medical Center, so we may have to do something 

a little different there, too. But there is a deficit of knowledge regarding that delta of wounded warriors in the National Capital 

Area. 

Mr. WILSON. I appreciate your efforts. Thank you, Madam Chairwoman. 

Mrs. DAVIS. Thank you. Dr. Snyder. 

Dr. SNYDER. Thank you. And thank you, gentlemen, for being 

here. Mr. Wilson’s opening statement made a comment that there 

is nothing routine about you all’s jobs and about military health 

care, and we appreciate you all trying to stay ahead of changes 

that occur in the lives of men and women in uniform and their 

families. 

Dr. Schoomaker, in the information that you handed out, give me 

the 10-second summary, why are over-the-counter pain medicines 

like Ibuprofen not recommended for treatment of mild headache associated with concussion? 

General SCHOOMAKER. We are very concerned about the use of 

non-steriodals and aspirin in theater, which would interfere with 

small-vessel blood clotting—— 

Dr. SNYDER. Okay. 

General SCHOOMAKER [continuing]. When you are at risk for a 

concussive injury or something that may require a robust clotting 

system. So we recommend that soldiers going down range suspend 

the use of aspirin and the non-steroidals. 

Dr. SNYDER. That makes sense to me. 

Same thing, Doctor. I had this discussion yesterday, and I want 

to ask you, and it is the issue of—I guess I will say the moderately 

severe traumatic brain injury patients. I am talking about the 

group of people that may have been in your rehabilitation facility 

for several months, have reached the point at which we think there 

is probably the steady state, but it becomes apparent to the caretakers and the medical team that they are probably going to need 

to be in a facility that watches them. 

I think in the olden days we called it a domiciliary. They may 

not be able to handle meals or they get lost, a fairly significant injury, but still walk around. Maybe they will do some work under 

their facility. 

How do you handle those kinds of folks as time reaches for them 

to be discharged from the military? How do we make sure that they 

are immediately transferred to a place in which we won’t lose them 

for an hour, a day, or a week, or a month while we are trying to 

find a proper placement for them? Is that an issue that you are 

having to deal with? 

General SCHOOMAKER. Yes, sir. I would explain that, beyond 

moderate brain injury, I would talk about anyone who had a lingering or an enduring problem. I think Admiral Robinson talks 

about this passionately in every forum we get to. We are into an 

era in which we are going to have an enduring requirement to care 
16 

for these soldiers and to assist their families for decades and decades to come. 

We have been intimately involved with the Veterans Administration since the end of the Vietnam War where the Defense Veterans 

Brain Injury Program, which has a network of certified centers 

that are community-based, such as you described, for assisting soldiers with moderate brain injury problems, but for rehabilitation 

and for assisting them in daily living requirements and location. 

But by extension, anyone who has an enduring physical or behavioral health problem, we partner very closely with the Veterans Administration. Our warrior transition units have veterans, counselors, embedded within them. And we have a program through the 

Army Wounded Warrior Program, any soldier with 30 percent disability or greater, with coordination of their care that goes into the 

Veterans Affairs system and beyond. 

So there is a very, very warm handshake now being conducted 

both into the VA system, as well as other private sector care that 

is required for these kinds of patients and patients who have other 

disabilities beyond just brain injury. 

Dr. SNYDER. Dr. Rice, in your written statement I think you refer 

to the fact that we still have—I don’t know if you said too high— 

but too high levels of smoking amongst our men and women in uniform. You also talk about the fact of the retiree issue we will be 

taking care of in terms of health care expenses for we hope decades 

and decades to come, when they live long, long lives of being productive Americans after a military career. The reality is the expenses for our country and their quality of life will not do well if 

they are smoking as young people in the military. 

Now, if we can’t get that under control, in the controlled situation of the military, I just don’t see how we are going to do it. Why 

are we lagging behind on that? 

Dr. RICE. Well, it is a complex issue. As you know, there was an 

Institute of Medicine Report in 2009 that talked about controlling 

tobacco use in the DOD and in the VA. The Department has been 

evaluating that very carefully to see which things the Department 

can enact and undertake on its own and those things for which it 

may need assistance from the Congress. 

The Navy—Admiral Robinson can correct me if I misstate this— 

but the Navy has already eliminated tobacco products from its commissaries. The Army and Air Force have yet to take that step. But 

we still have pricing for tobacco products in the military exchanges 

that are below the comparable civilian market. That is one factor. 

I think by far the most important factor has to do with role modeling for young men and women. Basic training is already a tobacco-free environment. But as soldiers, sailors, airmen, and Marines transition to their first assignments and they see older, particularly non-commissioned officers, who smoke and, by implication, are led to believe that it is okay for them. 

As you know, nicotine, tobacco products, are viciously addictive 

and the Department has—or the Military Health Care System has 

developed a number of smoking cessation programs, so that we 

work very hard to get people to stop smoking. This is an effort that 

will continue for years to come. As I say, there are some areas in 

which we may need your assistance. 
17 

Dr. SNYDER. Are you going to let us know what those areas are? 

Dr. RICE. Yes, sir. 

Dr. SNYDER. I thank the gentleman. 

Mrs. DAVIS. Mr. Fleming. 

Dr. FLEMING. I thank you, Madam Chairwoman. 

Well, first of all let me say to Admiral Robinson, I was a physician in the Navy some years ago, and served in three stations, enjoyed that, and certainly looked fondly upon those days, certainly 

in uniform. And then certainly for General Schoomaker and for Admiral Robinson. 

I have toured and visited with the wounded warriors at Walter 

Reed and Bethesda, and I am extremely impressed with the facilities there. You all are taking real good care of our wounded warriors. I appreciate that. I am even more impressed with the warriors themselves, the true warrior spirit. They don’t talk about 

what their service-connected disability will be or what their pension is going to be. I am sure it is appropriate at some point in 

time or in the future that they will explore that. What they talk 

about, which inspires me, is when they are going to get back to 

duty and how they are going to get back to duty, what they are 

going to do, and what is the best way to do that. So I am extremely 

impressed with that. 

Now for some questions. Dr. Rice, I have two major military installations in my district: Barksdale Air Force Base and Fort Polk 

Army post. I am finding in our area that the reimbursement to 

physicians through TRICARE is oftentimes slow and low, and that 

creates an access issue. It doesn’t seem to be quite as much a problem at Barksdale, because it is near a very large, or certainly a medium-size city where there are many physicians in the private marketplace to choose from. But in a more rural area like Leesville, 

Louisiana, there are some limitations. 

So I want to know, as we move forward with new contracts, is 

that being addressed and how is it being addressed? 

Dr. RICE. Dr. Fleming, as you know, the reimbursement level for 

TRICARE is tied to Medicare rates. And so by law, that has where 

that is. I am a little surprised and disappointed to hear that perception among the providers is that we are slow to pay. We have 

always prided ourselves on turning around payments very promptly. So if there is some specific information that you have, I would 

really be eager to look into that to see if we have a systemic problem that we need to fix. That is not the Department’s policy. 

Dr. FLEMING. That is more of a perception from history, not necessarily new information. When you say it is tied to Medicare, are 

you saying it is exactly the same for the same evaluation and management (E&M) codes or the same procedural codes? Or you are 

saying it is a percent above or a percent less than Medicare reimbursement? 

Dr. RICE. I have to check that to make sure, but I believe that 

it is at the same level as Medicare. 

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

page 117.] 

Dr. FLEMING. Okay, great. 

And certainly for the panel at large, if you can answer this, I am 

very interested in the electronic medical records. I think that is a 
18 

very important thing going forward, particularly in terms of quality 

of care and the special need for continuity of care when you have 

a worldwide mission such as our military does. 

Also, the interactivity or, if you will, the ‘‘interfacement’’ with the 

VA system. There have been some problems. I am told about the 

slowness of performance; that is, when you are connecting on the 

Internet and getting records, information exchanging, sometimes 

that can be so slow as to be impractical. 

There have been some difficulties with the VA and the active 

duty military systems talking to one another. Can you bring me up 

to date on that? 

Dr. RICE. Yes, sir. As you know, the implementation of an electronic health record is an extremely complex undertaking. Through 

my civilian academic career, I implemented two intensive care 

unit-based electronic records and two hospital-based, and I swore 

I would never do that again, but here I am. 

There are two or three challenges. First, with respect to response 

time, as you and Dr. Snyder know, we as physicians will sit down 

with a medical chart and spend 15 minutes going through to find 

the consultation report or the laboratory result that we want. But 

let the computer screen sit blank for five seconds, and our perception is it is slow. 

With that said, there is no question that performance and stability are key issues. Security and scalability are also important 

issues. We are having an intense effort inside the Department now 

to examine the underlying architecture for the electronic health 

record. Then we need to make sure that we build applications that 

sit on top of that underlying architecture so that they work for the 

clinicians. Whether it is the nurses, the physicians, the physical 

therapists, the pharmacists, whatever, it has to work for them. If 

it does not work for the clinicians, it is not going to work. 

I think that is a challenge that we have faced by using a system 

that was originally developed for other purposes and trying to challenge it towards use as an electronic health record. So it is a subject we are actively and vigorously pursuing and hope to have a 

very clear vector ahead very shortly. 

Dr. FLEMING. Thank you, I yield back. 

Mrs. DAVIS. Thank you. Ms. Shea-Porter. 

Ms. SHEA-PORTER. Thank you, and thank you all for being here 

and for the service you are providing our military men and women. 

I have had great concerns about the open-air burn pits. And so I 

wanted to ask you, Dr. Rice, because you did put in your testimony 

the responsibility for public health for the military. You said they 

have been there for eight years. And I have received a lot of information over the past year or so about the impact and how soldiers 

have talked about it and complained about it and gone to healthcare clinics and are showing up with skin diseases, blood diseases, 

neurological problems, et cetera. 

And so I know we have worked on it, we have got something into 

the last NDA authorization and will continue to do that. But it is 

a puzzle to me about how this could have gone on for so long. I 

would just ask you if you would tell me, has this been something 

that has been an issue for all of you and has it been discussed? 

And are you keeping the records that you need for these men and 
19 

women when they return from service and for the next years of 

their lives, so we can determine if we have had problems with them 

because of their exposure? 

Dr. RICE. Thank you for that question. The environmental impact of burn pits and its impact on our service men and women has 

been a source of concern. Let me ask General Schoomaker. I think 

your Public Health Command has taken a keen interest in that 

problem and has been tracking, which happens; is that right? 

General SCHOOMAKER. That is right. We have a Public Health 

Command, previously known as the Center for Health Promotion 

and Preventive Medicine, and the Veterinarian Command now 

have been combining Army Medicine into a single Public Health 

Command. Brigadier General Tim Adams commands that and has 

subject matter experts who have been tracking all of the topics that 

you have described ma’am. And we can take that question for the 

record and give you a more detail accounting of the burn pits. 

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

page 117.] 

Ms. SHEA-PORTER. Well, I know it is the acknowledgment now 

that this could be playing a factor in the health problems that some 

of the service men and women are experiencing. But my concern 

here is, is there an integrated approach and are we moving fast 

enough to find ways to substitute some of the products that are 

being burned in the pits? 

For example, we do know that we are still burning the plastics 

openly, and we could use recyclable materials in the kitchens which 

are producing a great deal of the plastic refuse each day. So can 

you step it up? And who are you working with? I know your field 

is medical, but are you talking to others who are responsible for 

what is being brought onto the base and how it is being disposed 

of? Are you fully engaged, in other words, because eight years is 

a long time and some of our soldiers have been exposed twice, 

three, and four times to this. 

General SCHOOMAKER. Well, ma’am, certainly there is a good 

linkage between public health monitoring and all the services and 

the operational commanders, specifics about the items you just 

talked about. I can’t speak with any real knowledge about that, 

but, again, I am more than happy to take that question for the 

record and give you a detailed accounting to tell you what we have 

done to coordinate with the in-theater operators. 

Ms. SHEA-PORTER. I thank you, General, and I am not trying to 

trap you. I am just trying to nudge everybody to get this taken care 

of as quickly as possible. Thank you, I yield back. 

Mrs. DAVIS. Thank you. Ms. Tsongas. 

Ms. TSONGAS. Thank you all for your testimony. I appreciate the 

extraordinary range of issues that you have to contend with for our 

young soldiers, and I appreciate the efforts that you are putting 

into it. 

I would like to ask a slightly different question, an outgrowth of 

Defense Authorization Bill. As we were leading into it, we were 

hearing that we needed to extend Reserve component access to 

early eligibility TRICARE from 90 to 180 days prior to mobilization. I think this was an issue that had been around for some time, 

and the purpose, obviously, being to allow service members with 
20 

treatable medical conditions access to TRICARE services earlier, in 

order to decrease the number of medically non-deployable service 

members. 

Can you all explain the implementation plan for providing Reserve component access—to try earlier access to TRICARE services 

in order to meet the provisions of last year’s Defense Authorization 

Bill? 

Dr. RICE. Yes, ma’am. I would be happy to tackle the first part 

of that question and then ask my colleagues to amplify. 

The Assistant Secretary of Defense for Reserve Affairs has the 

lead on implementing the statutory change, because it is primarily 

the determination of eligibility. So Reserve Affairs is now preparing 

the DOD policy and the functional requirements for the system 

changes have already been developed. So once the personnel have 

established the eligibility for reservists and updated the Dependent 

Eligibility Enrollment Reporting System (DEERS) system, the eligibility recording system, then any DEERS-eligible member who 

presents for care in the military health care system is provided 

that care. 

General SCHOOMAKER. Ma’am, I will just reinforce that to say the 

Army is very, very reliant on its Reserve, National Guard, and the 

United States Army Reserve for the conduct of the present conflict. 

At any one time, tens of thousands of our Reserve component soldiers were mobilized for deployment. And one of the important 

things in eliminating steps in getting Reserve component soldiers 

ready to be deployed is medical and dental readiness. We know 

that there are several factors involved in that identification of problems that need to be reversed in the dental and medical arena. A 

medical problem that may have a solution before a soldier can be 

deployed or a dental problem that needs some time for fixing, we 

find that. 

For a large portion of the Reserve component who may not have 

health insurance is a consequence of their employment or maybe 

for students don’t have programs available. This is an important 

incentive for them to be engaged in their Reserves, and it allows 

us the time necessary to get them fixed before they can go out the 

door. 

So, to my knowledge, the program is being implemented and is 

felt to be a very important adjunct to using the Reserves, as they 

are being used in the Army today, as an operational reserve rather 

than a strategic reserve, held only back for the most nation-threatening advance. We currently use them as a very active part of the 

force. 

Admiral ROBINSON. Ditto, from what has been said earlier from 

the Navy perspective. In addition, as the service member—the Reserve component service member is transitioning back to the private sector, whatever injuries and illnesses that that individual 

may have sustained will be evaluated before they are discharged. 

So the service member will stay on the active roles until we understand what the medical or condition is. 

From a family point of view, or from the service member 

transitioning and being able to utilize the TRICARE benefit for the 

180 days, that can certainly be given, too. But my point is, if at 

180 days there is not an adjudication, there is not some determina-
21 

tion of that, then the service member stays and is fully cared for 

until we can come up with that. 

Obviously, the issue is for those people who we say, We think we 

have the answer, but the service member says, I don’t think you 

have the answer yet—and there are a few people that fall under 

that category—we usually default—from the Navy and from our 

point of view, I default towards the service member and the care. 

So we usually back off until we thoroughly understand what the 

issue is. So we care for those individuals until we have a determination of what is in fact happening. 

General GREEN. And the Air Force has exactly that same program. We keep people who have medical conditions on active duty 

until we have resolved what is going on, and then have a transition 

assistance management program (TAMP) that allows them up to 

six months post-release from deployment, if they need that. 

Your specific question, however, is with regards to 180 days 

prior. We have tremendous volunteerism in our Guard and Reserve, and actually get great volunteers to serve. I am not as aware 

of the 180 days prior, and I am not certain that we have the full 

guidance yet to establish eligibility for that, so I am going to have 

to take that for the record and get back to you. 

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

page 118.] 

Ms. TSONGAS. Well, thank you all for your testimony. I know that 

we heard about this issue. I have heard about it quite frequently, 

and am also hearing that it is not being implemented as quickly 

as we might have wished. And so I look forward to hearing a little 

more about your plans to move it forward. Thank you. 

Mrs. DAVIS. Thank you. Mr. Heinrich. 

Mr. HEINRICH. Thank you, Chairwoman. And first I want to 

thank Chairwoman Davis and the members of the committee for allowing me to be here today. 

Dr. Rice and Surgeons General, as Chairwoman Davis mentioned 

a little bit ago, I recently introduced H.R. 4923, the TRICARE Dependent Coverage Extension Act. And if this legislation were to 

pass, it would allow our service men and women the opportunity 

to provide uninterrupted health care coverage to their children 

until the age of 26. This is the same opportunity that has been 

granted to civilians under the recently passed health-care reform 

legislation that was signed into law last month. And I was hoping 

that each of you might be able to give me your thoughts on this 

proposal, and also let me know if the Department of Defense is considering taking any action similar to this legislation that would 

bring their policies in line with what is now law for civilians. 

Dr. RICE. Thank you, Mr. Heinrich. We are well aware of the introduction of H.R. 4923, and have begun thinking through how we 

would implement it if it becomes law. We do not believe that the 

Department has statutory authority to extend eligibility up to age 

26, absent a change in the law. But if it does become law, we have 

made preliminary estimates about the number of potential enrollees and the estimated average annual cost for those enrollees. 

Mr. HEINRICH. Well, I look forward to getting together with you 

as well on some of those numbers, because that would be very helpful for us as well. 
22 

Are there any other instances that any of you have found, where 

the rest of the country will have benefits now that are incongruous 

or inconsistent with what you provide currently under the 

TRICARE system? 

Dr. RICE. No, sir. I am not aware of any others. 

Mr. HEINRICH. Thank you very much. I yield back. 

Mrs. DAVIS. Thank you. I wanted to go back to my question at 

the end of the first round and just ask, you know, as we look to 

the future and we are looking at what makes the best sense for our 

military health care system, what do you think that mix should be? 

There is always an ideal. But what is reasonable? Where should we 

be headed? 

Dr. RICE. Well, my own view—— 

Mrs. DAVIS. Or stay where we are? 

Dr. RICE. My own view is, as you identified in your opening comments, the purchase care system was originally intended to fill 

gaps. And the direct care system, I think many of our beneficiaries, 

if the system is convenient and accessible to them, many of our 

beneficiaries clearly prefer to be cared for in the direct care system. 

The challenge, as you pointed out, has been that during this eight 

year conflict, their primary care providers are deployed or transferred. And our primary focus has to be on the active duty service 

members. 

The question of what is the right mix is an intriguing one and 

can be looked at, in my view, from two or three different perspectives. One is, are we thinking about this from a cost perspective? 

The other is, are we thinking about this from the desire of the beneficiary population, where they would most likely be seen? And the 

third aspect that has to be considered is, what is the right mix for 

the training and education of the next generation of active duty— 

of military providers, whether nurses or physicians. I am not sure 

there is a single right answer. There is probably an optimum answer. It is one of the things that we hope to influence. I am not 

sure that we can control it, but we certainly hope to influence it 

with the next generation of TRICARE contracts. 

General SCHOOMAKER. I think we all have pretty strong feelings 

about this, so I will be as brief as I can. But I think this is one 

of the central issues that we are all struggling with. And I would 

point to the recent Military Health System Conference that was 

conducted in January, in which all three of us and Dr. Rice’s predecessor, Ellen Embrey, spoke; and we brought in national experts 

like Don Berwick, and Jack Wenberg, and John Cortezy and others 

to talk about the challenges that we face not just in the military 

health care system, but in the country at large. 

And I think that what we in the military are focusing upon are 

some of the central themes in a real health-care reform package, 

which is evidence-based practices, which is looking at outcomes of 

care rather than just processes of care. 

And I alluded earlier in my comments to an effort that we have 

undertaken now into its, probably, fifth or sixth year within Army 

Medicine, pioneered it in the southeast, of a performance-based 

budget program that links incentives to outcomes of care, evidencebased practices, and improvements in Healthcare Effectiveness 

Data and Information Set (HEDIS) measures, the measures of pop-
23 

ulation health, individual health, and compliance with evidencebased practices for such things as diabetes and asthma and the 

like. And this has shown very positive results. I think that is one 

that has got to be a major part of the centerpiece of what we do. 

We also, I think, universally agree that we need a very robust 

TRICARE system that is centered around a primary care-based 

system of the patient- and family-centered medical home process 

that gives continuity, it gives a site for tailorable, individuated 

care, and controls the hemorrhage or leak of care into the network. 

We have got to look very carefully at where that cost is coming 

from. 

Frankly, Army Medicine over the last several years has created 

more capacity. In the last year and a half or so, we have conducted 

about 1 million additional appointments. And we are continuing to 

bring more people into the direct care system run by the uniformed 

side. The problem that we have is that growth, especially in the 

white space between large installations and large metropolitan centers where we have a very robust system of health care for the direct care system, demand in that white space is increasing as we 

use Reserves more and as our TRICARE for Life program grows. 

So we are working very hard, internal to the services, to accommodate more and provide greater capacity. And I think we all agree 

very much that maintaining a very robust direct care system is one 

of the centerpieces based upon real reform of the health care. 

Mrs. DAVIS. Thank you. 

Admiral ROBINSON. I think that what Dr. Rice and General 

Schoomaker said is right. I am going to come back to the private 

sector care and the direct care. It is 67 and 33 percent respectively. 

I think that the problem is, to some extent, that there is a wall 

between the two care systems. The problem is that there is the direct care system and the private sector care system that TRICARE 

Management Activity (TMA) helps to build through our networks, 

and the network providers do an excellent job, but we are separated. We need a care system in which the direct care, the uniformed services are directly aided by the private sector care. They 

are actually a part of our system. And we can utilize them not only 

around our medical centers and hospitals, but in the white spaces, 

too. And the white space is the one area that is harder to get to, 

so I recognize that private sector care may be the method. 

We can still do a lot with the private sector care and how we 

process TRICARE, the types of forms that we use. If we could 

standardize in terms of, you know, a military medical health care 

formed by the different forms that we use. 

But I will get back to this to only say that the direct care system 

and the private sector care system are separate now in the sense 

that the monies that go into private sector care must pay bills from 

the health affairs perspective. I don’t disagree with that. But there 

is not a lash-up between the two systems that really help us provide the care that we need. I think that is the biggest thing that 

the new contracts—and I am thinking in terms of the T–4—could 

possibly do that would be revolutionary, in my opinion, for military 

medicine. 

Mrs. DAVIS. General Green, did you want to add anything? 
24 

General GREEN. I would. Actually, the reality of our situation is 

we are the most distributed system of any, with 75 bases and about 

80 clinics out there. As medicine has changed over the years and 

we have seen higher technology and, therefore, larger populations 

in order to support different specialties, what we have seen is we 

couldn’t always maintain hospitals in these small areas. Average 

wing for us is about 6,000 people, with families maybe 12,000 to 

15,000. It is very difficult to support specialty mix. 

And so the TRICARE contractors in those areas where we have 

small populations are really the only way to seek that care. In 

other areas where we have larger populations and where we have 

military bases with hospitals, I would love for us to get 100 percent 

of that care. And that is what Admiral Robinson is talking to, 

where we try to bring some of the people who are in surrounding 

areas to our facilities. 

I think that it is unreasonable for us to think that we would ever 

be able to provide primary care perhaps to 100 percent of that population, but there are ways that we can reduce federal costs by 

working arrangements with HMOs, with the VA, even with university partners, wherein either we bring our patients back to our facilities if we are in the area, or, in many cases we take our professionals and work in their facilities so that we can actually maintain 

skills and be ready for wartime missions. 

And so I guess I would tell you that it is a mix. In places where 

we are in rural settings, we really rely on the TRICARE contractors and the network. And so the mix is going to be different. In 

places where we have hospitals, we should be trying to bring everything that we possibly can back into the hospital to maintain currency. So my goal would be in larger population centers where we 

have hospitals, to gain 100 percent of the market; and in places 

where we have clinics, the mix that you described may be real. 

Mrs. DAVIS. I appreciate all of your responses. What is obviously 

important here is that people are working hard, focusing on this 

and really trying to address it. And the other reality, of course, is 

there are a lot of other things people are working on. And we need 

to look to the Defense Military Affairs and figure out whether we 

have got the people there that are trying to address these issues. 

And one of the concerns that I think we have is that there haven’t 

been the kind of political appointees that are there in place, nor are 

the nominations there. 

And I would think that that is a vital part of what we are talking 

about and that we do need to get moving with those. Dr. Rice. 

Dr. RICE. I agree with that. 

Mrs. DAVIS. I know you do. Do you have any suggestions? We are 

open. We are certainly interested. Mr. Wilson. 

Mr. WILSON. In fact, Dr. Rice, with all the hats you are wearing, 

back to your TRICARE hat. My understanding, the number of reservists who have taken advantage of TRICARE Reserve Select, 

TRS, is lower than the Department of Defense anticipated. 

What factors have contributed to the low take rate? What actions 

has DOD taken to make the program more attractive? Are members of the Reserves, who may want to enroll in TRICARE Reserve 

Select, having difficulty finding TRICARE standard providers? 
25 

Dr. RICE. Let me defer to my colleague, General Schoomaker, 

who has insight on that. 

General SCHOOMAKER. Yes, sir. I can answer that. You are right; 

we are seeing, overall, a rate of use in the Army of TRICARE Reserve Select of only about six percent or so. But it is growing very 

quickly. And in part, it is based upon the observation that those 

that don’t have a health-care program, we have been quite reluctant to impose a requirement that they maintain medical readiness 

as a condition of their employment, even though it is, in the Army 

regulation, already there. 

In other words, if you are in the Reserves, we expect you to be 

dentally and medically ready to be deployed. In the past, because 

we could not offer good programs necessarily, or couldn’t require 

someone who may not have an employment health plan—or maybe 

a student, or be unemployed—to have a plan to cover them, commanders were very reluctant on the Reserve side to impose or hold 

them to that standard. 

I think with the TRICARE Reserve Select program, which is very 

robustly supported by the military and by Health Affairs, and now 

with the growing availability of plans under health-care reform and 

the like, we are putting teeth into that. And I think you will see 

a growing use of TRICARE Reserve Select as we hold soldiers, appropriately, to the requirement that they be medically fit. 

Without abusing my executive privilege here, I just want to respond to one last thing on this last item, because we are also passionate about what we can do to sustain this program that we 

have. We have a very high-quality program. 

To answer Mr. Heinrich’s question earlier, I don’t see us having 

a lesser plan. I think we have a superior plan to the average American right now, and we all want to sustain this. But I think historically what we have focused on is business rules to control costs, 

and most of us now I think feel very firmly that what we have to 

focus on is good clinical practices and outcomes. And if we focus on 

that, the cost will be stabilized and possibly even be reduced. 

Mr. WILSON. And I want to indeed thank you. I can remember 

during the debate that we had in the Education and Labor Committee, that as I was working for an amendment to preserve and 

protect TRICARE, it was brought to my attention—and I can remember very well the organization, it was called the Wilson Institute, and that they had done a study of satisfaction by persons 

with their health insurance policies, and TRICARE for 9.2 million 

was at the tops. And of course, I will never forget the Wilson Institute. I was unjustly accused, Madam Chair, of making up an organization, but it actually exists. 

Dr. Rice, again, or whoever, the Department of Defense has esti- mated the resulting savings would be $12 billion, fiscal years 2010 

to 2015, by obtaining federal pricing discounts for TRICARE prescriptions dispensed by retail pharmacies. 

Is DOD on track to obtain these estimated savings? Are all drug 

manufacturers complying with requirements? What steps are underway to ensure that the required federal pricing discounts are 

obtained? 

Dr. RICE. Mr. Wilson, we are on track to realize that outcome. 

There is still—I think I have this right, and if not, I will certainly 
26 

correct it. I believe there is still a pending appeal, but the actions 

taken thus far have indicated that the drug manufacturers are prepared to comply with the federal pricing, and we anticipate realizing those savings. 

Mr. WILSON. It is good to hear something is on track. And in regard to TRICARE in general, any way that I and our subcommittee 

can be of assistance, we want to work with you. Thank you. 

Dr. RICE. Thank you, sir. 

Mrs. DAVIS. Thank you very much. Thank you, Mr. Wilson. And 

perhaps I will just go back to one of the questions he raised earlier. 

Do you think there is any confusion or discomfort believing that 

perhaps the Secretary of Defense is not in charge of Military 

Health Affairs? Do you have any? 

Dr. RICE. I don’t think so. I think Secretary Gates has it pretty 

clearly in his mind that he is. And I certainly have seen some correspondence from Secretary Sebelius where she has indicated that 

management of the Defense Health Program is under the supervision of the Secretary. 

Mrs. DAVIS. Because I know that has been raised in other circles 

as well, and I appreciate Mr. Wilson raising it. 

If I could, just quickly, I know we are going to have votes in a 

few minutes. The budget was characterized as being fully funded. 

And if I could go to you first perhaps, General Green, is that an 

accurate statement from your vantage point? 

General GREEN. Yes, it is an accurate statement. We are in very 

good shape for 2011. 

Mrs. DAVIS. Admiral Robinson. 

Admiral ROBINSON. Yes. Navy Medicine is fully funded. 

General SCHOOMAKER. Yes, ma’am. Nothing crossed. 

Mrs. DAVIS. You don’t have another list out there somewhere? 

Okay. 

One of the numbers that jumped out at me was just the research 

and development dollars going down somewhere in the neighborhood of about 61 percent, I believe, partly because there was a reduction in medical research and development (R&D). And I think 

that reflects dollars, $125 million, transfer of research to Defense 

Advanced Research Projects Agency (DARPA). But we don’t really 

see an accompanying increase in DARPA’s program to accommodate that. 

Dr. RICE. Yes, ma’am, I can speak to that. There is a decrement 

of 125 million in the research, development, testing and evaluation 

(RDT&E) priority elements for fiscal year 2010. There were decisions made in the Department in the fall of 2008 which enhanced 

the medical R&D budget by about $375 million a year, with the entire new budget going into the Defense Health Program RDT&E 

budget for fiscal 2010. 

There was an additional Department decision for fiscal 2011 and 

out that was that $125 million of that annual cost was to be contributed by DARPA, but under their control; that is, not transferred from DARPA to DHP, which reduced the new budget burden 

to the Department by 125 million. This would mean that DARPA 

would have to increase their medical RDT&E spending from about 

144 million by an additional 125 for fiscal 2011. And this is a com-
27 

pliance issue that is under that defense development research and 

engineering oversight. 

There is programmatic and regulatory risk when the Defense 

Health Program RDT&E advanced on the portfolio is dependent on 

the science and technology transitions from another agency within 

the Department which is more focused on very high-risk and very 

high-payoff investments. This is under discussion in the Department, but it is that decision that results in the number that you 

cited. 

Mrs. DAVIS. Where would we see the greatest shortfall if somehow this isn’t worked through, and what kind of R&D? Prosthetics? 

Or what kinds of things could that affect? 

Dr. RICE. It is not clear to me, at least at this point. It could be 

in a variety of areas, from basic research to information technology 

research to advanced battlefield efforts. 

Mrs. DAVIS. Okay. Thank you very much. 

Just one follow-up question to earlier discussion about electronic 

records. And the Virtual Lifetime Electronic Record, VLER, was 

announced by Secretaries Gates and Shinseki together that it 

would be this single record. But now I understand that the Department submitted a reprogramming request that would take $42 million from the Defense Health Program to establish the Office of the 

VLER. So why is the Defense Health Program only paying for that? 

Dr. RICE. The VLER is in part an electronic health record, but 

it also in part has to do with personnel records. So that comes outside of the Defense Health Program. 

Mrs. DAVIS. Is there a VA piece to this as well then? 

Dr. RICE. I am sorry? 

Admiral ROBINSON. The VLER piece would be actually—and I 

am probably the least information technology (IT) savvy of this 

group—but there will be a VA piece with this. And the VLER system will work with an electronic health record system, in this instance AHLTA, and with the VA Vista, to hook us to the commercial sector so that we can transpose that record to hospitals that 

are not DOD. So there are several sections that go with this. And 

I can’t tell you much more, but that I do know. 

Mrs. DAVIS. All right. We hope that comes together and that 

works out. 

And I don’t really expect you to answer this in any detail, but 

throughout all of the testimony and through all of the discussions 

that we know in terms of health care nationwide, the concern about 

unmanned positions, any number of specialties, practitioners that 

are needed in this country. Are people thinking out of the box 

about this enough? Because we know that bonuses are a good idea. 

We know that there are recruitment strategies, some of which have 

been very helpful, and I know you addressed that. 

But it also feels as if we have a lot of people in our country who 

would have an interest if we actually did something quite substantive in the country. People may not have agreed with the war 

on poverty, but at that time there were many, many people, myself 

included, who were incentivized to go into helping professions. And 

I am wondering now whether the military plays such a large role 

in this, and particularly among our men and women who are coming back from the war theater and have great, I think, aptitude to 
28 

be able to do this with the right encouragement, there are some 

programs out there. 

Are we spending enough time and effort into trying to really address this problem? 

Dr. RICE. With my other hat on, as president of the university, 

I spend a lot of time thinking about what our health-care system, 

what our health-care workforce is going to look like 15 or 20 years 

from now. 

We have an enormous challenge in the country as a whole, of 

which the military system is just a small part. And that is that the 

science and mathematics and engineering preparation in our middle schools and high schools has not helped focus our young people 

on careers in science and technology. And there are a number of 

misperceptions in students. 

In my previous job at the University of Illinois, I spent a lot of 

time going out and talking to middle school and high school students about careers in health care. And there were three things 

that struck me about what they would say about why they weren’t 

thinking about health care. 

The first is that they viewed us as low tech. And at times I was 

signing very large purchase orders for very expensive pieces of 

equipment. That didn’t resonate quite right to me, but that was 

their perception. 

The second thing is that if you have dealt with teenagers lately, 

you know that they are not interested in hierarchies. And the provision of health care is, at least as currently practiced, hierarchical. 

And the third factor that turned them off was we have schedules. 

And they are not interested in schedules. 

So I think we are going to have to rethink how we deliver health 

care in a pretty dramatic way, exactly as you allude. We are looking at—by the year 2020, it is estimated we will be 1 million 

nurses short of what we will need. And as I get into my old age, 

that becomes more and more of an issue for me. We are looking at 

a substantial shortfall in the number of physicians. And importing 

them from other countries is not the answer. That simply is not an 

ethical or moral approach to solving that problem. So I do think it 

is an issue that we need to spend a lot of time thinking on. 

Mrs. DAVIS. I was just going to mention that in last year’s bill 

there was a provision for undergraduate education and for encouraging more students and scholarships. And I don’t know whether 

that is anything that is moving along. 

General SCHOOMAKER. We have a pretty successful and robust 

program right now that I think is now being very successfully executed. I certainly agree with everything that Dr. Rice—who has a 

very long and distinguished career in medical education and the 

provision of the workforce. 

We are looking at, I think with the increasing number of women 

going into medicine and health professions who want to do job 

sharing, that want to have shifts—and I don’t think it is restricted 

to women only in this perspective—who want to have a career in 

which they can move in and out of the workforce more agilely. We 

are looking at a continuum of care between the active component 

and Reserve component, where you can turn on and turn off that 

kind of a career. 
29 

And, quite frankly, even from my experience among children, you 

have got to begin engaging children who are going into these technical fields, in middle school and sometimes earlier. So programs 

that are engaging earlier and earlier and getting mentor programs 

and the like. 

But I would submit in closing, although this really doesn’t address the problem of the workforce per se, that the real out-of-thebox thinking that we have to adopt in this country—and we are in 

the military—is one that shifts the paradigm from treating disease 

and treating injury after it has occurred, to preventing disease and 

preventing injury. 

I mean at Fort Jackson, South Carolina right now, we pin a hip 

fracture on a young woman, on average, once a week. Once a week. 

These are 18- and 19- and 20-year-old women who come into the 

force, who begin active lives after being sedentary, who are suffering from bone washout from drinking phosphate-rich sodas and 

being sedentary before they come in. And now we are getting hip 

fractures in basic training. 

We have a problem in this country in the overall health and fitness of the population and with growing childhood obesity, the tobacco problems that you addressed earlier. We have got to shift the 

paradigm away from one of disease and injury treatment to one 

that prevents it from the get-go. 

Mrs. DAVIS. Admiral Robinson, we have to go vote. But if you 

have a quick comment, that would be great. 

Admiral ROBINSON. One other thing. Actually, this is General 

Green, and that is, he said something the other day that was so 

intriguing to me; and that is, take enlisted personnel and actually 

get them certified to do mental health. So I think—and this happens, this works. But I think my addition to everything else is that 

we need to think in terms of how we provide the care. It needs to 

be preventative and wellness, and then we need to think in terms 

of how that care is given. Thank you very much. 

General GREEN. And just very quickly, I really do think we need 

to think out of the box. We are increasing our number of practitioners and extenders. We are looking at the mix to get the right 

team, using medical home to do outreach. For non-enrolled care, we 

think emergency rooms are going to be overrun in the near future 

because of the lack of primary care. We are preparing fast tracks 

in acute-care clinics to make sure we are ready for the increased 

workload. 

And I do think we do need to think beyond traditional mental 

health and look at the licensed medical counselors, to see whether 

or not we can train some of our enlisted force. Just like we are 

bringing enlisted to nurses, we may be able to increase our diversity by bringing enlisted into medical schools as they are prepared. 

So we are doing a lot of things to try to leverage our enlisted 

force to try to create new venues of care. 

Mrs. DAVIS. Thank you very much. Thank you to all of you. I 

mentioned earlier, it is the Military Undergraduate Nurse Training, section 525, from the former authorization that I was inquiring 

about. 
30 

Dr. RICE. Yes, ma’am. There is a report due to Congress. The 

three military nursing chiefs are actively working on that and anticipate having a report to you on time. 

Mrs. DAVIS. Great. Thank you very much to all of you. I hope 

that the hearing was helpful to you as well. It was to us. And we 

look forward to the next one. Thank you very much. 

[Whereupon, at 3:24 p.m., the subcommittee was adjourned.] 
A P P E N D I X 

APRIL 21, 2010 

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WITNESS RESPONSES TO QUESTIONS ASKED DURING 

THE HEARING 

APRIL 21, 2010 

(117) 

RESPONSE TO QUESTION SUBMITTED BY MRS. DAVIS 

Dr. RICE. The initial report on progress made in undertaking actions to enhance 

the Military Health System (MHS) and improve the TRICARE program as required 

in Section 721 of the National Defense Authorization Act for Fiscal Year 2010 has 

been drafted and is in the coordination process. 

A high-level working group was formed to address the report requirements and 

included representatives from a number of MHS entities. The initial report describes the progress made and future plans for improvement of the MHS. DoD senior leadership provided further guidance to the subject matter experts working on 

the areas Congress requested DoD study and consider planning to improve access 

to care. 

Note: Representatives from MHS entities include: 

• Chief, Policy and Operations Branch, TRICARE Policy and Operations Directorate (TPOD) 

• Director, DoD/VA Program Coordination Division 

• Chief, Purchased Care Systems Integration Branch, TPOD 

• Deputy Chief, Human Capital Office OASD(HA) 

• Program Director, Health Budgets and Financial Plans OASD(HA) 

• Director, Operations Division, TPOD 

• Director, Strategic Communications and Transformation OASD(HA) 

• Director, Population Health and Medical Management, Office of the Chief Medical Officer 

• Chief, Program Evaluation Branch, TPOD 

• Chief, TRICARE Operations Center 

• Deputy Chief, TRICARE Division 

• Army Medical Department (AMEDD) One Staff 

• Offices of the Service Surgeons General 

[See page 12.] 

RESPONSE TO QUESTION SUBMITTED BY MS. SHEA-PORTER 

General SCHOOMAKER. Surveillance documents, laboratory data, and field notes 

are available for future use to investigate the occupational and environmental 

health risks of respective burn pits. The US Army Public Health Command (Provisional) is the designated DoD lead agent for archiving all deployment occupational 

and environmental health (OEH) surveillance data for US military operations. It 

maintains the DoD OEH surveillance documents in Internet-based unclassified and 

classified document libraries identified as the deployment OEH surveillance data 

portal. US Army Public Health Command (Provisional) has a separate DoD database for archiving all of the laboratory data and associated field notes for deployment samples (e.g., air, water, soil) sent to the Army Public Health Command for 

analysis. This sample database is identified as the Defense Occupational and Environmental Health Readiness System—Environmental Health Module. [See page 19.] 

RESPONSE TO QUESTION SUBMITTED BY DR. FLEMING 

Dr. RICE. By law, Title 10 United States Code Section 1079(h)(1), TRICARE’s payment for a charge for services by an individual health care professional must be 

equal to an amount determined to be appropriate, to the extent practicable, in accordance with the same reimbursement rules as apply to payments for similar services by Medicare. Statute permits TRICARE reimbursement rates to be less than 

Medicare rates when providers have agreed to give network discounts. In addition, 

there is statutory authority to set TRICARE rates above Medicare rates if necessary 
118 

to obtain an adequate network of providers or to prevent severe access to care deficiencies. [See page 17.] 

RESPONSE TO QUESTION SUBMITTED BY MS. TSONGAS 

General GREEN. Based on my understanding of NDAA 2010, Section 702, when 

Guard/Reserve members receive federal delayed-effective-date active duty orders for 

more than 30 consecutive days in support of a contingency operation, the service 

member and their family are eligible for TRICARE. TRICARE coverage will begin 

the date the order was issued or 180 days prior to activation date, whichever is 

later. Current TRICARE coverage is for 90 days prior to activation date. 

As Dr. Rice mentioned, Reserve Affairs will be sending out the DOD policy to enforce this change. Although eligibility determination belongs to Air Force Manpower 

& Personnel (AF/A1), the Air Force Medical System (AFMS) will work with AF/A1 

to ensure full compliance across the Air Force. We have verified that the implementation date is projected for 1 Oct 10. 

Once implemented, Guard/Reserve members will need to register their family 

members and their records in the Defense Enrollment Eligibility Reporting System 

(DEERS) through the nearest service personnel office, ID card-issuing facility or 

DEERS Support Office. Once eligibility verification is made by AF/A1 and is accurately reflected in DEERS, the AFMS is prepared to provide the medical care to all 

eligible members and their dependents. [See page 21.] 

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