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1 

51–764 2010

[H.A.S.C. No. 111–60] 

HEARING 

ON

NATIONAL DEFENSE AUTHORIZATION ACT 

FOR FISCAL YEAR 2010 

AND

OVERSIGHT OF PREVIOUSLY AUTHORIZED 

PROGRAMS 

BEFORE THE

COMMITTEE ON ARMED SERVICES 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

MILITARY PERSONNEL SUBCOMMITTEE HEARING 

ON

BUDGET REQUEST ON DEFENSE HEALTH 

PROGRAM OVERVIEW 

HEARING HELD 

MAY 15, 2009 
(II) 

MILITARY PERSONNEL SUBCOMMITTEE 

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 

DAVID KILDEE, Professional Staff Member 

JEANETTE JAMES, Professional Staff Member 

ROSELLEN KIM, Staff Assistant 
(III) 

C O N T E N T S 

CHRONOLOGICAL LIST OF HEARINGS 

2009 

Page 

HEARING: 

Friday, May 15, 2009, Fiscal Year 2010 National Defense Authorization Act— 

Budget Request on Defense Health Program Overview ................................... 1 

APPENDIX: 

Friday, May 15, 2009 ............................................................................................... 31 

FRIDAY, MAY 15, 2009 

FISCAL YEAR 2010 NATIONAL DEFENSE AUTHORIZATION ACT— 

BUDGET REQUEST ON DEFENSE HEALTH PROGRAM OVERVIEW 

STATEMENTS PRESENTED BY MEMBERS OF CONGRESS 

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

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

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

WITNESSES 

Middleton, Allen W., Acting Principal Deputy Assistant Secretary of Defense 

for Health Affairs, Department of Defense; Lt. Gen. Eric B. Schoomaker, 

USA, Commanding General, U.S. Army Medical Command, The Surgeon 

General, U.S. Army; Vice Adm. Adam M. Robinson, USN, Surgeon General, 

U.S. Navy; Lt. Gen. James G. Roudebush, USAF, Surgeon General, U.S. 

Air Force; and Charles Campbell, Chief Information Officer, Military 

Health System, Office of the Assistant Secretary of Defense for Health 

Affairs, Department of Defense, beginning on ................................................... 4 

APPENDIX 

PREPARED STATEMENTS: 

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

Middleton, Allen W. .......................................................................................... 38 

Robinson, Vice Adm. Adam M. ........................................................................ 81 

Roudebush, Lt. Gen. James G. ........................................................................ 94 

Schoomaker, Lt. Gen. Eric B. .......................................................................... 57 

Wilson, Hon. Joe ............................................................................................... 37 

DOCUMENTS SUBMITTED FOR THE RECORD: 

[There were no Documents submitted.] 

WITNESS RESPONSES TO QUESTIONS ASKED DURING THE HEARING: 

Ms. Shea-Porter ................................................................................................ 113 

Mr. Wilson ......................................................................................................... 113 

QUESTIONS SUBMITTED BY MEMBERS POST HEARING: 

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

(1) 

FISCAL YEAR 2010 NATIONAL DEFENSE AUTHORIZATION ACT—BUDGET REQUEST ON DEFENSE HEALTH 

PROGRAM OVERVIEW 

HOUSE OF REPRESENTATIVES, COMMITTEE ON ARMED SERVICES, MILITARY PERSONNEL SUBCOMMITTEE, 

Washington, DC, Friday, May 15, 2009. 

The subcommittee met, pursuant to call, at 9:00 a.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, MILITARY 

PERSONNEL SUBCOMMITTEE 

Mrs. DAVIS. Good morning. Today’s hearing is on the Department 

of Defense’s fiscal year 2010 budget for the Defense Health Program. 

For the first time in three years, the Department of Defense 

(DOD) has not proposed massive TRICARE fee increases as part of 

their budget request. The increases proposed in previous years 

would have provided large savings for the Department, but most of 

the savings would have been the result of raising fees so high that 

large numbers of beneficiaries would choose to leave the system. 

We are encouraged that the Department has not chosen to pursue 

that course of action this year. 

The Secretary of Defense has said that his intent was to fully 

fund military health care in the fiscal year 2010 budget and then 

engage Congress in a dialogue about what comes next. We will obviously have to wait to start that conversation until the President’s 

appointees are in place, but we look forward to the discussion this 

committee has been trying to have with the Department for years. 

Our beneficiaries deserve no less. 

We must now closely examine the budget proposal to see if it is, 

indeed, fully funded. I should mention that we have only had the 

budget justification materials for about the last 36 hours and are 

still awaiting answers from the Department on various issues. It 

would be helpful if our witnesses could offer any insights they may 

possess on how certain amounts were chosen and how various decisions were made. 

During our annual reviews of the Defense Health Program 

(DHP) budget, we always ask questions about how the proposed 

budget will support our deployed service members and their families. In light of recent events, we will undoubtedly focus additional 

attention on how this proposed budget will improve mental health 
2 

services, as well as any unfunded mental health requirements the 

services may have. 

For our witness panel, we have the Acting Principal Deputy Assistant Secretary of Defense for Health Affairs, Mr. Allen Middleton, representing the Office of the Secretary of Defense. Until 

recently, Mr. Middleton was the Acting Deputy Assistant Secretary 

of Defense for Health Budget and Financial Planning. 

So we know, sir, that you will be able to answer our budget questions in great detail. 

We also have all the service surgeon generals: Lieutenant General James Roudebush, from the Air Force; Vice Admiral Adam 

Robinson, from the Navy; and Lieutenant General Eric 

Schoomaker, from the Army. 

General Roudebush, I understand that you will be retiring in August, and we really appreciate all of your service. We want to 

thank you for the quiet determination with which you have led the 

Air Force Medical Service and the unwavering commitment that 

you have displayed for our men and women in uniform. Thank you 

very much, sir. 

General ROUDEBUSH. Thank you, ma’am. 

Mrs. DAVIS. You will be missed, and we wish you well in your 

future endeavors. 

And now I will turn to Mr. Wilson for his opening 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, MILITARY PERSONNEL SUBCOMMITTEE 

Mr. WILSON. Thank you, Chairwoman Davis. 

Today, the subcommittee meets to hear testimony on the Defense 

Health Program, DHP, for fiscal year 2010. Although we routinely 

have an annual hearing on the DHP, I want to emphasize that 

there is nothing routine about the Military Health System and the 

extraordinary care it provides to our service members around the 

globe and their families. 

This subcommittee remains committed to ensuring that the remarkable 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 of the Military Health System 

(MHS) 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, for the first time in four years, a fully funded budget 

for the Defense Health Program. I applaud Secretary Robert Gates 

for hearing what Congress and our military beneficiaries have said 

repeatedly: Increasing TRICARE fees is not the solution for containing the rising costs of military health care. 

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

the Department plans to develop a comprehensive approach to providing world-class health care to our beneficiaries while, at the 

same time, controlling costs. I look forward to working with the 
3 

leadership of the Military Health System toward that end. I would 

also like to hear your commitment that all of the stakeholders in 

the military health care will be involved in the process. 

I am interested in hearing from the witnesses how the DHP 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 like to hear from our military surgeon generals whether 

the DHP 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 in the Global War on Terrorism, and care for those brave men 

and women through the long recovery process when they become 

injured and wounded. 

And, as we conclude, I want to join with Chairwoman Davis and 

commend General Roudebush on his service. 

And thank you very much, and we wish you well and a long, 

healthy, and happy retirement. 

General ROUDEBUSH. Thank you, sir. 

Mr. WILSON. With that, I would like to welcome our witnesses 

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

[The prepared statement of Mr. Wilson can be found in the Appendix on page 37.] 

Mrs. DAVIS. Thank you, Mr. Wilson. 

I also wanted to introduce Mr. Charles Campbell, chief information officer for the Military Health System, Office of the Assistant 

Secretary of Defense for Health Affairs, the Department of Defense. 

Thank you very much, sir, for being here. 

And I will start with some questions, and hopefully, you know, 

we might end up with a real dialogue today because, as you know, 

Members went back to their districts, and so we have fewer Members today. 

Mr. Middleton, Mr. Campbell, back in March, we, along with the 

Subcommittee on Terrorism and Unconventional Threats and Capabilities, held a joint hearing on the Department of Defense’s 

health information technology systems. And at that hearing, we 

heard from the services about the difficulties they had faced with 

Armed Forces Health Longitudinal Technology Application 

(AHLTA). We were encouraged to hear from Health Affairs that 

you agree that there are serious problems and even more encouraged when you presented what appeared to be an ambitious and 

comprehensive plan to overhaul the system to address all of the 

issues raised by the services and provide the best health information technology (IT) system possible for the Department’s beneficiaries. 

At that hearing—I am starting to ask you questions before you 

make your presentation, but maybe I will do that and you can start 

trying to incorporate them, if you will? Okay? 

Or maybe not. Let’s go ahead. Let’s just start the hearing with 

your presentations, and then we will get to our questions. I am so 

eager to ask that question. But it is important to hear from you 

first. 
4 

If you want to address the IT question, you can, but we will come 

back to it and come back to a number of other questions. As I mentioned, mental health is certainly on our minds, and we know that 

there are a number of issues that you really want to share with 

us, as well. 

So let’s begin with Mr. Middleton. Thank you. 

STATEMENTS OF ALLEN W. MIDDLETON, ACTING PRINCIPAL 

DEPUTY ASSISTANT SECRETARY OF DEFENSE FOR HEALTH 

AFFAIRS, DEPARTMENT OF DEFENSE; LT. GEN. ERIC B. 

SCHOOMAKER, USA, COMMANDING GENERAL, U.S. ARMY 

MEDICAL COMMAND, THE SURGEON GENERAL, U.S. ARMY; 

VICE ADM. ADAM M. ROBINSON, USN, SURGEON GENERAL, 

U.S. NAVY; LT. GEN. JAMES G. ROUDEBUSH, USAF, SURGEON 

GENERAL, U.S. AIR FORCE; AND CHARLES CAMPBELL, CHIEF 

INFORMATION OFFICER, MILITARY HEALTH SYSTEM, OFFICE OF THE ASSISTANT SECRETARY OF DEFENSE FOR 

HEALTH AFFAIRS, DEPARTMENT OF DEFENSE 

STATEMENT OF ALLEN W. MIDDLETON 

Mr. MIDDLETON. Thank you, Madam Chairman, members of the 

committee. Thank you for this opportunity to discuss the priorities 

of the Military Health System and its budget for fiscal year 2010. 

We are pleased to be here. 

The men and women of America’s Armed Forces are our country’s greatest strategic asset. And apart from defending the Nation, 

the Department has no higher priority than to provide the highest 

quality and support to our forces and, of course, their families. 

As Secretary Gates has said, at the heart of the All-Volunteer 

Force is the contract between the United States of America and the 

men and women who serve, a contract that is legal, social, and sacred. When young Americans step forward on their own free will 

to serve, he said, they do so with the expectation that they and 

their families will be properly taken care of. 

Indeed, the Military Health System has one overarching mission: 

to provide optimal health services systems in support of our Nation’s military mission anytime and anywhere. Today, the Military 

Health System serves 9.4 million beneficiaries: active duty, their 

family members, our retired military members and their families. 

In addition to force health protection and family support, the 

MHS provides humanitarian assistance at home and around the 

world and supports world-class education, training, and research. 

Our strategic plan, developed in concert with the surgeon generals and the joint staff, supports all of these three component missions. It also recognizes the outcomes the American people expect 

from their investment in military medicine. In addition to a fit, 

healthy, and protected force, our goals include the lowest possible 

rate of death, injury, and disease during military operations; superior follow-up care that includes transition to the Department of 

Veteran Affairs; healthy and resilient individuals, family and communities; and the high-quality, cost-effective care our Nation expects. 

We appreciate deeply the support that Congress, especially this 

committee, has provided to us to help deliver the very best health 
5 

care for our forces and their families, and in particular for our 

wounded, ill, and injured. I believe we have made significant 

progress toward each of these goals. 

And I have provided this information in considerable detail in my 

submitted written statement to you. For now, let me briefly summarize the uniform medical budget request for 2010. 

The Department’s total request for health care in fiscal year 2010 

is $47.4 billion, including the Defense Health Program; the wounded, ill, and injured for rehabilitation; military personnel; military 

construction; and contributions to the Medicare-Eligible Retiree 

Health Care Fund. 

The largest portion of our budget, almost $28 billion, is requested 

by the Defense Health Program for operations and maintenance, 

procurement, research and development, test and evaluation. $0.3 

billion is requested for equipment and systems procurement; $0.6 

billion is requested for military-relevant medical research; and $0.4 

billion to improve survivability and quality-of-life issues. 

For military personnel, the budget request is $7.7 billion to support more than 84,000 military personnel who provide the mental 

health care services to our deployed forces around the world, including aeromedical evacuation, shipboard and undersea medicine, 

and global humanitarian assistance and response. 

Funding for military construction is at $1 billion in fiscal year 

2010 for 23 construction projects, including phase one of the replacement at Guam and for an ambulatory care center at Lackland 

Air Force Base, Texas. 

In the Medicare-Eligible Retiree Health Care Fund, the fund 

which supports the TRICARE for Life program, our estimated normal cost contribution this year is just under $11 billion. 

For our wounded, ill, and injured members, the 2010 DHP budget includes $1.7 billion for enhanced care as well as research efforts 

to mitigate the effects of psychological health and traumatic brain 

injury. 

All of the requirements of both the service medical departments 

and the TRICARE management activity were funded by the Secretary, and we do not anticipate any additional requirements at 

this time. 

You will be interested to know that this budget does not include 

any benefit reform savings, as you mentioned, with beneficiary enrollment fee or co-pay increases, and they remain the same. 

The military treatment facility (MTF) efficiency wedge previously 

assumed has also been fully restored to the services’ medical departments. And the previously programmed military-to-civilian conversions are being restored in accordance with the fiscal year 2008 

National Defense Authorization Act, and that restores just under 

5,500 billets in 2010. 

Madam Chairman, the Military Health System is dedicated to 

doing the very best we can for the men and women who give everything they have for each one of us. We can never fully repay them 

for the sacrifices they make for our country and for our future, but 

we can and will continue to do everything we can to heal their 

wounds and to honor their courage and commitment to the country 

that we all love. 
6 

Thank you again for this opportunity with you, and we do look 

forward to your questions. 

[The prepared statement of Mr. Middleton can be found in the 

Appendix on page 38.] 

Mrs. DAVIS. Thank you very much. 

General Schoomaker. 

STATEMENT OF LT. GEN. ERIC B. SCHOOMAKER 

General SCHOOMAKER. Madam Chairwoman, Representative Wilson, and other distinguished members of the Military Personnel 

Subcommittee, thank you for the opportunity to discuss Army Medicine and the Defense Health Program today. 

In recognition, again, that 2009 is our year of the non-commissioned officer (NCO) in the Army, I am joined today by my senior 

enlisted medic and my battle buddy, Command Sergeant Major Althea Dixon. And she is my constant reminder that our NCO corps 

really is what makes Army and Army Medicine strong. 

What distinguishes military and Army Medicine from U.S. health 

care as a whole is our commitment to improving and sustaining the 

health of the force as a strategic imperative. On the Army strategy 

map that was a part of the packet that you all received, we used 

a Kaplan and Norton-developed Harvard Business School balanced 

score card approach to both leadership and management of Army 

Medicine. 

We have included two of our six strategic goals, or ends, that 

highlight the improved health and protection of our personnel, be 

they warriors or families or beneficiaries or civilians. The health of 

the force, and by extension that of our families and all of our beneficiaries, is a national asset. It is heightened by our reliance on an 

All-Volunteer Force. I will say that again: Our reliance on an AllVolunteer Force especially has pushed us toward an increased 

focus upon keeping the force healthy and able to be mission-focused 

from the beginning. 

In order to make the assertion that we are a system of health, 

as opposed to a health care system, delivering health care alone, 

that we are a system of health, we have taken several key actions. 

First, we stay focused at a corporate level on optimizing health 

through evidence-based practices, which raise our markers of future care, or proxies I call them, of current and future health, like 

vaccination rates or compliance with the United States Preventive 

Services Task Force guidelines for screening, and our Healthcare 

Effectiveness Data and Information Set, or HEDIS, measures. 

These are population health improvement and evidence-based practices which are being uniformly applied across U.S. medicine but 

especially within the Military Health System. 

A second issue or approach is by resourcing our commands to effect these population health outcomes and permit the generation of 

revenue, which encourages these and other best practices aimed at 

raising the health of the beneficiary population. This is different 

than much of American medicine, where preventative measures in 

optimizing health is not well-reimbursed and resourced. We have 

shifted our revenue stream increasingly toward optimization of 

health. 
7 

Third, we have moved toward maintaining strong links to like 

agencies and organizations which foster and reduce risky behaviors 

that enhance evidence-based practices and promote healthy lifestyles, the Department of Veterans Affairs (VA) being among them. 

We establish programs and partnerships which protect the 

health of the population through shared health surveillance, 

through the prevention of epidemic disease, enhanced food and 

water safety, enhanced resilience of the force, and the like. 

Army Medicine is currently reviewing options for developing a 

public health command within the Army, where we have a single 

focus of public health within the Army from all of those who contribute to that, whether they be veterinarians, public health officers, nurse community health workers, or the like. I think it would 

be beneficial to the Army and our soldiers to create a single point 

of expertise and responsibility for public health. 

These and other examples demonstrate that Army and military 

medicine—I am joined by my colleagues—are increasingly a system 

for health in every regard raised, from increasing HEDIS measures, to a health-focus performance-based budgeting process, to the 

development of the Army comprehensive soldier fitness initiative 

where we build resilience and the physical, emotional, intellectual, 

spiritual fitness in response—and it is illustrated by our response 

to H1N1 flu this year and our stance against future bio threats. 

It is one significant aspect of how military medicine is different 

from civilian medical organizations and why we cannot be compared entirely to civilian medicine. I strongly believe that we must 

focus on building and maintaining health and resilience and in conducting science-based, evidence-based practices focusing on optimal 

clinical outcomes when bad things happen to good people and they 

fall off this balance beam of health. That happens in combat; it 

happens with serious disease and injury. 

I believe—and you all posed this question—I believe that this approach will ultimately lead to the best results both for the Army 

and the military community, and it will deliver the most cost-effective system of health and health care. Focus on evidence-based 

practices, on health and on outcomes. 

Another striking difference between military and civilian medicine is our Wounded Warrior mission. It is an inherent—there are 

inherent, operationally driven inefficiencies involved in the delivery 

of care to this complex population of warriors in transition. 

On a per capita basis, the care of wounded, ill, and injured soldiers, or what we call Warriors in Transition, consume upwards to 

six times as much health care resources as a healthy population. 

Now, you see this when you go to our military hospitals in our 

Warrior Transition Units (WTU), where we have placed some of 

the talented officer and NCO leaders and where nurses and physicians and occupational therapists, physical therapists, behavioral 

health providers and many others combine their expertise in an intense effort to recover and rehabilitate and transition and reintegrate these great warriors and care for their families. 

The intensity of care delivered to these almost now 10,000 warriors is not comparable in any other civilian setting. These Warriors in Transition deserve every bit of the care and attention, as 

mentioned earlier by my colleague, from Health Affairs. But I raise 
8 

this as another example of the uniqueness of Army and military 

medicine. It is not replicated in the civilian setting, and it probably 

never will be because of expertise and cost inefficiencies in running 

such a program. 

Finally, let me just comment—as you asked, ma’am, and you, 

sir—about our efforts to prevent, mitigate, identify, manage, and 

treat behavioral health consequences of service in uniform and 

those arising from frequent deployments, long family and community separations, and exposure to the rigors of combat. 

Army leaders at all levels recognize that combat and repeated deployments are difficult for soldiers and they stress our families. We 

are making bold, sustained efforts to improve the resilience of the 

entire Army and its family, to reduce the stigma associated of seeking mental health care, and to provide multidisciplinary care which 

addresses specific behavioral and health needs promptly and 

expertly. 

We are resolved to prevent adverse social outcomes associated 

with military service and combat, such as driving while intoxicated 

and family violence and other such misconduct. 

Suicides are unacceptable losses of our soldiers. Realizing that 

the loss of even one soldier to suicide is one too many, we are looking closely at factors involved. And rather than post-traumatic 

stress disorder, as one might expect, we continue to see that fractured relationships and work-related stresses are the major factors 

in soldier suicides. We have numerous coordinated and integrated 

initiatives in place to help soldiers and their families. I am eager 

to discuss these and any other issues in this realm that you wish 

to address. 

In closing, I want to thank again the committee for their terrific 

support of the Defense Health Program and of Army Medicine. 

As I close, I would like to salute our non-commissioned officers 

for their professionalism and competence and leadership. 

And, ma’am and sir, I am pleased that you recognized my colleague, our colleague, Jim Roudebush, as he gets ready to depart 

a long and distinguished service in Air Force Medicine. He embodies, really, a scholarly wisdom, unflappability, and experience. 

And he has really taught us what being a wingman is. 

And what we are very pleased with is, as he leaves service, he 

leaves a son in an Army uniform in a Stryker Brigade in Fort 

Lewis, Washington. And so I will close by saying, ‘‘Army strong and 

air power.’’ 

[The prepared statement of General Schoomaker can be found in 

the Appendix on page 57.] 

Mrs. DAVIS. Thank you very much. 

Admiral Robinson. 

STATEMENT OF VICE ADM. ADAM M. ROBINSON 

Admiral ROBINSON. Good morning. Chairwoman Davis, Congressman Wilson, distinguished members of the committee, thank you 

for the opportunity to be here this morning. 

Navy Medicine continues on course because our focus has been 

and will always be providing the best health care for our sailors, 

Marines, and their family members while supporting our Nation’s 

overseas contingency operations. 
9 

As Admiral Mullen pointed out earlier this week, the Navy is 

doing a lot more than most people know about. Navy Medicine is 

meeting the mental and physical needs of our service members 

abroad and preparing healthy and fit sailors and Marines to protect our Nation and deploy. 

We are continuously making the necessary changes and improvements to meet the requirements of the biggest consumer of our 

operational support efforts, the Marine Corps. Currently, we are realigning medical capabilities to support operational forces in 

emerging theaters of operation. Navy Medicine’s combat medical 

support has proven exceptionally successful, and we will sustain 

and improve those efforts in the future. 

The Navy’s humanitarian and civil assistance missions are increasing, and this year, our efforts will include missions in the U.S. 

Southern and Pacific Command areas of operation. 

As previously announced, our plans included deploying the USS 

Dubuque (LPD 8) later this year as part of the Pacific Partnership 

2009. However, an outbreak of H1N1 influenza among the ship’s 

crew has altered those plans. We are actively engaged in finding 

alternative ways to deliver medical care to these nations and ensuring the medical care provided positively impacts the perception 

of the United States and our allies by other nations. 

I would like to take this opportunity to point out that, although 

the operational portion of our humanitarian missions are funded by 

the Navy’s Fleet Forces Command, Navy Medicine is not afforded 

any credit for the work performed during these critical missions. In 

fiscal year 2008, Navy Medicine deployed medical providers in support of worldwide missions. These providers had almost 130 outpatient and over 1,100 inpatient encounters worldwide. We are also 

taxed in our direct-care reimbursement funding as part of the 

Health Affairs pay-for-performance calculations. 

I also remain concerned about how the increases in private-sector 

care costs will be addressed, as the care we provide in our medical 

treatment facilities must be preserved in order to meet our dual 

mission of operational support and beneficiary health care. Growing resource constraints for Navy Medicine are real, as is the increasing pressure to operate more efficiently without compromising 

health care quality and workload goals. We continue to make improvements to meet the needs of sailors and Marines who have 

been injured and have significantly expanded services so wounded 

warriors have access to timely, high-quality medical care. 

Navy Medicine’s concept of care is patient- and family-focused. 

We never lose our perspective in caring for our beneficiaries. Everyone is a unique human being in need of individualized, compassionate, and professionally superior health care. 

As of May 2009, 171 medical case managers were assigned to 45 

medical treatment facilities and ambulatory care clinics, caring for 

approximately 1,500 Operation Enduring Freedom/Operation Iraqi 

Freedom casualties. The medical case care managers collaborate 

with Navy Safe Harbor and Marine Corps Wounded Warrior Regiment and new programs, such as Families Overcoming Under 

Stress, FOCUS, in working directly with our beneficiaries, our 

wounded warriors, their families and caregivers, and the multi-
10 

disciplinary medical team to coordinate the complex services needed for improved health outcomes. 

The Bureau of Medicine and Surgery (BUMED) Wounded Warrior Regiment Medical Review team and the Returning Warrior 

Workshops support Marines and Navy sailors, reservists, and their 

families by focusing on key issues faced by personnel during their 

transition from deployment to home. 

Navy and Marine Corps liaisons at medical treatment facilities 

aggressively ensure that orders and other administrative details, 

such as extending reservists, are completed. In addition, we recently hired 25 psychological outreach coordinators to identify and 

meet the mental health needs of our reservists. 

Navy Medicine has also partnered with Navy and Marine Corps 

communities to identify specific populations at risk for traumatic 

brain injury in frontline units, such as SEALs (Sea, Air, Land) and 

Navy Explosive Ordnance Disposal Units. 

Navy Medicine’s innovative deployment health centers, currently 

in 17 high fleet and Marine Corps concentration areas, supports 

the deployment health assessment process and serve as easily accessible and nonstigmatizing portals of entry for our forward mental health care. Since their establishment in 2007, the centers have 

accomplished over 150,000 health care encounters, with about 23 

percent for psychological health issues. This further demonstrates 

our expanded efforts where primary care providers are addressing 

the mental health needs of our sailors and Marines, as we continue 

to expand our operational stress and resiliency programs from boot 

camp through war college. 

Navy Medicine’s partnership with the Department of Veterans 

Affairs’ medical facilities continues to be mutually beneficial. This 

coordinated care for our warriors who transfer to or are receiving 

care from a VA facility ensures their needs are met and their family concerns are addressed. 

Working closely with the Chief of Navy Personnel, medical recruiting continues to be one of our top priorities. And we thank 

Congress for their generous support of our medical special pay and 

bonus authority. 

In spite of the successes in medical and dental corps recruitment 

into our scholarship programs, meeting our direct accession mission 

still remains a challenge. I anticipate increased demand for Medical Service Corps personnel, our most diverse corps with 31 specialties. This is especially true among Medical Services Corps specialties linked to mental, behavioral, and rehabilitative health and 

operational support, such as clinical psychologists, social workers, 

occupational therapists, physician assistants, and physical therapists. 

Consistent with increased operational demand signals, as well as 

to compensate for prior shortfalls in recruiting, the overall recruiting call for the Uniformed Medical Service Corps officers have 

nearly doubled since fiscal year 2007. For the first time in over five 

years, Navy Nurse Corps officers gained in 2008 outpaced losses. 

Despite the growing national nursing shortage and the resistance 

of the civilian nursing community to recession, the recruitment and 

retention of Navy nurses continues to improve. 
11 

Chairwoman Davis, Congressman Wilson, I would like to take 

this opportunity to offer my deep condolences to the Springle family and the families of the other victims of this week’s tragic events 

at Camp Liberty in Iraq. Commander Springle was a Navy social 

worker serving with the Army’s 55th Medical Company as an individual augmentee. 

I would also like to extend my congratulations to Jim Roudebush 

on being a wonderful shipmate, wingman, a wonderful partner in 

this military health establishment that we have here, and someone 

that was always dependable, both as a professional and as a friend. 

Thank you again for providing me the opportunity to testify, and 

I look forward to answering your questions. 

[The prepared statement of Admiral Robinson can be found in 

the Appendix on page 81.] 

Mrs. DAVIS. Thank you, Admiral. 

And, General Roudebush, if you would continue. And obviously 

you have been a tremendous mentor and colleague to many that 

you served with. And we thank you again. 

STATEMENT OF LT. GEN. JAMES G. ROUDEBUSH 

General ROUDEBUSH. Madam Chairwoman, Congressman Wilson, 

thank you for the very kind thoughts you have expressed, and certainly those of my colleagues. I will tell you, it is a privilege to 

serve, but as I move to the next chapter, each of us who serves may 

stop wearing the uniform but we never take it off and we continue 

to serve. And I look forward to that. Thank you, ma’am. 

It is a pleasure to be here today to talk to you about the Air 

Force Medical Service. Air Force Medicine contributes significantly 

to our joint capability as part of a joint team in the joint war-fight, 

serving those men and women in harm’s way and serving our Nation with combat casualty care, wartime surgery, and aeromedical 

evacuation. 

On the ground, at both the Air Force Theater Hospital in Balad, 

Iraq, and the SSG Heath N. Craig Joint Theater Hospital in 

Bagram, in Afghanistan, we are leading numerous combat casualty 

care initiatives that will positively impact combat and peacetime 

medicine for years to come. 

Air Force surgeons have laid the foundation for a state-of-the-art 

intervascular operating room at Balad, the only DOD facility of its 

kind. Their innovative technology and surgical techniques have 

greatly advanced the care of our joint war-fighters and coalition 

casualties. And in conjunction with our Army and Navy brothers 

and sisters, they have literally rewritten the book on the use of 

blood in trauma resuscitation. 

To bring our wounded warriors safely and rapidly home, our 

Critical Care Air Transport Teams, our CCATTs, provide a unique 

intensive care unit (ICU) care in the air within DOD’s joint en 

route medical care system. We continue to improve the outcomes 

of the care of our CCATT wounded warriors by incorporating lessons learned in clinical practice guidelines and modernizing equipment to support that mission. 

This Air Force-unique expertise also pays huge dividends back 

home. When Hurricane Katrina and Rita struck in 2005, Air Force 

active-duty Guard and Reserve medical personnel were in place 
12 

conducting lifesaving operations. Similarly, hundreds of members 

of this total force team were in place September 1st, 2008, when 

Hurricane Gustav struck the Louisiana coast and when Hurricane 

Ike battered Galveston, Texas, less than two weeks later. During 

Hurricane Gustav, Air Mobility Command coordinated the movement of more than 8,000 evacuees, including 600 patients. Air 

crews transported post-surgical and intensive care patients from 

Texas area hospitals to Dallas. I am extremely proud of this incredible team effort. 

The success of our Air Force mission directly correlates with our 

ability to build and maintain a healthy and fit force at home station and in theater. Always working to improve care, our Family 

Health Initiative establishes an Air Force medical home. This medical home optimizes health care practice within our family health 

care faculties and clinics, positioning a primary care team to better 

accommodate the enrolled population and streamline the processes 

for care and disease management. The result is better access, better care, and better health. 

The psychological health of our airmen is also critically important. To mitigate their risk for combat stress symptoms and possible mental health problems, our program known as Landing Gear 

takes a proactive approach with education and symptom recognition, both pre- and post-deployment. We educate our airmen that 

recognizing risk factors in themselves and others, along with a willingness to seek help, is the key to effectively functioning across the 

deployment cycle and reuniting and reintegrating with their families. Likewise, we screen very carefully for traumatic brain injury 

at home and at our forward-deployed locations. 

To respond to airmen’s needs, we have over 600 active-duty and 

200 civilian and contract mental health providers. This mental 

health workforce has been sufficient to meet the demand signal 

that we have experienced to date. That said, we do have challenges 

with respect to active-duty psychologist and psychiatrist recruiting 

and retention. And we are pursuing special pays and other initiatives to try to bring us closer to 100 percent staffing in these two 

critically important specialties. 

For your awareness, over time we are seeing an increasing number of airmen with post-traumatic stress disorder (PTSD). One 

thousand seven hundred fifty-eight airmen have been diagnosed 

with PTSD within 12 months of return from deployment from 2002 

to 2008. As a result of our efforts at early post-traumatic stress 

identification and treatment, the vast majority of these airmen continue to serve with the benefit of treatment and support. 

Understanding that suicide prevention, as well, lies within and 

is integrated into the broader construct of psychological health and 

fitness, our suicide prevention program, a community-based program, provides the foundation for our efforts. Rapid recognition, active engagement at all levels, and reducing any stigma associated 

with seeking help are hallmarks of our program. One suicide is too 

many, and we are working hard to prevent the next. 

Sustaining the Air Force Medical Service requires the very best 

in education and training for our professionals. In today’s military, 

that means providing high-quality programs within our system, as 

well as strategically partnering with academia, private-sector medi-
13 

cine, and the VA to ensure that our students, residents, and fellows 

have the best training opportunities possible. 

While the Air Force continues to attract many of the finest 

health professionals in the world, we still have significant challenges in recruiting and retention. We are working closely with our 

personnel and recruiting communities, using accession and retention bonus plans to ensure full and effective staffing with the right 

specialty mix to perform our mission. 

At the center of our strategy is the Health Profession Scholarship 

Program (HPSP). HPSP is our most successful recruiting tool, but 

we are also seeing positive trends in retention from our other financial assistance programs and pay plans. Thank you for your unwavering support in helping us both establish and fund those programs. 

In summary, Air Force medicine is making a difference in the 

lives of airmen, soldiers, sailors, Marines, family members, coalition partners, and our Nation’s citizens. We are earning their trust 

every day. 

As we look forward to the way ahead, I see a great future for the 

Air Force Medical Service, built on a solid foundation of topnotch 

people, outstanding training programs, and strong partnerships. It 

is indeed an exciting, challenging, and rewarding time to be in Air 

Force and military medicine. I couldn’t be more proud of this great 

team. 

We join our sister services in thanking you for your enduring 

support, and I look forward to your questions. 

[The prepared statement of General Roudebush can be found in 

the Appendix on page 94.] 

Mrs. DAVIS. Thank you, General. 

As I started to ask you earlier about the health IT system, this 

is obviously something that is of great concern. Going back to 

March, along with the Subcommittee on Terrorism and Unconventional Threats and Capabilities, this committee held a joint hearing 

on the Department of Defense’s health information technology systems. And we heard from the services about the difficulties that 

they were really having with the AHLTA system. 

We were encouraged to hear from Health Affairs that you agree 

that there are serious problems, and even more encouraged when 

you presented what appeared to be an ambitious and comprehensive plan to overhaul the system to address all the issues raised 

by the services and provide the best health IT system possible for 

the Department’s beneficiaries. 

And at that particular hearing, Dr. Casscells and you also, Mr. 

Campbell, assured us that you were committed to moving forward 

with your proposed solution but that you could not discuss cost details because both the fiscal year 2009 supplemental request and 

the fiscal year 2010 budget were still in progress. 

But now that we have received the 2010 budget justification materials, we can’t seem to find any mention of any of the promises 

that you made during the March hearing. And a review of the fiscal year 2009 supplemental request did not turn up any mention 

of that plan either. So, as you can imagine, we are trying to understand that. 
14 

And sometimes this kind of conflict is not really unprecedented. 

During preparation of last year’s National Defense Authorization 

Act, Mr. Campbell, you and Dr. Casscells both assured us, during 

a Member briefing, that you were aware of the problems with 

AHLTA and would provide us with a plan to fix the problems. 

And following that meeting, Health Affairs provided us with a 

roadmap for the way ahead. But, again, none of the elements of 

that roadmap ever found their way into either the 2008 supplemental request or fiscal year 2009 budget request at that earlier 

period. And so, we have some concern that things are not moving 

forward. 

Could you please share with us what is going on? What is happening in the decision-making around the issue? And when will we 

see some fulfillment of the commitments that were made to the 

committee back in March? 

Mr. CAMPBELL. Yes, ma’am. Thank you for the question. 

Going back to the 2007 discussion that we had, as you mentioned, it wasn’t in the budget for that year. What we did, though, 

is, within the budget that we had, we focused our efforts to meet 

the requirements of the theater health information systems that 

were—— 

Mrs. DAVIS. If you could get a little closer to the mike. Thank 

you. 

Mr. CAMPBELL. Sorry, ma’am. 

So we focused that year, in 2008, and part of also 2009, we continued to focus our efforts on the theater health systems. And within our budget at that time—we didn’t ask for additional dollars, but 

within our budget at that time we implemented that services-oriented architecture approach that we had talked about for doing the 

larger-scale system and have made some great improvements in 

that, in setting up that application or that system that allows us 

to more quickly develop capabilities for the users and to allow us 

to more seamlessly share that information across DOD and across 

the VA. So that was implemented over last year, in 2008, and we 

are still working that in 2009 within our current budget. 

You are absolutely right in that, when we were here in March, 

we had a very comprehensive plan. We still have that comprehensive plan. It wasn’t complete at that time. I think we mentioned 

that at the end of March was when the blueprint was going to be 

finished. The blueprint was finished and turned in. And we are in 

discussions right now on how we are going to implement that within the current budget. 

So we are doing things to improve the systems now with our current baseline. For example, one of the key components that the 

services and others have mentioned to us is maintaining the stability of the system. A key to that stability is our one central data 

repository that we have where all of the information is stored. If, 

for some reason, that goes down and is not working, then everyone 

goes into a failover mode. 

So we have focused some efforts recently, within the last two 

months, on stabilizing the central data repository so that we can 

keep it up and running. And we have made some good improvements on that. 
15 

Mrs. DAVIS. Mr. Campbell, could you identify the dollars that you 

have available to you to do this work? 

Mr. CAMPBELL. Within our current budget? 

Mrs. DAVIS. Yes. 

Mr. CAMPBELL. Yes, ma’am. Within our current—I think it is the 

2009 budget, I think for the total electronic health record system 

in our current budget, I believe it is around $500 million, in our 

current budget for 2009, for all parts, all components of the electronic health records system. That includes the infrastructure 

piece, that includes the central data repository, the old legacy system, Composite Health Care System (CHCS). 

A lot of that money is used to sustain our current efforts, but it 

also has some dollars in there for development and for procuring 

new equipment. 

Mrs. DAVIS. What would you anticipate then—where are the 

shortfalls going to be? Are there any, in terms of being able to do 

all the work that you really feel that you need to do to speed up 

this effort? 

Mr. CAMPBELL. And, ma’am, we are going through that right 

now. We are analyzing that now to determine where all of the 

shortfalls are, what other parts of the electronic health records system we can postpone fixing until we fix these main issues. So we 

are still in the deliberations of that right now, ma’am. 

Mrs. DAVIS. So there are some areas that won’t be addressed? 

Mr. CAMPBELL. The focus will be to fix the stability, the performance, and the usability of AHLTA. 

Mrs. DAVIS. Is there a sense of how important this is? 

Mr. CAMPBELL. Absolutely, ma’am. Absolutely. This is key. We 

understand—and, you know, we have had many different forums 

where we have talked to the users, whether it is through the Web 

halls, through town hall meetings. I have gone out to many facilities and directly talked with the providers there. We absolutely understand how important this is to fix this and make it right. 

What we are doing with this not only is, though, important for 

just DOD, the stabilizing, making this work, building this new architecture we know is extremely important to support and enable 

what President Obama mentioned was the, you know, virtual electronic record with VA. And so this does support and enable that. 

So we understand how important this is, ma’am. 

Mrs. DAVIS. For people who are watching and for families out 

there, I think we talk about the system itself, but how does this 

really affect the men and women who serve and their families? 

Why is it important to them? 

Mr. CAMPBELL. From my perspective, ma’am, it is important for 

the users, the providers who use the system, who treat the patients, to have all of that information available wherever they are 

at and all of the information that they need to provide that care. 

It is absolutely important that they have that information and it 

is always available and the data is always available and the system 

is always available. 

So we understand how important it is to the individuals. And not 

only that, from the longitudinal health record perspective, we understand how important it is to capture all of that information electronically so that, when a service member does retire or separate 
16 

and goes to the VA, they get all the benefits that they have earned 

and deserve. 

Mrs. DAVIS. I wonder if the surgeon generals would like to respond. Is that a satisfying answer to you? And what information 

could you share with us, as well? 

General SCHOOMAKER. Well, ma’am, I will take a stab. 

I mean, I completely concur with what Mr. Campbell just talked 

about, as far as the central role of electronic health record. I mean, 

quite honestly, we are in an era—— 

Mrs. DAVIS. I think I am referring more to the issue we have 

around the budget and whether or not we are going to be able to 

do the work that is required and in a timely fashion. 

General SCHOOMAKER. Well, I can’t speak to that as much. I 

mean, I can tell you that, since the hearing earlier, the joint hearing that was held around the information system, certainly Health 

Affairs has redoubled their efforts to bring the services inside the 

building of a comprehensive strategy, rather than to piecemeal a 

plan that just Band-Aids over problems. I am getting feedback from 

our representatives on that group that we are doing some very serious, truly building the comprehensive strategy. 

Mrs. DAVIS. That is good. Would you say that that wasn’t the 

case before? 

General SCHOOMAKER. No, ma’am, I wouldn’t. That is what we 

said at the time. 

Mrs. DAVIS. Okay. Thank you. Good to hear that. 

Admiral. 

Admiral ROBINSON. I am always careful when I get into the IT 

world because it is not something that I know a lot about from a 

technical point of view. 

From a patient- and family-centered care point of view, the question you asked is, how is this important to the men and women, 

our beneficiaries? And the essence of care centers around the availability of relevant information that can be easily attainable at any 

time of the day and night in any place in the world. 

So the impact of the casualty care system that we have encountered in Iraq, Afghanistan, with the CCATTS, with the Army, 

Navy, Air Force coming together, part of that has been based upon 

having good information. We have to have the same type of electronic medical records system in this country. 

And I would also say, it is a patient issue, but it is also a provider issue. Our providers, in all services, want to have, must have, 

a capable system that is user-friendly and that will allow them to 

make the encounter with their patients the most meaningful and 

with the best quality of care. So this hits a number of issues, but, 

at the essence, it is the patient and the care issue and the quality 

issue that this becomes extraordinarily important. 

There comes a point when trying to get it done isn’t good enough; 

you have to get it done. And I am speaking now as a surgeon and 

as a physician, not as an administrator. You just have to—sometimes you have to get it done, and you have to get it done right. 

I think that we are at the point now where Health Affairs—and 

Chuck and Mr. Campbell and all of the folks—are, in fact, doing 

the best that they can. But we really have to solve this because 
17 

this becomes a quality and a care issue that is not going to go 

away, and we will have to get this solved. 

Mrs. DAVIS. Thank you. 

General. 

General ROUDEBUSH. Ma’am, I would certainly echo the thoughts 

provided. Information that is accurate, timely, and available is absolutely essential to the standard of care that we provide at home 

and deployed. It is absolutely critical to providing that level of care 

that is both expected and deserved. So I think everything that we 

need, in terms of delivering that care, needs to be present. Information is a central piece of that. 

I would agree that the emphasis is appropriately provided. I 

think we are all in agreement that this is a central and critical 

issue. We are also in agreement that we have great work to do, 

much work to do, and that there is much yet to do. 

I would offer one additional perspective. It is very important to 

the patient, no doubt about that. It is very important to the provider to be able to deliver that kind of care. But I would also suggest that it is an important retention issue for our providers, because it is a source of great frustration and very time-consuming 

as our medical professionals attempt to have balance in their lives, 

as well, between a satisfying and engaged practice of medicine at 

all locations—personal growth, professional growth, and time with 

their families. Having an information system that is an ally and an 

asset in delivering that care, finding that balance is important. 

And AHLTA, frankly, has not been a positive factor in this discussion. It needs to be. And I believe the leadership has the appropriate focus. We will work to assure that we have the right plans 

and strategy in place. But we need to see that progress; this is a 

‘‘show me’’ discussion. 

Mrs. DAVIS. Uh-huh. 

General SCHOOMAKER. Ma’am, at the risk of being gaveled down, 

I just have to pile on the one aspect. I mean, you held me to a discussion only about whether this can be done with the funding 

available, but I just have to add my thoughts to what my colleagues have said about how critical this is. 

We tend to think of an electronic health record as an electronic 

way to manage our checkbook. But we have gone way beyond that. 

We are now in the realm of knowledge management, so that your 

checkbook is now embedded with an electronic universe where you 

are literally seeing the evolution of knowledge about how to use 

your money, how to invest it, where to place it, in real time. 

And it is a very simple analogy, but one of the things that I 

would respond to you earlier in your question about how we are 

going to contain health care costs is by exploiting this knowledge 

of the network that we are developing. 

I will give you two real quick examples. Earlier last year, the 

Food and Drug Administration (FDA) released a warning about a 

drug that was in common use. And they were getting anecdotal response that this was a potentially dangerous drug and it had side 

effects, but had no idea how big the denominator of use was. We 

were able to go in, through our electronic health record and the 

fact that we have catalogued all of those pharmaceutical uses and 

prescriptions, as well as any side effects and symptoms that are out 
18 

there, and almost immediately respond that, ‘‘Wait a minute, in 

our universe of users of this drug, we are not seeing problems, and 

it is probably far safer than you think it is.’’ 

H1N1 is another good example. We are able to monitor syndromes of illness, in real time, in people who show up at our hospitals and clinics, so that we can literally identify people who 

might be carriers of H1N1 and then surge to respond to that. 

I mean, that is a knowledge network. And so it is organic to how 

we now give care. In fact, I monitor the use of AHLTA and the 

electronic health record not as an information measure of performance but as a clinical measure of performance. Does that make 

sense? 

Mrs. DAVIS. Yeah. Absolutely. 

And I think one of the issues that we have heard from men and 

women who are serving is even their location in the war theater 

and some of the problems that they are experiencing, how close 

they were to explosions that were occurring and whether or not 

those were deemed to be sufficient enough to have created a traumatic brain injury (TBI) or whatever that may be. And I think all 

of that kind of information is certainly critical. 

Thank you. I appreciate that, and we may come back to it. I certainly want to let Mr. Wilson weigh in here. 

Mr. WILSON. Thank you, Madam Chairwoman. 

Thank you all for being here today. 

Mr. Middleton, the National Defense Authorization Act for Fiscal 

Year 2008 required the Department of Defense to establish a joint 

pathology center (JPC). Can you tell us what the status is of the 

creation of that center? 

Mr. MIDDLETON. Yes, sir, I can. We have an extensive working 

group that is looking at the mission that is described by the National Defense Authorization Act. As you know, that requires a certain management of the military referrals for pathology to oversee 

the tissue repository that remained from Armed Forces Institute of 

Pathology (AFIP). Will not be doing civilian consults, as you know, 

as well. So it is under way. 

The placement of it in the organization is still being discussed. 

The Defense Health Board has looked at this, which is an independent advisory board that convenes at the behest of the Secretary of Defense, has looked at the JPC to figure out and make 

recommendations about the joint pathology center, its organizational location, et cetera. 

So I think we are well on our way to implement what was described by law, for us build the JPC and, in concert with that, close 

down AFIP, which was described in the 2005 Base Realignment 

and Closure (BRAC). 

Mr. WILSON. And there would be an opening date goal? 

Mr. MIDDLETON. Yes, sir. 

Mr. WILSON. And when would that be? 

Mr. MIDDLETON. I will take that for the record and get back to 

you, sir. 

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

page 113.] 

Mr. WILSON. Good. Thank you very much. 
19 

And for our surgeon generals, I want to thank you all for your 

service. I am very, very grateful, as the son of a veteran; General 

Schoomaker and I were speaking a few minutes ago about my dad 

serving in the Army Air Corps. I am very grateful I served 31 years 

in the Army Guard and Reserves. I am particularly grateful that 

I have four sons currently serving in the military. And, with that 

background, I am so appreciative. 

To me, I want more Americans to know and understand that 

American military medicine is the best ever. You are leading the 

world in prosthetics, promoting the ability for people to have replacements of arms, legs, hands. It is extraordinary what you are 

doing. 

And I had the privilege of visiting with Major David Rozelle at 

Walter Reed, and I have visited Bethesda, I have visited Balad. I 

am grateful for the Wounded Warrior Programs that I have seen 

at Moncrief Army Hospital at Fort Jackson, at Beaufort Naval Hospital. 

It is just so impressive what you are doing. And for the general 

population, it is going to be so helpful. And I want, particularly, 

persons who are in the military, their families, and then prospective members and their families to know that military medicine is 

the best in the world. 

Additionally, with trauma care, particularly with improvised explosive devices, with brain injury, head injury. When I served in 

the State Senate 20 years ago, I worked on head injury issues, and 

now, thanks to military medicine, it is better than ever. I want to 

thank you. 

And in regard to mental health issues, I really want family members to know that the military is uniquely situated to help people 

with mental health issues. General, you mentioned your battle 

buddy right back there. That is the way the military feels, and that 

is that each person who serves in the military, it is like a giant 

family. You care about each other. And you also have a finite population; you have a somewhat controlled population. 

And so people should know that the ability for mental health 

care, I think, is better in the military than any other segment of 

our population. And I am the former president of the Mental 

Health Association. I have worked on this issue for 40 years. And 

so I know the extraordinary abilities and efforts that are being 

made for our personnel. 

A concern I do have is screening prior to recruiting persons. And 

then, we know the stresses of normal life—and that is, it can be 

financial, it can be the breakup of a family, it can be a divorce, 

child custody, it can be drugs and alcohol. But what is being done 

for prescreening, and then what is being done for our service members who have not just post-traumatic stress disorder but the normal stresses that Americans and world society face? 

General ROUDEBUSH. Sir, we, the military, live in the broader 

population of the United States. As men and women raise their 

right hands, swear to support and defend, we are drawing from 

communities across the Nation. We have individuals who come to 

us in good health. They are appropriately screened in terms of 

their physical and mental health history. But each one arrives as 

an individual, with their own set of coping skills, their own history, 
20 

if you will. And, as a military, our job is to assure that they are 

provided the support that they need in order to both serve and operate in some very demanding environments, but to also have the 

help and support that they might require at some point, if, in fact, 

circumstances dictate. 

I believe our screening is appropriate. I believe our screening is 

bringing us individuals of good physical and mental ability. I think 

it is incumbent on us that we continue to have very strong continuing screening and surveillance to assess and detect circumstance as they occur during an individual’s period of service 

and to have the capabilities to intervene appropriately as we move 

through. 

So I believe that our pre-screening and our pre-assessment 

brings us good individuals willing and able to do our Nation’s work. 

And our job is to ensure that we continue to support them in that 

endeavor and to have the right capabilities to assist them if such 

assistance should be required. 

Ms. SHEA-PORTER. The first one has to do with the report that 

the defense contractors have been receiving medical care and not 

reimbursing the Federal Government. It has been costing taxpayers about $1 million a month for that. And indeed, when the 

Inspector General (IG) took a look at the report, you didn’t even 

have any standards set up or any way for military medical personnel to keep track of how many people they were treating. And 

so my question to you is, why did that happen? Why did the taxpayers have to pay, in addition to all of the other money they pay 

contractors, a million dollars a month for the medical care? And 

what are you doing about it, please. 

Mr. MIDDLETON. Thank you. 

The issue of how that happened, I think, had to do with exigencies of a war situation and moving many contractors in where we 

hadn’t seen that before; providing emergency care for those that 

are injured in the line of their duties during the period of their 

time; and our lack of those kinds of business operations systems in 

the deployed setting. 

In our civilian setting, we have collections, and we have registration. We have scheduling. We have all of the revenue cycle issues 

that you would see in a normal health care setting. We didn’t have 

all of those initiatives, those things, in a deployed setting. 

Ms. SHEA-PORTER. Well, can I interrupt right now and ask, why 

not? Because when they drew up the contracts, they are pretty detailed contracts for pretty much everything, and the contractors 

manage to get in coverage for many, many things. And so if we 

were putting that much attention to contracts in general and knowing that they would be requiring medical care, I don’t understand 

the answer, if I understood you correctly, that we were too busy, 

too rushed, too many people coming in. Because they managed to 

take care of their part of the business contract, and I think that 

we should have taken care of the taxpayers’ part of the business 

contract. 

Mr. MIDDLETON. I would certainly agree with you, ma’am. And 

as a result of that Government Accountability Office (GAO) report, 

we have taken a look, with the Services, to take a look at what we 
21 

can do in that deployed setting in order to capture that information 

that we need in order to make those claims for health care dollars. 

So we didn’t ignore that GAO report. We are certainly going to 

take action on that GAO report. In fact, there is a working group 

that I am familiar with that is actually looking at that right now 

in fact to figure out how we can go about doing that process. 

Ms. SHEA-PORTER. Will we be reimbursed? 

Mr. MIDDLETON. I don’t know the answer to that question, 

ma’am. I don’t know the contractual arrangements of that for that 

particular answer, but I will certainly take that back as part of the 

work group to find out. 

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

page 113.] 

Ms. SHEA-PORTER. Thank you. 

And then the second part is I wanted to ask you a question about 

dwell time. I was an original cosponsor of requiring more dwell 

time for our troops. And as a former military spouse, I think this 

is absolutely essential for these family members to have this. My 

husband never went into combat, but it was during the Vietnam 

era, and we certainly saw a lot of the fallout, if you will. 

And so my question is, how much time do you think our military 

men and women need as a minimum for dwell time? And are there 

any plans to create more dwell time for them? 

Mr. MIDDLETON. Ma’am, I don’t think that is a question that I 

would have the answer to personally. That is not something that 

is in the cognizance that I have and the responsibilities that I have 

been given. Not to defer to the surgeons, but they may have better 

insight on that from the service perspective. 

Ms. SHEA-PORTER. I am happy to do that. I was going to work 

my way right now. Thank you. 

General SCHOOMAKER. Well, ma’am, the Army does focus on 

dwell time. It has been a major frustration to Army leadership and 

soldiers and families that the demand on soldiers, prior to the 

growth of the Army, has really demanded deployments with sometimes dwell times, that is time back at station with family, that did 

not equal to or exceed the amount of time spent deployed. That was 

especially true during the surge when we went to 15-month deployments. 

I was asked by another committee last year about what I felt on 

the medical side and, especially from the standpoint of behavioral 

health, what the optimal deployment length was, and at that time, 

based upon the results of the—and this is a medical response, not 

an operational response. I mean, the operational—the length of a 

deployment is much driven by and dictated by the operational requirement. 

Below a certain point in the Army, for troops on the ground, one 

could make the argument that it is dangerous; that one needs to 

have sufficient time to have continuity of command and to learn 

and to operate effectively and in theater. But based upon the results of the Mental Health Advisory Teams that we have put into 

Iraq and Afghanistan now, the sixth one is on the ground now in 

Afghanistan and has just finished in Iraq, I responded by saying 

that I think there are three factors. 
22 

One is the length of the deployment. We know that after nine 

months or so, deployment length for soldiers is quite onerous. 

Above 12 months and into 15 months, we saw very clearly that 

problems began to almost grow exponentially. 

I thought the second factor is dwell time. And at that time, I 

gave the kind of seat-of-the-pants answer that the best advice I 

could get from those who have experienced that is 18 months minimum. 

I think the current Mental Health Advisory Team, which is just 

coming back from Iraq and Afghanistan, will give us some of our 

best data. And I have not seen that data yet, and I am anticipating 

it coming out, and it will help give us an idea of optimal dwell time 

is. 

And then the last thing I said was the number of deployments, 

frequency of deployments. 

So I think it is a function of length of deployments, dwell time 

between deployments, and the frequency. All three are determinants. The Army’s aspiration is to have soldiers dwell, you know, 

at minimum 24 months between deployments, so you are one out 

and two back. And for the Reserves, to be on a more generous cycle 

of four to five years of dwell between deployments. 

Does that answer your question? 

Ms. SHEA-PORTER. Thank you. Yes, and I know you have had 

concerns about this issue, and I appreciate it. 

Admiral ROBINSON. I think that General Schoomaker summed up 

my view on this very much in his three answers, and I think that 

the dwell time is absolutely incredible. 

I think that the thought on dwell time has been what my mental 

health experts have said is a way to not only reset the individual 

but also reset the family. So it is not just a soldier, sailor, airman, 

or an active person’s reset; it is also a family’s reset. And it has 

to occur over a length of time where the reset can actually occur. 

That was my only addition. 

Ms. SHEA-PORTER. Thank you. 

General ROUDEBUSH. Yes, ma’am. 

And from an Air Force perspective, of course, this is a line discussion which by extension we certainly reflect from a medical perspective our support of the line activities. 

General Schwartz has made it very clear that the Air Force is 

all in, so the driver is the demand signal: What is required to support the mission, wherever we find it in the world? 

Now, having said that, we also understand that for a repetitive 

aerobic deployment cycle, that dwell time is critically important. So 

as we look at the operational requirements, which at times may require an extended deployment to work effectively in some of the environments, building relationships, working extended programs 

with individuals where that relationship is paramount, can drive 

some of those operational requirements, and that exists medically 

as well. But our line leadership has been very forward leaning 

about matching the pipeline to the demand signal. 

And if we need to make a difference in terms of building more 

of an asset, could be low-density, high-demand asset, in order to increase the opportunity for individuals to deploy, but then come 

back home, retrain, reblue, reintegrate with family before the next 
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deployment experience, that is a key parameter of what we do. Our 

banding efforts in doing that I think have gone a long way. 

But I share my colleagues’ concerns that, that dwell time is critically important for an All-Volunteer Force, the majority of whom 

have families and want to continue to serve and do so effectively. 

Ms. SHEA-PORTER. Thank you very much. 

Mrs. DAVIS. Thank you. And I am going to follow up, and I understand you have another question, and we will come back in a 

second. 

As we have spoken about this, we know how important it is. And 

getting back perhaps even to the IT system, how much tracking is 

done of the number of deployments that people have had and that 

our service members have had and their dwell times? And how is 

that communicated to the military leadership, the commander on 

base and some of the subordinates there? Because I am just wondering whether there is an appreciation of what that service member has gone through and how that factors into any other relationships or any other concerns that are made. Is that information 

readily available, and how is it used? 

General ROUDEBUSH. Ma’am, I can speak to that from the Air 

Force. 

Our Air Force Personnel Center and our Air Expeditionary Center, which oversees both deployment and operational engagement, 

follow that very closely. Particularly if in fact an individual may 

deploy, come back to home station, and then be transferred to another home station; do they enter into a new environment where 

that deployment is not recognized? No. That is tracked through. 

Now, from a medical perspective, we also track closely on cohorts 

of individuals perhaps at increased risk, our explosive ordnance 

personnel, our terminal attack controlling personnel, among others, 

security forces, because their exposure and their experience puts 

them at higher risk of post-traumatic stress, TBI, those sorts of 

outcomes. So we track them as well to assure that we are monitoring and supporting them over an extended period of time and 

not simply during a singular deployment. 

Admiral ROBINSON. From the Navy’s perspective, Navy Personnel 

Command has this wrapped up very tightly. It has been an interesting evolution because, in this particular conflict, or conflicts, or 

wars, there have been individual augmentees. So there has been— 

and on the Navy side, there are 14,000 individuals, and there are 

comparable numbers on the Air Force. The Army and Marine 

Corps side have the same, but they also have units. So for the services that have had the individual augmentees, it has become a 

challenge at the very beginning to make sure that we did keep up 

with them and make sure that we did know who was coming in 

and out of certain theaters and where they had been. And when 

they got transferred—and this is very important—or even when 

they came back to their home station, often there would be people 

there or whole groups of folks that wouldn’t understand where that 

individual had been. 

So this has been taken up from Chief of Naval Operations (CNO) 

and Chief of Naval Personnel, and these are tracked. We are right 

on top of where the individuals are, where they have been. We absolutely wrap them up and keep a close contact with who is gone. 
24 

And in some instances, we even, in some types of positions and 

jobs, we even have policies in place that you don’t repeat a deployment or you don’t repeat the same deployment for that individual. 

You have to get new people in. It depends on what the situation 

is. But they are very well tracked, and the Navy Personnel (PERS) 

and Chief of Naval Personnel has this information. It is readily 

available to all of us who need it. 

General SCHOOMAKER. And, ma’am, for the Army it is exactly the 

same thing. The personnel community tracks this down to the day, 

and it is reported to the very highest level. I know that all senior 

leaders of the Army, the Chief and Secretary and Vice Chief level, 

track this extraordinarily closely. 

Rather than just repeat everything that my colleagues have said, 

because it is identical in the Army, let me just comment about 

when in dwell. Another thing that has become very evident to us 

is that when back home, if you return from combat and then almost immediately go out to train, it is equivalent to being deployed 

again, although not to a combat zone. So there is a lot of focus 

being placed upon reintegration and reset. 

In fact, I think the chief’s ambition is that we have an almost 

inviable six-month period once a soldier returns where they can reintegrate and reestablish with family, that we can do the necessary 

screening for the emerging symptoms that they may experience 

from post-traumatic stress and the like, and that we can institute 

that human dimension reset that we have talked about. 

And I think what we are learning, and your questions are very 

well poised to address, is what is the human dimension inside of 

these almost institutional and industrial processes of iteratively 

preparing a soldier to go to war, deploying that soldier, and then 

bringing them back and reset. You can reset the equipment. You 

can reset their tactics, techniques and procedures, but the human 

dimension sometimes is on a different time scale. 

Mrs. DAVIS. I think one of the concerns that I have heard is, it 

partly relates to readiness, but the fact that a smaller percentage 

of men and women are able to actually return to theater after multiple deployments, or that we are relying I think on a smaller proportion of people who are serving. Is that a correct assessment? 

General SCHOOMAKER. Ma’am, I don’t think that is an entirely 

accurate depiction of that. 

I mean, some of the most frequently deploying units are, for example, Special Operations units, which have deployed maybe 10 

times or more. And deployment experience alone—I mean, in suicide, for example, suicide is not necessarily predicted by more frequent deployments. In fact, a third of Army suicides are in soldiers 

who have not deployed at all. And as one deploys more, what we 

are finding is that the suicide rate drops. 

Now, that might be a reflection of the fact that once—that if you 

have difficulty with deployment, that you are unlikely to remain 

longer after that first deployment. And so that we enrich for a population of families and soldiers who can endure multiple deployments. 

Mrs. DAVIS. Are we pulling people from theater when we do see 

after several deployments that in fact this is not something that is 

going to move forward with a good outcome for them? I mean, is 
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that something—do we have numbers that are being assessed once 

returning to theater that it is not a good idea for them to be there? 

General SCHOOMAKER. Well, we certainly in theater very aggressively address in-theater behavioral and mental health. We have, 

again, one of the major efforts of Mental Health Advisory Teams 

that have been going in for the last six years was to exactly assess 

that: What was the level of mental health support? And was it 

available to a very disbursed force, both in Afghanistan and Iraq? 

As you saw the other day in the tragedy, I mean, this was a Combat Stress Control Team that was out there with soldiers and Marines and others and sailors that was conducting health care on the 

battlefield, literally. 

Mrs. DAVIS. Mr. Wilson. 

Mr. WILSON. Another perspective on deployment, I know our office has helped expedite in my local community with the National 

Guard one of the most prominent certified public accountants 

(CPAs) in our community who wanted to be transferred from one 

National Guard unit to the other to be deployed. 

And then, Admiral, I am very grateful that, at Fort Jackson, 

South Carolina, the augmentees you mentioned, the sailors, the 

naval personnel are being trained there to be sand sailors. And it 

has been very inspiring to me to go out and visit these sand sailors 

as they are on their way to Iraq and Afghanistan. And when I visit 

with them in Kabul or Baghdad, they are so grateful for their opportunity to serve. 

And I am also very pleased, I can now also mention my Air Force 

connection, I am very proud to have a nephew who has recently returned to theater, and it is his second deployment. And these are 

volunteers. They want to serve. They want to protect our country. 

So thank you very much. 

General ROUDEBUSH. Madam Chairman, if I might. If I could put 

one other perspective on your scope. 

We have significant numbers of people who do not in the traditional sense deploy. Our airlifters, who are moving people and 

things critically important to our effort as well as providing air 

medical evacuation around the world, do not deploy. But they are 

gone from home for extended periods of time, launching every 90 

seconds around the clock, 24/7, 365. They, too, need to be very carefully supported and attended to because of their critical piece of the 

mission. 

We have unmanned aerial vehicle (UAV) operators at Creech in 

Nevada who don’t deploy but have not had leave, have not had 

time away, have been basically focused on providing that 

unblinking eye above our Marines and soldiers in important parts 

of the world who have a particular kind of stress that applies to 

their life and their world as well. 

So it is broad spectrum of people who serve who may not traditionally deploy but are pulling their boots on every day to serve 

combatant commanders and our Nation in a variety of ways that 

we can’t lose sight of either. 

Mrs. DAVIS. Thank you. 

Just one quick follow-up, and then I want to go to Ms. Shea-Porter. 
26 

I know we have done a far better job in trying to educate our 

military leadership in the field at all levels in which they are accountable for their troops to be more aware, to be able to help 

share information, to create an atmosphere where people are comfortable. But I am wondering if there are some ways in which we 

can do an even better job there in trying to help them in how they 

help their troops deal with the death of comrades, best practices or 

trying to at least—everyone is not going to respond to the same 

way to these tragedies, but perhaps helping them understand better the way that the next few days weigh out really for them makes 

a difference in the way people are going to be able to handle. 

How much time are we really spending in trying to help educate, 

to consult, to counsel them in that way? It is a busy theater. There 

is not a lot of time to do that. And I am just wondering how critical 

it is and whether we just need to think more about how we do that. 

General SCHOOMAKER. I will tell you about three initiatives the 

Army has undertaken in the very least. One was about a year ago, 

the senior leadership of the Army initiated really an unprecedented 

chain teaching effort, right from the very top of the Army, the 

Chief of Staff and the Secretary right down to the last soldier, to 

impress upon them the importance of reducing stigma and recognizing that the human cost of deployment and exposure to combat 

for all humans was experiencing some degree of behavioral and 

health challenge and emotional challenge. 

We are working in the comprehensive soldier fitness arena to 

make that experience not a lifelong disability, but actually to exploit post-traumatic growth, because as many more people return 

from this experience having been enriched in the sense of having 

seen a meaningful aspect of their life in uniform that they didn’t 

experience before. That goes back for many wars and many militaries. So that was the first. 

The second is a more recent effort to intervene and prevent suicide, in which we have had a mandatory standdown as an Army, 

with small unit teaching by facilitators using, in a very good interactive video, called ‘‘Beyond the Front,’’ in which you role play several different roles. One is a young soldier who is deployed and is 

experiencing many challenges to include the breakup of a relationship back home, a loss of a buddy in combat, financial issues, and 

the like. And you work through this interactive video. 

The other is, back in home station, a senior NCO who has got 

a fellow NCO who is literally falling apart in front of his eyes with 

family problems, alcohol use, and the like. And you are asked in 

this interactive fashion to make decisions what you are going to do 

and then go down those branches and sequels, and then go back 

and restudy it. 

Those are just several very important efforts that we have undertaken to educate and train. 

The last is the Battlemind Training. The Army has developed a 

series of sort of branded tools called Battlemind Training that prepares soldiers and families to be deployed, and then are used even 

in redeployment that sensitize the entire force to, again, the emergence of symptoms and problems that are associated with service 

and deployment. And these have been integrated into all enlisted 

and officer training throughout the life cycle of every soldier so that 
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they are exposed, again, to your point being made, that, are we 

making efforts to educate and train? Absolutely. 

Mrs. DAVIS. Thank you, General. And I guess the next question 

is, how are we evaluating that? And are we going to be able to— 

I am interested and I don’t know. 

General SCHOOMAKER. Battlemind has actually been validated. 

And the Mental Health Advisory Teams have seen in subsequent 

years that stigma, for example, has been reduced when they go out 

and survey the force. 

Mrs. DAVIS. Thank you. 

Ms. Shea-Porter. 

Ms. SHEA-PORTER. Thank you. 

I really appreciate your sensitivity, all of you, to the needs of the 

military. I want to talk about their families. And I know you share 

those concerns. But I had a chance to mention to Secretary Gates 

the other day to please consider this, and I wanted to bring it up 

to you also. 

I know and I have heard some stories about children whose parents are both deployed in theater. And I worry about the impact 

on the children. I do know that the mission has to come first, and 

that if you need personnel, you need personnel. However, I would 

like to ask how much consideration you give to those couples who 

have children who are seeing repeated deployments. 

And the stress on the children is pretty awful and the stories 

that the parents tell are heartbreaking. And so, can you give me 

an idea of how many, first of all, parents are there who are both 

deployed in theater, so that I can see the extent of the problem? 

And what is being done for the children and the families to try to 

minimize the impact? Are you trying to rotate so they are not both 

in theater, et cetera? 

General ROUDEBUSH. Ma’am, I can speak from the Air Force perspective. That circumstance is, fortunately, relatively rare. Our Air 

Force Personnel Center and the Air Expeditionary Forces (AEF) 

center do work to avoid simultaneous deployments. 

But I would also add that the family has the opportunity to 

weigh in on that both in terms of providing plans that are appropriate for their family to assure that the youngster, if in fact the 

circumstances might dictate a simultaneous deployment, to place 

those children in the most appropriate place, whether it is with a 

close relative, whoever might be the most appropriate. 

Ms. SHEA-PORTER. The problem with that is that with repeated 

deployments it is more and more difficult for those. And plans fall 

apart. People who have the best intentions suddenly have circumstances change. And so I appreciate the fact that there are 

plans, but we both know that life gets in the way of plans. 

General ROUDEBUSH. I don’t diminish the importance of that at 

all and understand that certainly can occur. But to the extent fully 

possible, our Personnel Center, our AEF center, including the individual’s commander, those individuals’ commanders have a voice in 

that decision. So we do find that to be relatively rare in the Air 

Force. 

General SCHOOMAKER. Ma’am, for the Army, I would have to 

take it for the record as to what the actual numbers of both parents being deployed are, and we will get that back to you. 
28 

[The information referred to can be found in the Appendix beginning on page 113.] 

General SCHOOMAKER. But I think we have a number of singleparent families that for whom the parent is deployed, and so some 

of the concerns I think that you have expressed with both parents 

being gone extends to those families as well. 

I can tell you that there are several initiatives ongoing within 

the Army and the military community in general about this. Our 

current Secretary of the VA, Secretary Shinseki’s wife, Patty 

Shinseki, is very active in the Military Child Education Coalition, 

which is doing outreach into the education community to find support for children and to be sensitive to the needs of military children, especially those for deployed parents. 

There are pilots ongoing in the Pacific Northwest around Fort 

Lewis, Washington, and Tripler Army Medical Center in Hawaii for 

that right now, and they are undertaking a number of studies and 

outreach programs and educational for that. 

Our chaplains are playing a very role, too, with outreach to the 

ministerial community to extend services and be sensitive to it and 

be monitoring and helping our children in those kinds of situations. 

So I think there is great sensitivity about what you are addressing, 

ma’am, and we are looking very actively at that. 

Ms. SHEA-PORTER. Is there any particular place they can go 

when a family feels strained to the breaking point? And what is the 

procedure? How would a mother, for example, say, I thought I had 

a good plan, but then my husband got deployed, and we left the 

kids with grandma, but she got sick, and then we passed the children off to so and so? Do you have some kind of caseworker or person assigned to follow, and I am sure that the number of families 

aren’t that great, but to work particularly with those families? Or 

do you think that would be helpful? 

General SCHOOMAKER. Ma’am, that happens. All of those assets 

are available, and starting with the chain of command for the soldier. The NCO and officer chain of command is immediately engaged in situations like that, because the health and well-being of 

that family is extraordinarily important to that command. 

Ms. SHEA-PORTER. But do they have criteria or directions, say, 

if they do take it to the chain of command, and the chain of command may or may not consider that as critical as the family member does, what is the next step? 

General SCHOOMAKER. The chaplains getting involved. The 

health care community gets involved in a sense validating or documenting the state of the family. And commanders are very sensitive to this, in my experience, and will bring a deployed soldier 

home or divert them from an assignment that they may be undergoing until that family situation stabilizes. 

Ms. SHEA-PORTER. I just want to make it very clear for the families that they know where to go and what path to take. 

So thank you. 

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

And I know that some of those questions come out of the trip 

that we took to Afghanistan over Mother’s Day and spoke to a 

number of, happened to be, mothers who were experiencing some 

of these difficulties with double-deployed households. And it wasn’t 
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easy, and we tried to support them and try and lead them to some 

of the services that might be available to them. It is tough. 

I want to thank you all very much for being here. I know we 

have some deadlines that we have to meet today. And we appreciate it. 

One of the issues that you brought up earlier and we didn’t address in any great detail was really developing the men and women 

in the health care professions that would be needed over the next 

number of years. And we also didn’t talk about the private sector 

and what we can do to encourage more professionals to come in 

and be supportive, either through other contracts or what communities services, and so that would be an issue that we will ask you 

about in written questions and look forward to some responses in 

that as well. 

Again, I want to thank you very much. 

Thank you, Mr. Wilson and Ms. Shea-Porter. 

And the meeting is adjourned. Thank you. 

[Whereupon, at 10:38 a.m., the subcommittee was adjourned.] 

A P P E N D I X 

MAY 15, 2009 

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WITNESS RESPONSES TO QUESTIONS ASKED DURING 

THE HEARING 

MAY 15, 2009 

(113) 

RESPONSE TO QUESTION SUBMITTED BY MR. WILSON 

Mr. MIDDLETON. Based on the recommendations of the Joint Pathology Center 

Work Group (JPCWG), the Defense Health Board, and the Senior Military Medical 

Advisory Committee, the Assistant Secretary of Defense for Health Affairs selected 

the Joint Task Force National Capital Region Medical’s (JTF CapMed’s) proposal to 

establish the federal joint pathology center. JTF CapMed, with input from the 

JPCWG, developed a concept of operations and an implementation plan for the center. Initial operating capability is targeted for July 2010 and full operating capability is planned by mid-September 2011. [See page 18.] 

RESPONSES TO QUESTIONS SUBMITTED BY MS. SHEA-PORTER 

Mr. MIDDLETON. Billing and collecting for medical care provided to contractors by 

deployed medical units in Southwest Asia is being pursued. The January 7, 2007 

Office of the Secretary of Defense, Comptroller (OUSD(C)) memorandum established 

medical billing rates and requested the Military Departments to establish policies 

for eligibility, billing, and collections for deployed medical or non-fixed medical facilities. A working group, chaired by OUSD(C), is determining roles and responsibilities and developing specific policy for implementing and overseeing a billing process 

in Southwest Asia. This will include a process to bill for healthcare provided in prior 

years to contractors. [See page 21.] 

General SCHOOMAKER. According to information provided by the Defense Manpower Data Center, since 11 September 2001 the Army has simultaneously deployed 

over 2800 dual-military couples with dependents. The Army implements the Department of Defense (DoD) policy as it relates to dual-military couples with dependents 

or single parents deployed into combat zones or imminent danger areas. DoD personnel assignment and deployment policies exist to enhance the capability of the 

Military Services to meet National Security objectives. Each member similarly 

qualified takes his or her turn at assignments or deployments to various geographical regions and positions. These assignments and deployments include duty 

in imminent danger and hostile fire areas or in combat zones, without regard to relationship to other Service members. 

The nature of an all-volunteer force shapes our assignment and deployment policies. Our Soldiers voluntarily entered the profession of arms, cognizant of the possibility of assignment to hazardous duty for themselves or any other Family member 

who may be serving. Entering the military is a voluntary acceptance of the risk that 

they or a Family member might be killed, disabled, missing in action, or captured 

while serving in the defense of the Nation. It is this sense of shared sacrifice that 

helps bind the military together, enhances morale, and is the basis of an effective 

fighting force. 

The underlying principles of equality and voluntary acceptance of the inherent 

dangers associated with military service form the basis for current Family assignment policy. Currently, there is no specific DoD or Army policy that precludes the 

assignment or deployment of multiple Family members to combat zones at the same 

time. This includes both a single parent with custody of children and members of 

a dual-military couple with Family members. As such, current DoD and Army policy 

requires that dual-military couples with Family members and single parents with 

custody of children have an approved Family Care Plan (FCP) on file, which is the 

means by which Soldiers provide for the care of their Family members when military duties prevent the Soldier from doing so. The plan includes proof that guardians and escorts have been appointed and thoroughly briefed on the responsibilities 

they will assume during the Soldier’s absence. Soldiers without approved plans may 

be considered for separation from the Service. 

While these policies may seem inadequate or harsh, they are not absolute. DoD 

tempers these policies in an attempt to ensure that no single Family is asked to 

bear an inordinate share of the burden of armed conflict. The following are examples of relief available: 

(1) Existing policy addresses the concurrent assignment of multiple Family members to the same unit or ship. The policy provides for reassignment of all but one 
114 

member to a different unit or ship. Approval may not restrict the concurrent assignment to combat zones or imminent danger/hostile fire areas, but would ensure they 

are not serving in the same unit. 

(2) Consideration will be given a request for a combat deferment or exemption 

based on the Soldier or the Family experiencing severe humanitarian or compassionate problems. 

(3) Soldiers who acquire Sole Surviving Son and/or Daughter status are exempt 

from assignment/deployment to a combat zone or imminent danger/hostile fire area. 

In addition, if a service member of a Family is killed or dies while serving in a designated hostile fire area, other service members of the same Family shall be exempt, 

on request, from serving in designated hostile fire areas or if serving in such an 

area shall be reassigned from there. 

(4) A married Soldier who becomes a parent or a sole parent may apply for separation under hardship if evidence exists that the role of the parent and Soldier are 

incompatible and that the Soldier cannot fulfill his or her military obligation without neglecting the child or children. 

The current policy on simultaneous deployments of Family members, the equitable assignment policy, and the built-in exception provisions are longstanding, have 

proven adequate, and should be retained. 

The Army is also taking steps to minimize the impact of deployments on military 

children. The Family and Morale Welfare and Recreation Command ensures that 

children of dual-military parents receive priority at all child development centers. 

Families that serve as guardians for children of deployed parents have been granted 

access to military commissaries. Resources are made available to families through 

the Military Child Education Coalition and through Military and Army OneSource, 

which provide 24/7 toll-free assistance as well as short-term, non-medical counseling 

options. The Army Medical Command (MEDCOM) has established a Military Child 

and Adolescent Center of Excellence at Madigan Army Medical Center at Fort 

Lewis, Washington to promote optimal wellness and resilience in military children 

and adolescents through direct support of interdisciplinary, integrated systems of 

care, advocacy, training of staff, oversight and quality assurance, and reduction in 

stigma. The Center of Excellence is developing a better understanding of the unique 

impacts of deployment on children. It has facilitated research on the impact of parental combat deployment on children and families and presented research and findings at public forums to increase awareness. MEDCOM is in the process of identifying other sites for expansion of the concept. [See page 28.] 
QUESTIONS SUBMITTED BY MEMBERS POST HEARING 

MAY 15, 2009 

(117) 

QUESTIONS SUBMITTED BY MS. SHEA-PORTER 

Ms. SHEA-PORTER. I read the following submitted testimony by Allen Middleton, 

the Acting Principal Deputy Assistant Secretary of Defense for Health Affairs: ‘‘With 

regard to environmental health protection, Service Occupational and Environmental 

Health specialists routinely monitor air, soil, water, and other aspects of the environment in theater to detect and prevent hazardous exposures before they occur. To 

date, more than 11,000 environmental samples from Iraq and Afghanistan have 

been collected and analyzed, and new samples are constantly reassessed. Findings 

to date indicate a low risk to our Forces for any long-term health effects from environmental exposures.’’ However, U.S. bases throughout Iraq and Afghanistan dispose of large quantities of waste through burning in open pits. Fumes from these 

pits produce toxins that can present an acute health risk to our Service members, 

and these toxins include carcinogens like dioxin. The Disabled American Veterans 

has identified over 200 veterans who say exposure to these burn pits has made them 

seriously and often chronically ill. I am very concerned about the risks of the continuing use of burn pits for the health of our Service members. This practice would 

never be allowed in the United States of America. Could you please comment on 

the Department’s plans to address this potentially dangerous situation that could 

have serious impact on our Service members’ heath? 

Mr. MIDDLETON. The Department of Defense (DoD) takes its responsibility to protect the health of its personnel seriously and is very aware of the heath concerns 

relating to burn pit smoke at many of our forward operating bases in Iraq and Afghanistan. The Army, Navy, and Air Force preventive medicine teams have gathered and analyzed more than 17,000 air, water, and soil samples in the U.S. Central 

Command area of responsibility since the start of Operation Enduring Freedom. The 

purpose of the monitoring was, and continues to be, determining potential environmental health risks and identifying any hazards requiring mitigation to ensure our 

personnel are operating in a safe environment. 

In 2006-2007, Joint Base Balad was selected for a screening health risk assessment focused on burn pit smoke because it was the largest burn pit in theater and 

the large number of U.S. Service members that worked and lived close to the emanating smoke. When the health risk assessment began in early 2007, before the currently operating incinerators were in place, 163 air samples were taken and analyzed for 30 different parameters providing over 4,000 data points. The screening 

health risk assessment, using worst case exposure assumptions (breathing the 

smoke for 24 hours a day, 7 days a week for up to a year) and conducted in accordance with many of the Environmental Protection Agency methods, indicated the risk 

of long-term (including cancers) and significant short-term health effects for exposure to those chemicals was unlikely. In February 2008, the Defense Health Board, 

a Federal independent advisory committee, provided a third party review of the 

Joint Base Balad Burn Pit Risk Assessment to ensure its methodology was correct 

and its conclusions valid. This board of medical experts, including university professors and renowned scientists in the fields of epidemiology, preventive medicine, and 

toxicology determined, ‘‘Given the data available, the screening risk assessment provides an accurate determination of airborne exposure levels for Service members deployed to Balad Air Base.’’ They went on to conclude that no significant short- or 

long-term health risks and no elevated cancer risks should be anticipated among 

personnel deployed to Joint Base Balad. The DoD continues to closely assess any 

health hazards that may be associated with the burn pit smoke to ensure that our 

personnel are not exposed to hazardous agents that present a significant health 

risk. 

Over the past year, U.S. Central Command has made a concerted effort to reduce 

dependence on burn pits. Currently, 17 solid waste industrial incinerators are operational, including three at Joint Base Balad. Twenty-two incinerators are under construction with completion dates ranging through December 2009. Recycling plastics 

and aluminum and use of landfills to reduce the amount of solid waste for disposal 

have been implemented at a number of our bases. Since January 2009, used cooking 

oils and grease from Joint Base Balad have been sent to a local Iraqi rendering facility, reducing the amount of burned material. Furthermore, there are two haz-
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ardous waste and 24 medical waste incinerators operating in Iraq with nine additional medical incinerators in the acquisition process. Despite these measures, we 

will continue to need burn pits during contingency operations to control wastes and 

ensure waste does not pose a health hazard nor provide a breeding ground for disease-carrying vectors. To this extent, much effort has gone into locating or relocating pits to remote areas of bases to minimize smoke exposures, training personnel on proper operation of the burn pits, developing and circulating correct operating procedures, and assessing burn pit operations to include corrective actions. 

Ms. SHEA-PORTER. As you may know, sexual assaults in Iraq and Afghanistan 

rose 26 percent from 2007 to 2008. In previous hearings on this issue, we were informed that rape kits were not available at all forward operating bases because 

there are insufficient personnel to administer the rape kits. What steps are being 

taken to resolve this issue? 

Mr. MIDDLETON. The ability of our providers to take care of rape victims is not 

hindered by lack of availability of sexual assault forensic examination (SAFE) kits 

or other medical supplies. However, not all forward operating bases have the capability to conduct a SAFE because of training and other support requirements. Normally, a SAFE is conducted at a Combat Support Hospital located at Division level. 

However, Level II medical treatment facilities (MTFs) within the Division, when 

they have properly trained personnel and when approved by the Multi-National 

Corps-Iraq Surgeon, can also conduct SAFEs. Deployed Sexual Assault Response Coordinators (DSARCs) and Uniformed Victim Advocates (UVAs) arrange for examinations and medical care for victims who make restricted or unrestricted reports of 

sexual assault in deployed environments. A victim at a Forward Operating Base 

may require evacuation to a facility where a SAFE can be completed by trained provider. The DSARC or UVA facilitates transport. 

To ensure continuity of care at designated MTFs, the facility must meet the following requirements: 

(a) SAFE-trained medical provider assigned 

(b) Mental health support 

(c) Criminal Investigation Division reporting capability 

(d) Victim advocacy 

(e) Chaplain support 

(f) Judge Advocate/Legal support 

(g) Appropriate laboratory support 

Ms. SHEA-PORTER. As you may know, sexual assaults in Iraq and Afghanistan 

rose 26 percent from 2007 to 2008. In previous hearings on this issue, we were informed that rape kits were not available at all forward operating bases because 

there are insufficient personnel to administer the rape kits. What steps are being 

taken to resolve this issue? 

General SCHOOMAKER. The ability of our providers in all operational environments 

to conduct the victim sexual assault forensic examination (SAFE) is not hindered 

by lack of availability of a SAFE kit or other medical supplies. Instead, because of 

their mission and location in theater, not all forward operating bases have the capability to conduct the SAFE. 

Normally SAFE care and examination is conducted at the Level III, Combat Support Hospital. However, Level II Medical Treatment Facilities, when approved by 

the theater Surgeon, can conduct victim SAFE. To ensure continuity of care, designated Level II MTFs must meet the following requirements: 

(a) SAFE medical provider assigned 

(b) Mental health support 

(c) CID reporting capability 

(d) Victim advocacy 

(e) Chaplain support 

(f) Judge Advocate/Legal support 

(g) Appropriate laboratory support 

Level I facilities (Battalion Aid Stations) are designed to stabilize Soldiers. The 

focus of these facilities is on resuscitative care and lifesaving interventions. When 

sexual assault victims present at Level I or Level II facilities without SAFE capacity, the healthcare staff stabilizes the victim, orders priority MEDEVAC to a Level 

III facility, and monitors the victim until his/her departure. 

Ms. SHEA-PORTER. As you may know, sexual assaults in Iraq and Afghanistan 

rose 26 percent from 2007 to 2008. In previous hearings on this issue, we were in-
119 

formed that rape kits were not available at all forward operating bases because 

there are insufficient personnel to administer the rape kits. What steps are being 

taken to resolve this issue? 

Admiral ROBINSON. The Bureau of Medicine and Surgery (BUMED) has oversight 

over all CONUS and OCONUS Military Treatment Facilities (MTF), and ensures 

sexual assault kits are in stock and available in the event of a sexual assault. 

CENTCOM (Central Command) has responsibility for the availability of sexual assault kits in the deployed regions of Iraq and Afghanistan. Questions about SAPR 

in CENTCOM (including availability of kits) should be referred to CENTCOM Surgeon. 

BUMED is taking steps to improve the effectiveness of SAPR Navy-wide. The 

BUMEDINST 6010.11, (SAPR) instruction, was approved by the Surgeon General 

of the Navy and published in June, 2009. The instruction gives very clear and concise guidance on the process and protocol for care of the sexual assault victim, and 

on performing an appropriate exam with follow-up. It also provides the information 

necessary for obtaining sexual assault exam kits. 

BUMED has initiated an aggressive training program to ensure widespread training in the sexual assault exam and evidence collection. We have already completed 

the sexual assault forensic exam (SAFE) training curriculum at the Uniformed Services University of the Health Sciences, Naval Hospital Okinawa, and Naval Hospital 

Naples; and several Nurses and Physicians have been trained at each facility. Arrangements are being made for training at several other MTFs at this time. 

Ms. SHEA-PORTER. As you may know, sexual assaults in Iraq and Afghanistan 

rose 26 percent from 2007 to 2008. In previous hearings on this issue, we were informed that rape kits were not available at all forward operating bases because 

there are insufficient personnel to administer the rape kits. What steps are being 

taken to resolve this issue? 

General ROUDEBUSH. Since the Air Force established full-time Sexual Assault Response Coordinator (SARC) positions at primary operating locations within combat 

areas of interest in 2006, there is no known instance of an inability to provide a 

Sexual Assault Forensic Examination (SAFE) kit for a victim of sexual assault. As 

identified in the Air Force previous annual reports to DOD on the Sexual Assault 

Prevention and Response Program (SAPR), medical functions maintain availability 

of SAFE kits in the deployed areas. During Fiscal Year 2008, the Air Force had 154 

emergency room physicians trained to complete forensic examinations. Emergency 

physicians are fully qualified to perform sexual assault forensic exams without additional training. 

Additionally, for the combat areas of interest, the Air Force Office of Special Investigations field detachments are required to retain SAFE kits on-hand as part of 

their technical investigative supplies and have secured suitable evidence storage capability for sexual assault cases in Iraq and Afghanistan. The full-time SARCs at 

Air Force Air Expeditionary Wing (AEW) locations oversee any geographically-separated unit that is attached to a main operating location controlled or hosted by the 

Air Force. Each deployed location has ensured that SARCs have sufficient supplies 

and materials to provide assistance to victims of sexual assault. SARCs in the deployed environment utilize trained victim advocates to enhance victim response. Restricted reporting is an option available in the deployed environment and has been 

utilized by sexual assault victims. Airlift and ground transportation are available 

and have also been used to assist victims/get victims proper care in a timely manner, to include availability of processing SAFE kits. 

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