Cuts to the military medical budget over the years and delays in implementing reforms across the Defense Department health system have undermined the Pentagon's ability to care for troops in wartime, a panel of experts warned Congress on Tuesday.
The system, which provides health care for 9.6 million beneficiaries, including roughly 1.3 million active-duty service members, is struggling with what is known as the "peacetime effect" -- making sure that physicians, nurses, medics and corpsmen have needed military training and experience needed to care for troops during conflicts.
It also is dealing with systemic changes initiated in 2017 that have not been fully realized, leaving hospitals short-staffed and patients seeking care elsewhere, witnesses said at a Senate Armed Services Committee hearing on military medical combat readiness.
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The Defense Department began reorganizing the military health system nearly a decade ago with a plan to focus the service medical commands on troops and training medical forces for garrison and wartime operations, with the Defense Health Agency managing support services, facilities and health care for family members and other beneficiaries.
Staffing miscalculations, combined with the COVID-19 pandemic and a budget that has not kept up with medical inflation, has left the system unprepared for trauma medicine, retired military trauma surgeons and the first director of the Defense Health Agency said.
Retired Air Force Reserve Col. Jeremy Cannon, who deployed to Iraq and Afghanistan and currently manages a trauma training partnership between Penn Medicine and the U.S. Navy, said just 10% of military surgeons currently are combat ready -- a result of not having enough patients or a variety of cases.
"If we maintain the status quo and enter a pure conflict unprepared, we will condemn thousands of warfighters to preventable death. Without urgent intervention, the [military health system] will continue to slide into medical obsolescence," Cannon said.
In 10 years, the budget for military health facilities has declined by nearly 12%, according to committee chairman Sen. Roger Wicker, R-Miss., while medical inflation has risen an average of 5.1% per year.
A concerted effort to rein in health costs in the last decade has greatly affected military physicians' ability to provide care and maintain their skills, said retired Air Force Major Gen. Paul Friedrichs, who served as the Joint Staff Surgeon from 2019 to 2023.
"Health care is not cheap. The mistaken belief that somehow military medicine can be done at a lower cost than in the civilian sector and be ready for conflict is just that," Friedrichs said.
In late 2023, then-Deputy Defense Secretary Kathleen Hicks issued a memo calling for the system to bring patients back into military treatment facilities -- family members and retirees who left either by their own choice because they faced challenges getting care at military hospitals and clinics or were forced out with the increased emphasis on active-duty personnel.
The former officers said that, although those patients usually don't present opportunities for practicing trauma skills, care for acute and chronic conditions helps military medicine maintain proficiency.
For example, Friedrichs said, similar skills are needed to reconstruct or remove a bladder that has been damaged by a gunshot wound as are used to operate on a patient with bladder cancer.
"We need our military medics taking care of sick patients. That is how we have done it historically to maintain the proficiency of surgeons or critical care nurses or the medical logistics staff. ... It's not a perfect analog, but it is the best surrogate," Friedrichs said.
In addition to bringing back patients and keeping hospitals staffed, the military health system should ramp up efforts to become premier trauma centers in their communities, they added.
Cannon said the system should establish "five to six" high-volume military facilities that serve as centers for trauma and burn care and are part of the national emergency preparedness system, open to military and civilian emergencies.
Currently, Brooke Army Medical Center in San Antonio, Texas, is the DoD's only highest-level trauma center, although other hospitals, including Walter Reed National Military Medical Center in Bethesda, Maryland, have received lower-level trauma designations.
Retired Air Force Lt. Gen. Doug Robb, who served as the first head of the Defense Health Agency, and Friedrichs also added that the Defense Department and the Department of Veterans Affairs should increase the level of their partnerships, working together to treat patients in co-located or integrated facilities.
"What I think is really important is that we have to create a capability," Robb said.
Friedrichs, who commanded the joint venture DoD-VA hospital in Anchorage, Alaska, said success has been achieved in similar partnerships in Pensacola, Florida, and at Travis Air Force Base in California.
"We want access to critical care patients for our proficiency, and the VA wants access to resources, which is either excess capacity on space or in staff, and so I think that's continued movement forward," he said.
The three urged lawmakers not to shutter any pipelines for medical personnel training, given the shortage of providers in the military and civilian sectors, and they pressed for the creation of a Joint Trauma System responsible for spearheading combat casualty care.
Currently, according to Cannon, no single command heads up this important mission.
"In 2017, the Joint Trauma System, or JTS, was codified in law. This committee must now strengthen the statutory language to affirm that JTS owns combat casualty care and to provide this precious resource with both top-down authority and bottom-up support," Cannon said.
The recommendations come as the Trump administration has launched an effort to reduce the size of the federal workforce. An estimated 5,400 Defense Department employees were expected to lose their jobs in the first round of cuts, including some from the Defense Health Agency.
Wicker and the committee's ranking Democrat, Sen. Jack Reed of Rhode Island, said they would consider crafting legislation to help improve readiness, and they urged the Defense Department to continue pursuing reforms.
"We must stop scapegoating the Defense Health Agency. The DoD must request adequate resources to ensure that the department's hospitals and clinics are properly staffed and equipped. This is the best way to ensure that the military health system is ready for the potential demands of large-scale combat operations in the future," Wicker said.
Reed added that the system must be fixed to ensure that U.S. forces aren't caught without access to care, especially in remote locations where medical responders might not have access to logistics and support.
"The Department of Defense made progress to break through [its] inertia in 2023 when it issued a memorandum with specific directions to stabilize and improve the military health system. ... More work remains to be done, and I hope that the Trump administration will continue the momentum in this area," Reed said.
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