Today and we welcome them. Lieutenant dingell, rear admiral bruce gillingham, surgeon of the u. S. Navy. Lieutenant general dorothy hogg, Surgeon General of the United States air force. Mr. Mccaffrey, assistant secretary of defense for Health Affairs and lieutenant ronald j. Pace director of Health Agency and mr. Bill tinston Program Executive officer of Defense Health care and management systems. Today we have serious questions on how medical reforms have been accounted for in the president s budget for fiscal year 2021. We will have members coming in and out. We are getting briefings on covid19 as we speak and theres a few other meetings going on. Your full testimony is available and i know members had it like i did last night to read through it. Well get start. Across is the spectrum of the military health care to benefit care in many cases the budget justifications lacks adequate detail for the subcommittee to make informed decisions. We hope the Witnesses Today can address the subcommittees questions and concerns. Out of particular interest we look forward to hearing about the role of the department in addressing or assisting other federal agencies dealing with the epidemic or pandemic possible outbreaks such as covid19. The departments study on reducing and eliminating Certain Health Care Services at many military Treatment Facilities and an update on the departments Electronic Health care records system msa genesis. We look forward to hearing about these topics and more and with that i want to thank you for appearing before the subcommittee and now i want to recognize our distinguished Ranking Member mr. Calvert for his comments. Thank you, madam chairman. I want to thank you referring to this horrible disease as covid19. Im from corona, california, we want to make sure we call the disease what it is. I did it for you. I appreciate that very much. I want to welcome our distinguished panel. This is a critical year for the military Health Care System with a lot at stake, trying to keeps the covid19 virus from impacting readiness and going through significant structural changes to the system. These changes include transitioning military Treatment Facilities from the services the Defense Health agency and consolidating facilities and shifting medical specialties to focus more on operational readiness all while continuing to implement a new Electronic Health records system. Currently you have a lot on your plate. Given these issues will impact a broad population, to include military personnel, dependents and retirees, i cant overstate the importance of keeping us apprised of your progress and informing us when you need help. We must ensure that health and safety are not adversely impacted as a result of these structural changes. During my time ill ask you to address some of these issues starting with your preparedness and resourcing for covid19, we all know the impact it has globally and ill be interested in your plans to mitigate its effect on the force. In addition ill ask about your views on the structural changeses to the military Health Care System and their potential impact on readiness. Finally i look forward to hearing about the progress on implementing the new lec trop nick Health Record. Thank you for your service. I look forward to your testimony. I yield back. Thank you. They are hoping to be joining us and break for any statements they wish to make when they arrive. As i said earlier your full written testimony will be placed in the record and members have copies at their seats and i told some of you i was riveted reading last night. We have it and we thank you for it. In the interest of time, however, im going to strongly encourage each one of you to keep your summarized statement to three minutes or less and i will let you know when youre at three minutes. I will do so gently and then it might get louder with the gavel. Lieutenant general dingle will you lead us off with a threeminute remark. Thank you, vice chairman. Ranking member calvert and distinguished members it is an honor to speak before you today. The mission of Army Medicine is to conserves the fighting strength. As armsy is called upon, we accomplish this not independent lit but as part of a joint force that is represented before you today. The chief of staff of the army says people first and winning matters because there is no second place in combat. Like general mcconville i and everyone in Army Medicine recognize the strength of our army lies in our people, soldiers, their families, our civilians and soldiers for life. They are our greatest strength and most important asset. My vision for Army Medicine is to ensure we remain ready, reformed, reorganized, responsive and relevant in this area of global complexity, change and uncertainty. In support of multidomain operations, large scale combat operations. As the army undergoes modernization to support the battlefield, we will lead through change. And reorganize to remain responsive to the war fighter. However our unwavering commitment to save lives will never change. In tomorrows multidomain battlefield our adversaries may possess area denial capabilities that will test our ability to provide prolonged field care. Consequently our medics will have to sustain life in austere locations. This requires training in our doctor and training solutions. To remain relevant Army Medicine must leverage 21st Century Digital technology along with research and development to remain proficient. Similar to hiv and the ebola responses Army Medicine is working with leading agencies and institutions to combat covid19. Army medicines ability to prevent and detect and treat diseases depends on the armys Research Development and Public Health capabilities that enable a medical ready force and a force that is medically ready. I want to thank the committee for allowing my colleagues and i to speak before you this morning. America entrusts the military Health System, Army Medicine and the services with this most precious resources our sons and daughters. It is imperative that we get it right and we will. Your commitment and continued support assures the joint force when a wounded soldier cries out medic in combat we will be there ready to respond because Army Medicine is armstrong. I look forward to answering your questions. That was delivered with precision timing. Thank you. Rear admiral gillingham your statement please. Good morning. Madam chairwoman mccullum, Ranking Member calvert, distinguished members of the subcommittee on behalf of the over 60,000 of men who comprise the navy ready mission team im pleased to be here and grateful for the trust you place in us. The mission of Navy Medicine is linked to those we sieve. The United States navy and marine corps. Their ability depends on their medical readiness and our capability to enhance their survivalal in a highend fight. Survivability is Navy Medicines contribution to lethality. Our priorities of people, platforms, performance and power are strategically aligned to meet these imperatives. Welltrained people working as cohesive teams on optimized platforms demonstrating high velocity performance that will project medical power in support of naval superiority. I can tell you these priorities are rapidly taking hold. On any given day Navy Medicine personnel are deployed and operating forward in a full range of diverse Missions Including damage control resuscitation and surgery teams, trauma care at the nato role 3 multinational medical unit in kandahar, afghanistan, humanitarian assistance aboard our hospital ships and Expeditionary Health Service Support around the world. There is no doubt that people are the epicenter of everything we do, dedicated active and reserve personnel, Navy Civilians serving around the world in support of our mission. To meet current and future challenges we must recruit and retain talented medical and civilian workforce. Navy medicine continues to focus on several key areas, both our officer enlisted communities including critical war time and operational specialties as well as Mental Health care providers. Importantly we are now embedding 29 of our uniformed Mental Health providers directly with fleet, Fleet Marine Force and training commands to improve access to care and to help reduce stigma. All of us have a responsibility to do Everything Possible to reduce the incidents of suicide. Its important its impact is devastating and affects family, ship mates and commands. Collectively, substantive military Health System reforms directed by congress fiscal years 2017 and 2019 National Defense authorization acts represents an important Inflection Point for military medicine, catalyzed our efforts to strengthen our system of readiness and health. Navy and marine corps leadership recognize the tremendous opportunity we have to refocus our efforts on medical readiness while transitioning Health Care Benefit administration to the Defense Health agency. You would expect from a transformation of this scale, mhs reform presents both challenges and opportunities in point to progress made to date however all of us recognize there is much work ahead. In summary, nation depends on our unique expeditionary medical expertise to prepare and support our naval forces. It is a privilege to care for our sailors, marines and families. Thank you for your leadership and i look forward to your questions. Thank you. Lieutenant general hogg, please. Vice chairwoman mccullum, representative calvert and distinguished members of the subcommittee it is my distinct honor to testify on behalf of the 64,600 active duty guard reserve and civilian airmen who comprise the air force medical service. At home and abroad, air force medics answer the call across a Broad Spectrum of operational, humanitarian and Disaster Response missions. From the clinic to the battlefield and even the back of an airplane, our ability to deliver lifesustaining care is the most in the most challenging environments ensures our warriors return home to their families. The air force medical Services Corp competency of Aerospace Medicine and evacuation focuses on the needs of air and Space Operators and maintainers. Since september 11, air force air medical evacuation crews have conducted more than 340,000 Global Patient movements including 13,500 Critical Care missions. In the deployed environment, roughly 30 of downrange care is trauma related and the remaining 70 is disease nonbattle injuries. These injuries range from occupational, denl and musculoskeletal injuries. Our training and currency opportunities mirror these scenarios to produce wellrounded, flexible medics who can accomplish any mission under the most unpredictable conditions. As the National Defense strategy shifts focus to global conflict and peer competition, the air forces posture to increase lethality, strengthen alliances and realign resources the air force medical service is evolving in support of these National Defense objectives by investing in our air medical evacuation platforms, surgical teams and broadening every medics skill set, preparing them to deliver care in environments where we may not have the access to functioning airfields or stateoftheart equipment. The story of colleen mitchell, a young medical technician, drives home the criticality of this point. In january airmen mitchell was on her first deployment when al shabaab militants attacked the air fields in kenya killing three americans. Awakened by the chaos she assumed the role of lead medic spending hours triaging and treating patients working with limited personnel and supplies she operated well above her pay grade and outside her comfort zone to save lives. Airmen mitchell demonstrates the qualities that makes our medic reese markble. Leadership, technical skill and unwavering commitment to mission and those whom we serve. As a Surgeon General my responsibility is to prepare every medic to do what airman mitchell did and i do not take this task lightly. They remain our primary readiness platform but sometimes fall short of offering patient volume, diversity and acuity needed to sustain clinical currency, leveraging additional training opportunities through civilian and Government Health organization is paramount and will grow as we rescope the direct care system. Military medicine presents unique challenges that a civilian Health Care System does not encounter. Our medics will continue to rise to those challenges. Thank you for your continued support and i look forward to your questions. Thank you, Lieutenant General please. Vice chairwoman mccullum, calvert, just a few comments to my colleagues. The dhas principle mission is supporting readiness and within that are two distinct responsibilities first to ensure that every person in uniform is medically ready to perform their job anywhere in the world. Second is to ensure our military medical personnel have the cognitive and Technical Skills to support the full range of military operations which our leaders may call on us to perform. The Defense Health agency is accountable to the assistant secretary of defense, the combatant commands and the military departments for same. The dha assumed responsibility for managing all military hospitals and clinics in the United States in october of last year. Working closely with my colleagues, the service Surgeon General and the joint Staff Surgeon we view our medical facilities as readiness platforms where medical professionals from the army, navy and air force obtain and sustain their skills from which these professionals deploy in support of military operations. The d. O. D. s leadership recent assessment of which medical facilities best support this Readiness Mission provides the basis for moving forward and implementing these decisions. We intend to execute this plan there a manner that ensure our patients continue to have timely access to quality medical care. Ill highlight a few points. Active duty family members who are required to transition to civilian Network Providers will incur little to no additional outofpocket costs for their care. Second, all beneficiaries in these locations will still enjoy access to the mtf pharmacy. Finally well implement changes in a deliberate fashion at a pace local Health Care Markets can handle. If market capacity in a location is more constrained than we estimated well reassess our plans and potentially adjust them. The surgeons general and i are assuring the proposed medical personnel is coordinated. This synchronization will be reflected in the personnel Reduction Plan required by the fy 20 nda section 719 as due to the congress in june. The dha is scrutinizing every part of our budget to ensure were using the resources provided by congress in a manner that supports our Readiness Mission. Weve established four Health Care Markets to integrate health care in specific regions of the country and establishing additional markets throughout this year. Local military medical leaders will have the authority and responsibility to allocate resources in a way that improves patient care and our readiness functions. Im grateful for the opportunity to provide further detail on our efforts to standardize military medical support to combat and commands, the departments and to our patients. Thank you to the members of this committee for your commitment to the men and women of our armed forces and the families who support them. Mr. Mccaffrey, please. Vice chairman mccullum, Ranking Member calvert and members of the subcommittee on behalf of the secretary of defense it is an honor to speak before you today representing the dedicated military and civilian professionals the military Health System who support our war fighters in care for the 9. 6 million beneficiaries that our system serves. I am pleased to present to you the Defense Health budget for fiscal year 2021, a budget that prioritizes the medical readiness of our military force in their readiness of our medical force while sustaining access to Quality Health care for our beneficiaries. Our proposed fy 21 budget requests 33. 1 billion fort Defense Health program. This proposed budget reflects our continued implementation of a number of comprehensive reforms to our Health System as directed by congress and department leadership. Some of the significant reforms are the following consolidating administration and management of our military hospitals and clinics under the Defense Health agency. Right sizing our military medical infrastructure to focus on readiness within our direct care system and finally optimizing the size and composition of the military medical force to best meet our Readiness Mission. In implementing these reforms, the department is guided by two critical principles. First, that our military hospitals and clinics are first and foremost military facilities whose operations need to be focused on meeting military readiness requirements. That means that our mtfs serve as the primary platform by which we ensure Service Members are medically ready to train and deply. It also means our mtfs are utilized as training platforms that enable our military medical personnel to acquire and maintain the Clinical Skills that prepare them for deployment in support of combat operations. Second, that as we reform the military Health System we continue to make good on our commitment to provide our beneficiaries with access to Quality Health care. While we implement these changes to the Health System we also continue to pursue our other priority initiatives that have contributed to the achievement of the highest battlefield survival rates in history while providing worldclass health care to our millions of beneficiaries. That includes our continued deployment of our Electronic Health record and our ongoing operation of our cuttingedge research and Development Programs which congress and this committee have long championed. That work and that area is playing a significant role in support of the whole of government effort on the covid19 issue. I want to thank the committee for your continued support of these efforts and to the men and women of the military Health System and the millions depending on us. Your support has helped us achieve and continue to drive forward unparalleled success in building and sustaining a military Health System that delivers for our Service Members, our beneficiaries and our nation. Thank you. Thank you. Mr. Tinston. Vice chairwoman mccallum, Ranking Member calvert, and members of the subcommittee, thank you for your invitation. I represent the Program Executive office Defense Health Care Management systems, also known as the pdohs. Its my honor to represent this team and their efforts to achieve a Health Record for our Service Members, veterans and their families. Patient centered care is not only an ethos we use to describe our mission but fundamental to our design from capturing data on the battlefield to veteran medical facilities we understand the patient is our focus. Our patient centered model highlights the Broad Spectrum of people who depend on mhs genesis. Systems do not create success. People do. Our progress depends on the hard work and talent of clinicians, engineers, and other business professionals who comprise our mhs genesis team. I want to thank our functional champion Major General payne and maiava counterpart for their partnership as we deliver a single common record. In september 2019, we completed waive travis at four installations in california and idaho without any Patient Safety issues. The medical staff at travis demonstrated competency. On day one when the patient arrived in the emergency room before the official goal, the team had a choice they chose mhs genesis and that was the right decision. With every deployment we hone our process and improve capability delivery. For instance, establishing peer to peer training proved successful, so successful, in fact, that general payne initiated a commanders workshop to strength commanders engagemented a we move forward with deployments. This summer they will deplore more than doubling the number of deployed sites. We seek to industrialize our process while meeting the unique needs of each site to optimize delivery to the enterprise. Weve proven mhs genesis improves the Patient Experience any time we can enhance patient care we should as part of that process we will continue to assess risks and ensure fiscal stewardship making every dollar count. Critical to making every dollar count is optimizing decisions with the va to increase efficiencies. Within the next few months we will launch a joint Health Information exchange with the va, expanding d. O. D. Connections with private providers. In closing as the son and brother of veterans im invested in the success of this program. Spending significant time at walter reed with my parents i understand the city callty of delivering patient centered care and im confident we have the right people in the right place to complete this mission and val transparency and you the committee. Its amazing what can be achieved as long as we dont care who gets the credit. The team em exemplifies this wisdom. Thank you again for your time and i look forward to your questions. Thank you. With great humility and honor i turn to the chair of the Appropriations Committee miss lowey for her questions. Thank you. Oh, boy. Thank you. I need some health care i think at this moment. It was all checked out. I just lost my voice. But i wanted to come to this hearing because as you probably know, this committee and the other committee focusing on veterans has been waiting with baited breath to get a health care record system that works. As you probably know, mr. Tinston, for decades this committee has funded efforts to m modernize the Health System at the va and the department of defense. In particular, efforts to address Electronic Health records. Now i understand, because ive had briefings, hearings on this, the last five years at least, so i know its difficult. But frankly, our Service Members and their families have been waiting for far too long and the taxpayers have invested too much to continue with problems and delays. Im not saying that its all va and that d. O. D. Is perfect, but are you learning anything by this . We had a hearing not too long ago with the va and the last number i looked at is the department is requesting another billion, in case anyone in the audience thinks i said million, another billion in fy 21. I dont get it. Maybe you can explain why this has taken so long. If this happened in the private sector, they would probably be out of business, but you are too valuable and in no way can you be out of business, but i dont understand why you cant get this done. My colleague, mr. Rogers, is not here. Weve had closed door hearings, open hearings, private discussions. Another billion dollars. Why cant you get this right . Maam, in september we we deployed the d. O. D. Deployed to travis which was double which doubled our installed base. It was a successful deployment. We changed the way we delivered the infrastructure. We changed the way we delivered the training. We prepared people to be effective at doing their jobs and we found it to be a very effective deployment. At this point we have 66 site under way with wave nellist with ten sites so i think were doing we are making progress in getting mhs genesis the modern Electronic Health record deployed to the military Health System. We also work very, very closely with the va program because were really deploying a joint system here. Its a single record for both departments. So as the va starts to bring their site on, we will have one instance of the record about the patient, not where the care was delivered or who delivered the care, available to any provider about the patient when its necessary. Can you give me a better explanation as to why youre still bringing onsites . Why is this so complicated . When you the va, if the va isnt up to standards, then they cant get records from disaster incidents that may have happened two years ago, three years ago, theyre not getting Adequate Health care. So when youre delivering an enterprise system like an enterprise Health Record, Electronic Health record at mhs genesis is, the i. T. Element is a small piece of the transformation that has to happen in the organization. Its an organizational transformation. Its a training challenge so you have to work you deliver the right capability in the record which weve done. You then have to customize that record to meet the Physical Plant of the facilities that youre supporting and you have to train people to be effective clinically with the new work flows that youve introduced. Its not just a turn itted on and let everyone start using it. You have to be deliberate ate bringing people up to speed so they can be effective so we dont compromise the Health Care Delivery as we deploy mhs genesis. 4. 6 billion. Now you want another billion. I am sure that our great military has had many, many complicated missions and, frankly, i dont understand. I understand what youre saying, but i dont understand why you cant get it right. I just hope that next year you wont ask for another billion again and another billion with 4. 6 billion and the expertise that you have in the military, it would seem to me that this task could have been completed. Ive been hearing one excuse after another, year after year, and if my colleague, mr. Rogers was here, he would probably get even redder faced than i am because weve had public meetings, private meetings, one to one meetings, two to one meetings. I guess we have to give you another billion dollars. I can think of a lot of other things. I sure hope you get it right this time. Can you guarantee this is going to do it . You have finally the expertise to do it . Congresswoman, we have the right people in the right place to be effective at delivering ive heard this the last five years, you know. Yes, maam. These people are more expert. They really understand the systems. Yes. Okay. Mark that down in the record. Thank you very much. So noted. I recognize mr. Calvert. Thank you, madam chairman and thank you again for your all being here. I would like to start off with a question on the covid19 since were all aware of the Significant Impact its having around the world. I was speaking to general tinston, the commander earlier this week and he noted that a map showed the u. S. Army africa headquarters, the part they have over in italy is surrounded by new cases of the virus in a local community and indicated that fortunately so far, they have not as of this morning they have not been affected and thats a testament to the great work that people have done in their preparedness to protect our force. As this virus continues to spread what steps are you taking to ensure installations overseas and in the United States are protected and do you need Additional Resources beyond the fiscal year 2021 president s budget request or in the supplemental there may be some assistance, may be available to the military also, but to continue the safeguard for the force against covid19 . I dont know where to start. Maybe well start with the admiral. Down here at the end. I would be happy to kick it off. My colleagues can chime in. Mr. Calvert, so when the d. O. D. Looks at the covid19 issue, theres really a handful of priorities we look at. First is the safety and health and well being of our Service Members. Thats very much tied to our ability to, as we deal with this issue, to continue to meet mission, and third how we the d. O. D. Can support the rest of the federal government in the all of government approach and strategy on the covid19 issue. With regard to the guidance around the health and well being of our Service Members, the department has issued a series of force Health Protection guidance to our Service Members and our commanders built largely around cdc guidance and so things around identifying best science and cdc guidance on risk to personnel, Health Care Worker protection, protocols for screening of patients and reporting any detected virus, its also around giving guidance on to selfprotection, you know, common hygiene in terms of protection against viruss and we also are giving guidance with regard to working with the cdc and the department of state travel guidance in terms of restriction of travel to and from select countries. Most recently, sir, giving guidance to Installation Commanders, the Combatant Commanders with regard to how to assess their particular situation on the ground, be it at installations here or overseas, and what kind of guidance they should use in making their flexible judgments about protections to put in place on their bases. Again, everything from restricted travel and access to their bases. As the cdc issues Additional Guidance or things change in terms of travel advisories, we will continue to update that guidance for the field. Thank you for that. Any other comments on the force itself . I was curious since yesterday, has there been any other trans transmissions . Not that im aware of. We have had disease containment and pandemic influenza plans we have exercised at different points in time and now were using those plans to help guide and direct our actions in relationship to the cdc and health and Human Services guidance. From an Army Perspective, weve taken a threeprong approach of prevent, detect, and treat. The prevention is the Education Air awareness of all the soldiers and family members within that Installation Commander or senior commanders footprint. The detection piece are the screenings were doing as well as the testing to verify the presence to acknowledge if it is, in fact, symptomatic and those have identified. South korea specifically. Yes, sir. Are we you still have nod hat additional transmissions youre aware of . No additional. One soldier and we have two dependents right now in the treatment mode and then that is the last phase of treatment where we have implemented our pandemic expansion plans or response plans and every installation, Emergency Preparedness and were even going as far as worse Case Scenarios on bed expansion plans. Were taking a wholistic approach of prevent, detect and treat as an army. In south korea specifically, is it general abrams pretty much has all the fliacilities shut dn at this point . The prevention piece to ensure we are not spreading and they have not implemented some of the normal activities that bring together large gatherings. Whether if its school, each Installation Commander makes that call under the guidance of general abrams, yes, sir. Okay. Admiral, anything to add . Yes, sir. I would just say that i would like to thank the committee for the investment that has been made over the years in the president s budget for our network, worldwide network, triservice network, of Research Labs, specifically can say for navy, our Research Labs that are in singapore, as well as in italy, are at the forefront of the Global Response to this emerging pandemic. But that investment has in our scientists and really worldleading knowledge and research is now bearing fruit and youre seeing that dividend in the sense that we now have 12 of 14 d. O. D. Labs actively able to do diagnostic testing around the world. Thank you. And congressman, just d. O. D. Wide, so we have, as of last night, four confirmed cases and 12 suspected that are being tested. Where are those cases at . I dont have that breakdown. This is across the d. O. D. Any cases within the United States youre aware of . I do not believe d. O. D. Cases as of yet but i can get you the updated numbers today and break it down. Appreciate that. Thank you. Thank you. Im going to ask you to submit to the a report to the committee as soon as possible on the two following questions following up on my colleague from california on covid19. 3 billion of the supplemental goes towards research and development of vaccines considering the departments experience working with sars and mers over the years, two illnesses similar to covid19 i would like to know what the department of defense and army are doing to work with our other federal agencies and partners, fda, cdc and nhs in develops a vaccine . The other information i would like you to share back with us, the federal government maintains stockpiles of res pir raters and its come to all of our attention a number of these res pir raters have been applied to expire. The military usually does logistics and stockpiling with great, great precision. So we would like information on the department and how youve been maintaining your own stockpile of respirators and masks and would distribute them within the different branches of service if needed. With also again with your knowledge in this area, what role should the d. O. D. Play or could play in working with our public agencies to maintain proper stockpiles of critical medical supplies so our country can be better prepared for the future health care crises. If you would follow up and get that information to us. My question is on military downsizing. Secretary mccaffrey, as you know the department provided congress with a report on february 19th for a plan closing and downsizing of up to 50 d. O. D. Military Treatment Facilities and i would stress the word report here because most is just a list of impacted facilities. Some of the comments on the downsizing would where there would be no outofpocket costs to families or soldiers or airmen, and that their prescriptions wouldnt change. But there are other things that can impact the delivery of health care not only to the person wearings the uniform, but the family thats behind that person and our uniformed members need to know their families are well taken care of. Bottom line, we still dont have a timeline, projections of cost savings, a real plan for implementation of those downsizing and closures. While i understand the department wants to focus on increased medical readiness of our troops and medical forces, the impacts of these organizations will be significant and trust me, we will hear from the individuals that are impacted by these changes. Some numbers i have seen indicate up to 200 family 200,000 family members and retirees across the country would be pushed away from d. O. D. Medical Treatment Facilities to civilian providers. We need to understand what that plan looks like. Mr. Secretary, your office has clearly been thinking about this for a long time since you do have a list of facilities that have been impacted. So there must be a document somewhere to back up these facilities and how they were chosen. So mr. Secretary, how can you expect us to be, you know do Due Diligence with our appropriate necessary funds to reorganize the militarys Treatment Facilities when we havent seen a comprehensive transparent plan from the department on what, when or how this restructuring will be implemented . Additionally, the report submitted on february 19th states and i quote, upon submission of this report, detailed Implementation Planning will begin with implementation beginning at less than 90 days later. We need the information. That language to me and to many sounds as though the department believes the does not require congressional approval prior to moving forward with the implementation. Secretary mccaffrey, does the Congress Need to stamp its approval on the recommendation prior to the departments moving forward with the Implementation Plans to descope services at military Treatment Facilities and the final question, for now, as we wait your written response as soon as possible, if you are not ready to transmit to us a comprehensive and transparent plan, why not just ask for a delay of the reorganization so we can get it right and not cause any confusion for congress in appropriating its funds when your pairpts patients, our soldiers and airmen and marines ask us what is happening to them and their families . Yes. So i will try to go through each of the questions and if i miss something, let me know and we will follow up. With regard to the review that the department has done, this was coming out of nda 17 direction from congress to assess all of our military hospitals and clinics to ensure that we were aligned and matched with their primary mission, being military facilities and being training platforms for our medical force as well as ensure that our active duty are getting convenient access to care in order to be medically ready to do their jobs. So that is thats the focus. The reason why, in our report to congress we identified some facilities that we are recommending for a reduction of Services Available to the mtf, it is because of this attempt to tie the operation of the mtf to that Readiness Mission. What do i mean by that . There are some facilities where the volume and type of patient caseload that is provided at that particular mtf is not a good match for the type of case load and acuity that our uniformed military providers need to maintain proficiency and those skills that we expect them to have currency in mr. Mccaffrey, we have limited time. When can we expect the followup . You seem to have made i believe that you did Due Diligence in making your decisions, but we were given none of the supporting documents to follow up with them. Were being asked to make decisions in a time frame within a matter of months and as you said, congress charged you with this, so when can we expect a followup in the supporting documents . I will outline that. So the report to congress identified and shared that we did a screen of 348 u. S. Based hospitals and clinics out of those the department determined 77 needed a deep dive examination. The report went through the methodology we used to identify those, the methodology that was used in looking at the Community Availability of Community Health care. Out of the 77 we determined 21 we have the report as you pointed out. With when is the Implementation Plan coming . Including in the report there is for each of the 50 facilities being recommended for a change, there is an entire use case that goes through all of the data we used specific to that mtf. The report very clearly says theres not going to be any immediate change to operations, that its not a onesizefitsall implementation timeline. It will be based upon our work with the individual mtf in that community our staff seems to think and i would agree with based on what i and others have seen, that we need some more information here. I will ask you to please follow up with the committee because i have as lot of members here who have a lot of other questions that i know youre going to want to hear about, whats on the mind of other members of congress. I thank you for that, but at this point in time i would say that the Appropriations Committee doesnt feel that its fully informed and ready to go. Well be happy to provide you additional information. Thank you. With that i lost my mr. Carter. Thank you. Thank you. I appreciate all of you being here. Im trying to learn all this stuff. This gets dang complicated. Lieutenant general place, how is the transition of military Treatment Facilities to the dha going . What are some of the successes youve seen . What are the challenges youre facing . And while these Treatment Facilities transition to dhs, this past october, the services are still supporting dha to keep the train on the tracks. The Surgeon General describes the support that you continue to provide to the military Treatment Facilities in dha. Lieutenant general place, what is the plan to decrease reliance on support from the services . Forgive my voice. Sir, thanks for that question. So in terms of the first part, how is it going . I would say that i will agree its an extraordinarily complex and challenging transformation. That said, overall, i think were going very smoothly according to the plan. Not that everything is perfect, not that there havent been challenges associated with it, but in general, as we measure the effectiveness of the care that were delivering and measure the effectiveness of our actions to plan, were actually making good improvements in the quality of the care, in the speed with which were delivering the case and the use of the resources that the congress has been generous enough to provide. In terms of the successes, the success were finding actually is in a particular regional market and i will use here in d. C. , for example, our ability to utilize all the resources of each of the facilities to include the staff to align themy to the location where they can best provide health care, similarly were able to use the particular location where youre enrolled to this particular military medical Treatment Facility or another to move patients around to achieve the best quality of care, so the standardization within a market has been a success. In terms of the challenge, youre exactly right, and that is the reliance on the Service Medical departments continue to provide direct support. The reason for that is the staffs that have been doing it for decades in services are slowly but surely transferring into our both our headquarters and into our regional markets. As were doing that, were sharing responsibility for the delivery of health care and sharing responsibility for oversight of that staff. That plan should continue for approximately another six months or so. My anticipation at the end of the summer, the majority of the staff who will need to be transferred will be transferred into the Defense Health Agency Headquarters and the reliance on the Service Medical departments at least for u. S. Based support will be significantly diminished in almost every area. Theres some theres some challenges that are still there for the way we do our financing, for example, because we use different financing systems in each of the different services, so we still have to collaborate on some functions, but the majority of them will have transferred. I think i got all your questions, sir, if i didnt, please remind me. Any of the other services have any . Yes, sir, i would echo this is a very complicated merger of four cultures, if you will, and well get there as long as we get there using manageable risk. What that means for me is we need to transition before we transform, so we need to be able to continue supporting the Defense Health agency and capabilities to manage these military Treatment Facilities because if you remember in the past, dha wasnt didnt come out of that. They came out of the old tri Care Management activity, and their core competency was writing and managing contracts, not managing mtfs so we need to help them do this mission. And so i would i would ask if we not add additional changes until the Defense Health agency is standing on their own, is wellestablished and has been managing the market with demonstrated success for a period of time. And mr. Carter, i would add the complexity as you mentioned is extremely difficult, and from the Army Perspective, you know, what we have always championed is that we cannot fail at this. We have to get this right, and in order to get it right, the focus should be on the mtf transitions, which starts with the standard headquarters. The headquarters is not up and operational and running, and it will continue to require their direct support. After you get that headquarters set up, you can start transitioning the military medical facilities and we should also be focusing in that transition on the Electronic Health record. From the Army Perspective we believe that is the key thing and anything else are just distract t distractors that are not allowing us to get it right . Is there anything at the the question i guess, the real question we ought to be asking, how are the patients feeling about the care . Are they seeing anything thats pulling them off balance, theyre not getting treated well . Thats who im going to hear from. If hes not getting what he needs. Thats a great point, we continue to track the Patient Satisfaction at every location that has already transitioned into the Defense Health agency, and the Patient Satisfaction scores at each of those installations are at or above at every single location thats transitioned is at or above what they were at baseline before transition. Not perfect, im not trying to tell you that it is, but improving. Sir, i would just add that we remain committed in Navy Medicine to creating a truly integrated system of readiness and health. Going through this transition has forced us to look very carefully at our medical readiness requirements, and i will tell you that as we have done that, we have identified opportunities for focus. I mentioned in my opening remarks, we now have almost onethird of our Mental Health professionals embedded in the fleet and Fleet Marine Force, so we believe that we are seeing as citing as success, we are seeing increased focus on the wellness and readiness of our war fighters. Well, and not to change take too much more time, but this morning i was thinking about the navy because a cruise ship is coming back into the United States waters because of the once again, viet rrus, a thought, my gosh what happens if we get that on an Aircraft Carrier or a submarine and the complications thats going to make for our naval forces. I appreciate that concern, and thats something weve thought very carefully about. And as mr. Mccaffery said we are working closely with the cdc, world health organization, north com and other joint staff to understand how to eliminate that risk, so that is why one of the one of the requirements is that weve established in the fleet is that no ship, no ship having left port will go to another port or arrive in another port and disembark within 14 days. Thank you. Thank you. Thank you mr. George carter. Thank you, madame chair, thank you for being here. Appreciate your work. I want to direct my question on the coronavirus and the use of basis, as you know, the secretary of defense mr. Esper approved a request for assistance from the department of health and Human Services for Housing Support for those that had to be quarantines. One of those places is my area in san antonio, lackland, air force base. As you know, there was a particular situation that they released an individual, and i know that youall are providing suppo support services but just want to know if you all are coordinating. They released somebody that was still pending a test. That person went to north star mall, went around san antonio, of course, that caused a problem because the second test came back. There was a protocol modification that the cdc director sent off. Are you all familiar with this letter that got sent off on the modification of protocols . Anybody . Im not sure which communication youre referring to but . Yeah, its just basically the modification on cdc changes, that is there were two changes, one that is if you will a quarantine ed individual, that person will only be released if they have had two sequential negative tests. Modification number two, the most important, was that no person will be released if theres a pending test result and thats what we saw in the san antonio area. My request is that i know that you all are supporting providing support services, but i think modifications should be something that we should apply whether its in south korea or wherever the case might be. I would ask you if you all are not familiar with this, i would ask you to please be familiar with this. Any thoughts or comments on this, and then i want to ask you a second question. Sure, we will make sure that we have the same guidance. I believe we do have what youre showing us, and as you pointed out, this is a good example of where the department is in a supporting role to the all of government effort. So the use of military installations in terms of receiving patriated citizens, the role there was we made available our installations and health and Human Services and cd cdc, once those folks were on the ground had that responsibility, in terms of managing, providing care, doing testing and any kind of referrals in the private health care sector. So we defer to them on making and managing that area, but we will take a look at it. And understanding, but even if youre providing support services, youre off abroad somewhere, lets say south korea, then we better be familiar with this protocol. I would ask you to do that. The second thing i would ask you is the Walter Reed Army institute of research is working on a vaccine against the coronavirus. Can you give us the status on that progress and, number one, and also, i think theyre working on a diagnostic testing kit and how close are we on those two points . Yes. So the military Health System is part of the broader interagency on looking at everything from diagnostics, vaccine research, as well as antiviral therapies for if you have the condition how it can be treated. So in fact, we are, cdc, nih all have in progress have Research Going on on a vaccine, and it has been ongoing. I believe Clinical Trials for that will not be for another few months, and so in terms of a final determined fda approved vaccine, likely were looking at, you know, 16, 18, to 24 months. Thats from the research were doing. I cant speak to Similar Research nih or cdc are doing on that. Similarly, on an antiviral therapy, we may be closer there in terms of having something that can be usable. Its actually in Clinical Trials right now for testing of efficacy. Well, as i close, i just ask you all to i know were putting a lot of federal dollars and research and i understand that in different areas. I just want to make sure that were coordinating, working together as we use this large amount of federal dollars, and as you saw the house passed the supplemental bill yesterday, appropriations. I want to make sure were all coordinating. Thank you for your service. Thank you, mr. Womack. Thank you, madame chair, and thanks to the entire panel. I want to direct my question to general dingle and admiral gillingham, and im going to pivot away from all these flavors of the month covid19, et cetera, et cetera, and i want to come back to tactical medicine for just a minute. I have a it is my strong belief that in the last two decad decades thanks to the efforts of in the entire readiness scenario to better prepare our men and women in uniform to perform Battlefield Medicine has saved a lot of lives. There are a lot of people that have been able to go home to their families, albeit maybe banged up a lot, that in many previous wars would have died on the battlefield. And in my regiment back many years ago, we had a robust combat Lifesaver Program, and i think that combat Lifesaver Program was probably the reason why weve done so well. I know that the military services are transitioning from the traditional combat Lifesaver Program to a more robust Tactical Combat casualty program, so id like an update. It is my understanding that that process is still evolving and that the tier 2 tc3 program is going to become that bedrock training for our Readiness Posture that in the event that we were to engage in a near peer combat scenario, more force on force scenario, that a much more robust combat program, combat Medic Program would be important. So can you explain to me where we are in this process . How it is going, and what you see unfolding in the next year or two . Mr. Womack, first and foremo foremost, let me thank you for recognizing the First Responders. Oftentimes a combat medic and that combat lifesaver do not get the recognition that they deserve when they are the very First Responders that stop the bleeding that are enablers to the sustainment of life in combat. With that said, you are absolutely correct. Our program is going tremendously within the army. We call it the Army Medicine medical skills sustainment program, which it involves everything from Expeditionary Combat medic care where were teaching them expeditionary medicine and how to provide p prolonged care in austere environments all the way to where were taking our trauma teams as you mentioned, and embedded them in our civilian facilities, those trauma sistces so that they can get the touches not just as a trauma surgeon but a trauma team. Were going to expand that this year in fy 20 for those trauma teams to three more, and then we have about another eight more that are right behind those. In reference to those enlisted training officers, we have what we called our strategic medicals a asset readiness training. That focuses once again on that combat medic, not just training them in simple training environments, but also pulling them out and putting them into some of those Trauma Centers, too, so they can get those individual critical task lists trained to proficiency, so when they are called upon theyll be ready to respond. Bruce. Thank you, congressman womack. As an Orthopedic Surgeon who served as the officer in charge of a surgical shock trauma platoon in fallujah in 2004, this is an sbinteresting to me that we continue to get this right. I will tell you that in addition to moving up in terms of the capability at the for the our enlisted providers for tccc, were actually in the process of training the entirety of the ship to have those basic skills because as terrific as our independent Duty Corpsmen are who are responsible for the medical care on our smaller ships, they would be rapidly overwhelmed. So we are in the process of training the entire crew in fundamentals of tactical casualty care, sir. I have one followup question regarding new medicine, and that is theres a lot of technology out there regarding clotting material in the application of certain bandages and that sort of thing. Are we okay with our stockpiles . Are we procuring these new te technological advances in a timely way so that so that we can use the very best that we have because, you know, in just a in that golden hour or in those first few minutes, those types of that type of equipment is going to be critical to helping save lives when of otherwise they would be lost immediately. Sir, i cant speak directly to the supply that we have, but i will tell you that theyre and perhaps general place or mr. Mccaffery can speak in greater detail, but i can tell you theres a tremendous commitment in our Research Enterprise to make sure that we have absolutely the best possible, you know, equipment and technology in the hands of our first providers. Yes, sir, ill add onto that. Both in terms of quality and in terms of the quantity, the research that has been occurring within the military and Health System specifically for intraabdominal clothing for example, or hemorrhage cases where extremities come into the thorax or into the abdomen, those are also important. We have Cutting Edge Research that has given us new clotting technologies to be able to use in those conditions. Its not just the quantity of them, yes, sir, we have good stocks of them, but its also new qualities of hemorrhage control capacities that we have. Thank you for the service for all of your service, and i appreciate the answers to my questions here this morning. I yield back. Thank you, i saw some of the clotting techniques that they were working on at fort detrick just recently, truly amazing and well later on have application in the civilian Health Care World as well. Ms. Kirk tpatrick. Thank you, madame chair, and thank you to all of the panel. Excuse me for being here. Prior to coming to congress, i was a hospital attorney. I represented a Regional Hospital that had a number of smaller clinics within it and spent a great deal of my time on medical records completion. Its not easy. Its very complicated, and one of the things that i discovered was that there was a real reluctance by some members of the medical staff to use electron Electronic Medical records, so they were used to dictating their charts as they made their rounds, and then that chart would go to medical records, and then somebody would transcribe that chart in medical records so that it could be electronic. It was very ccumbersome, took weeks, and weeks and weeks to complete. So i want to know a couple of things. The other thing weve found is that its really difficult to attract young people to residencies in the v. A. , and so id like you to address what youre doing to recruit and attract young people into the Health Care System, in the delivery system, and then whats been done to improve the use of electronic records, let alone interoperab interoperable, we cant even get to that until we have the electronic records in the system. Thats an open question to anyone on the panel who feels like they can address that. Let me start with kind of the larger question you asked and probably would defer to the military departments in terms of the specific question of things that were doing to recruit and retain young people and to i mean, from our perspective and to the medical side of the military, but you indicated the challenge of adopting an Electronic Health record, and i think thats somebody really to foot stomp for everybody. My experience in the private sector is even systems like kaiser that are have been around, very sophisticated, when they adopted a new Electronic Health record, it took several years for them to do for just many of the reasons you pointed out. Its not so much the technology. It is how do you train your work force including clinicians on that new technology. What are the work flows you need to use to match it up, and its changed management, and i think and ill let mr. Tinston weigh in with some more detail, but we purposely, when we rolled out for the department of the defense, rolled out the ehr, we did it in a test way in four facilities to see what we needed to learn and informed the larger deployment, and we learned many of those things. I think that is what has led to the most recent deployment in september went far better, and we believe were really wellpositioned now as we pursue additional waves of getting it out throughout the system. But i dont know if you have anything to add on that. So mr. Mccaffery, we did learn a lot. We even did the initial Pacific Northwest sites. We didnt have all the capabilities sir, if you would speak into a microphone so it can be picked up. Sorry about that. Not a problem. We took some time to make sure we have the capabilities right with the records and the work flows and then we began training those work flows to get people job ready, teaching them how to use the i. T. , which is one of the mistakes we made out of the gate, so weve had much better results with wade travis, and we anticipate Continuous Improvement as we proceed to wave malice and future waves. Ea as i said earlier, we have 66 sites in the deployment process at this moment. Are you working with medical schools to train young doctors before they get to residency how to use that i. T. Software . Zb maam, most of the medical students who are on the scholarship programs that end up bringing them into our system, they do rotations in our organizations already, so yes, they are being trained on our systems before they ever get into it. Let me add one other comment to it. Weve been using an Electronic Health record within the military Health System for two decades, so the challenge that youre describing is really not a challenge that were having. Were used to using Electronic Health record. The downside of it it was home grown, it was clunky. There were challenges with it. Our culture has challenged to accepting the Electronic Health record. The challenge were having now where we did our own work flows even locally sometimes differently to the commercial off the shelf that we purchased, transitioning to that. Its not the reliance on the Electronic Health record that were having the challenge with. Are you using software you just purchased off the shelf . Yes, maam, it as commercial off the Shelf Software program. All right. The other challenge we ran into was maintaining confidentiality. So when records are being transferred around to different institutions, how do you maintain the confidentiality of the medical record . So were fortunate in that were part of the department of defense, and so from a Cyber Security and a Data Protection perspective, we have the baseline of the departments cyber rules and standards to base our implementation off of. So we manage the Cyber Protection with the v. A. Because its a joint record that were creating between the d. O. D. And the v. A. To meet the d. O. D. Standards. And as far as the interoperability and exchange of data with external providers, we do that through the theres data use agreements in place, and we do that through hl7 standards and were engaged with the Standards Agency organizations to make sure that we have influence on how those are. It is a tremendous problem, and i appreciate your attention to it. Anything that i can do to help solve that problem, ive been working on it for decades, so feel free to call on me. Thank you, and i yield back. Thank you, mr. Ruppersberger. First thing, panel thank you for being here. What youre doing is very important. We appreciate your competence. I want to get into the strategic readiness program. I know congressman womack dent with it. Lieutenant dingle, we must ensure that we continue to take care of our american soldiers. A few weeks ago i had the privilege to accompany your deputy chief of staff to the shock trauma at the university of maryland. That is rated one of the top Trauma Centers in the world, j research, development, and we have the air force has been there for many years and has a really good relationship, and were focused right now on the army and maybe the navy and marines later. In fact, that Trauma Center saved my life 50 years ago, and if it werent for their expertise and competence, i wouldnt be here today. Maybe thats a good thing for some people. Anyhow, during our visit, we discussed the Smart Program, which provides combat medics the opportunity to get hands on training alongside their civilian counter parts and the studies show that during the first few years of wars in afghanistan and in iraq, we could have saved one in seven troops lost if they had access to reliable trauma care. Now, what are your plans to expand this Vital Program . Does the fy21 budget support this, and as our military shifts to near peer competition, can you explain why trauma Care Experience is so important to our medical corps . Thank you, representative. As youve experienced the great treatment from the baltimore shock and trauma, one of the beauties of the Smart Program is its taking, again, that combat med skp medic and expoupding and building upon something weve had in the army called medical proficiency training in the old day to where we were leveraging our military medical Treatment Facilities. And then those hospitals who are those civilian Trauma Centers, theyre exposing these medics in a twoweek rotation with the ability to put handson trauma injuries, and trauma cases, so that is exponentially increasing their skill set, their individual critical task list, and it is just priceless. We are expanding to two programs this fiscal year, this summer we have plans to expand to about six, seven more almost each year, and again, we have not had any issues with funding as we continue to expand and our intent is to expand across the thats good. Yes, sir. So as you know, weve used baltimore for quite some time. We have other c stars capabilities out there with cincinnati and university of Medical Center in nevada. What we are also looking at is embedding entire teams in civilian facilities 24 7, 365 days a year were there getting the touches on a regular and consistent basis. Thats good, keep up. I want to move to the peer review Orthopedic Research program, secretary mccaffery, id like to ask you about this program the Orthopedic Research program. Ive been supporting this program for years. Its a Research Program which has demonstrated results enrolling more than 15,000 patients to date in military Relevant Research with the potential to provide Health Care Solutions for injured Service Members, veterans and civilians. Now, the conflicts in iraq and afghanistan have result instead 52,000 battlefield injuries including more than 2,200 major limb amputations. The unique nature of these wounds which primarily results from explosive blasts and high velocity gun shot has been well documented. The Orthopedic Research program has been funded since 2009 and has received level funding at 30 million per year since fy 2012. These funds have allowed our orthopedic docs to work miracles stabilizing limbs, helping with tissue regeneration and even the full face transplant. They are conducting the research are asking for an increase to 35 million in order to provide Stable Funding for the consortiums. Which includes the Major Extremity Trauma Research Consortium metric anchored at Johns Hopkins university. Can you walk us through the history of the Orthopedic Research program and the consortiums at work, and also, do you believe the program could benefit from increased funding designated to support the services on an ongoing basis . Do you agree a force multiplier that provide the greatest return on investment . So thank you for the question, congressman. To be candid, i cannot walk you through the history of this particular Research Program. I would need to get back to you in terms of well, i probably can more than you then. Some of the questions, im not aware of the request for increased funding in this particular Research Program, but i am happy to take back your questions and provide you the ill get my staff to get in contact with you or your staff today. I want to try to make this a priority if we can. Sure. Okay. Yield back. If we could have the army follow up on that to the committee. Mr. Crist. Thank you very much, madame chair, and i thank all of you for being here today. We appreciate your service to our country. As you know, iran launched 11 Ballistic Missiles at the Al Asad Air Base in iraq. While we thought that all Service Members were safe, over 100 Service Members have since been diagnosed with traumatic brain injury. What is the status of the Service Members who were in the attack, and out of those who have returned to duty, how many are on light or Restricted Service . And thats for any of you who feel comfortable responding. So congressman crist, this may be a little dated. This is probably numbers from a couple of days ago, but my understanding out of the roughly 100, 109 Service Members that were identified, 75 have been reviewed, evaluated, and are actually back in duty in iraq. The remainder i would need to go back and check in terms of what is the status with regard to their evaluation, and are they have they been returned to duty and what type of duty . I dont have that handy, but i can get back to you on that. Thank you, sir. I appreciate that very much. Im concerned obviously because enthough the bunkers mostly held and they had ample warning to take shelter over 100 Service Members were diagnosed, and thats very disconcerting obviously. That number will likely increase, too, im told. As general miley said, the troops in the attack will need to be monitored for the rest of their lives, but he also said, quote, that theres nothing we could have done, end quote. Because the missiles were so powerful if we are making investments to counter russia and china, we also need to protect our Service Members against the powerful weapon systems, including the Ballistic Missiles. What we are doing to protect Service Members, what are we doing to protect Service Members from Ballistic Missiles or other causes of tbi . So a couple of things. One of the areas that congress has asked the department to work on and we are in process, and that is focused especially on the implications of blast exposure. Right. And we are in the middle of doing a study on that to figure out better ways to measure it, but then more importantly, what we find out about the impacts of blast exposure on brain health that then needs to inform everything from what weapons we acquire, the training we put in place, not just in a deployed setting but training, you know, here at home to inform what we can do to best protect our Service Members, and then most importantly, i think you kind of referenced it was what we are doing, i believe its the special forces command right now is really doing a good job at baselining all of their Service Members with regard to their cognitive abilities and have that as the benchmark then to evaluate over time to see if any of their, you know, in training and deployments, any potentially concussive events have affected that baseline as a way to monitor and evaluate. So those are some of the things that we are looking at. Great. Weve known that brain injuries are a problem, and weve known that our adversaries have these weapons, so how have we not considered what would happen in an attack like this . So i believe we have considered based upon the evidence we have and what kind of protective gear based upon research we have done, what we believe, you know, makes sense in terms of protection, and most importantly we do have standard across the board policy with regard to if a Service Member has experienced a concussive event, there are very strict protocols around reporting that, screening that Service Member, getting the efgvaluation, and tn pursuing whatever medical care is required before a return to duty or something else. Thank you, sir. Weve seen patches of coronavirus here at home including in my home of tampa bay, home to cent com and so com. As you know, there are also larger outbreaks near military installations overseas. What are you doing to stop the spread of coronavirus in our troops . So we the department has issued a series over the last four to five weeks, force Health Protection guidance, largely built around cdc guidance, and part of that, though, is how we apply that guidance to the military environment and guidance we give to Installation Commanders both here and abroad and how they can apply that to their particular situations on the ground to inform what they want to do with their Service Members in terms of screening, access to the installation as part of the effort to contain any infection at their base or surrounding area. Thank you, i appreciate that. Just finally, do military installations have access to testing . And then i yield back. The installations, so its tied to where we have the Lab Technology at military installations in terms of our mtfs. Right now, my last information is i thought we had nine or ten of our military labs had the access for the testing thats approved by the cdc. Were seeking to get all of our labs, which is about 14 or 15 to have that ability. Thank you very much. Thank you, ma dad chadame chair if youd follow up with the committee on that testing. Mr. Ryan. Thank you madame chairman, thank you for your service, thank you for being here. I want to go in a little bit of a drircifferent direction. I think im the only one who sits on the defense appropriations subcommittee and the military or the military construction v. A. Subcommittee. So the issue of health as it relates to all of you and active duty and as it connects to veterans is important. And one of the things and ive tried to look through a lot of your testimony. Its very technical. Were talking about records and all of that. I want to talk to you about obesity rates. From what i can gather, the obesity rates for active duty are going up. 15. 8 a couple of years back, and now 17. 4 . In the navy its 22 , air force is 18, army is 17. Males between 35 and 44 years old have almost a 30 obesity rate and when you look at the increase in Blood Pressure and diabetes and heart disease, all of the stuff you know way better than i do, this is a problem that were not even talking about, and its got a relatively simple or simpler solution than everything weve just talked about, and for the last few years, my staff and i have been trying to dig in on the food that is being fed to our soldiers, the fact that the, you know, commissaries and calf fe a cafeterias are closed and people are working late and the only thing left on the whole base is the burger king thats open, and so they go and do that over the course of many years. Now, we need a big strategy to reverse the obesity rates, and i mean, i think most people would be shocked to think that we watch tom brady and we see these high performing athletes, and we look at their diets, and we look at their lifestyles, and we are spending billions of dollars to have high performing men and women serving our country, performing at peak levels in very high pressured situations, and for us to have an obesity rate thats creeping up to 20 and zero strategy on how to fix it, thats a real problem, and then you come back and you want more money for this and more money for that, andst the there kinds of Research Going on in reversing type 2 diabetes with food as medicine and all kinds of innovative things that are happening in the real world that we have got to make sure its getting into the military. Now heres the connection for us who sit at, you know, 30,000 feet. The diabetes rate for veterans is one in five. The diabetes rate for the average american is one in ten, so here were blowing all this money. Were ive been on ships before, and you walk in and its all the sugary cereals. Look, im not a prude on this stuff. Im an 80 er right, 80 of the time you work out, you eat healthy 80 of the time, but we cant have this, folks. This is unacceptable that were going to continue. Is there any strategy thats in place, mr. Secretary, that is addressing this in an aggressive way . So we have in part working with your office, i know last year have been putting together what i would call more of a framework or a skeleton in terms of what would be the key components of a strategy. As you mentioned, part of it in terms of on the health side is, you know, what are the Health Guidelines and Health Recommendations that then feed into how our installations are operated and the decisions made about what types of food, access to that, and where we have not completed that is that closure, that link between the medical side and how we are operating our infrastructure so to speak in delivery of food. So there is more work to be done on that, and you make very good points in terms of, you know, part of lethality is our Service Members and their health and their ability to do their job. And this is a negative impact on that. Its a waste of money is what it is. I mean, its inefficient. Its obviously it goes to production. Then they go into the v. A. System and they have diabetes, and then diabetes when you look at diabetes with any other sickness just jacks up the cost. It extend your stays in the hospital. It complicates any other issue you may have. If you have to go to surgery or if youve got a heart problem and diabetes, it just makes it this much worse. So ill leave here and ill go sit in another committee, the v. A. And talk about how we dont have any money. And so weve got to start seeing these systems as integrated, and you know, we could have a whole discussion on k through 12 school. When i walk into a school and these kids are getting a rice crispy treat and a thing of chocolate milk and start their day with 80 grams of sugar and then theyre on the medicaid program, and with the public money we spent to buy them rice crispy treats and chocolate milk. American people are sick of this. This does not make any sense, and i want the military in the United States to be the leader in this. So i only have probably a little bit of time left, and i would just like to give it to the Surgeon Generals if any one of you have a comment on this. Sir, ill be real quick, mr. Ryan. Within the army, we are have a very pragmatic approach to the health of the force, and we have many programs from go green, healthy choices, spartan that get after the eating as well as the activity, as well as the entire life process or approach to living, and then our Holistic Health and fitness, going after the spiritual, physical and mental well being of our soldiers. The wellness centers, all designed to educate our soldiers where weve got programs that are also inculcated into the units, not just special forces, but treating every soldier as athlete. Id certainly agree very similarly in the navy we have a similar program. Certainly we understand the importance of wellness. I think, sir, one of the points you make are the social determinants of health that we really have to get after, and the environments in which our sailors, marines, and soldiers live and so we are working with commissaries, for example, with our dietitians to provide guidance so its available in the commissary as individuals purchase their groceries. Sir, we agree with you 100 , and we are working very hard. Weve got a lot of work to doings and this committee is going to push every single one of you to make this happen. Thank you, mr. Ryan. I think everybody has gotten the message. We actually are out of time for a vote, and i do want to follow up with one we cannot to be responded here today, but reported back to the staff. It goes back to the military Health Personnel restructuring. The d. O. D. In your announcement that the plan of Health Care Restructuring roughly 18,000 uniformed health positions will be gone with no plan to replace them, yet, youre talking about putting people into the marketplace. We know that there is a shortage in our Health Care System throughout this country. Were also concerned about your ability when these facilities close to be table able to retai of the docs in high specialized individuals that are serving us. You also function as Teaching Hospitals, and Teaching Hospitals are closing and limiting the number of training opportunities all across this country. We cant afford to lose you as part of our backbone for not only our military health, but for our all over u. S. Health care system, especially when it comes to ob gyns and pediatricians. And with more women serving, ob gyns i have to say i have some familiarity with them having had an army doctor deliver both of my children and, you know, we cant afford to be losing those kinds of specialties and keep and recruit and retrain women as well as women who are family members. So weve got some serious questions on that. We want to be helpful with you as you make that decision, but i think we need to look at a whole of health care. I want to thank you so much for coming. This also goes to mr. Carters question about, you know, some of the outside treatment happening as well. Thank you so much for being here. Thank you for your service, and thank you for getting back to us promptly because were starting to mark up the bills. With that, this meeting is adjourned. This hearing is adjourned. To follow the federal response to the coronavirus outbreak, go to cspan. Org coronavirus. 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