Hearing of the Defense Subcommittee of the House Appropriations Committee - Defense Health Program


Hearing of the Defense Subcommittee of the House Appropriations Committee - Defense Health Program

Chaired By: Rep. John Murtha (D-PA)

Witnesses: Ellen Embrey, Deputy Assistant Secretary Of Defense For Force Health Readiness And Protection; Lieutenant General Eric Schoomaker, Army Surgeon General And Commander, U.S. Army Medical Command; Vice Admiral Adam M. Robinson, Surgeon General Of The Navy; Lieutenant General James G. Roudebush, Surgeon General Of The Air Force; Vice Admiral John M. Mateczun, Commander, Jtf Capmed; Brigadier General Philip Volpe, Deputy Commander, Jtf Capmed

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REP. MURTHA: We appreciate this distinguished panel. Mr. Young is caught in traffic. He has got a long ways to travel, but there is nobody been more involved than he and his wife. And I assume all three of you have heard from his wife periodically -- all four periodically, if there is something wrong. But I appreciate her dedication to the military and dedication to making sure that the people are taken care of. And we appreciate what you folks do.

As I said to you privately, lately when I go to the hospitals there are a lot less patients there, but I hear nothing but compliments. As a matter of fact, when I stopped at Landstuhl about a year ago, there were only a couple of patients. And they were injured -- no, the two patients were having babies. So, that was the only two patients that I saw. So it was a real change from the time I went and they didn't have air conditioning.

But we appreciate -- we think you put the money to good use that we've added. And we compliment you on the fact that you've added money this year. And we don't have to make up for that billion dollars that you were short every year.

With that, I'll ask Ms. Embrey to give her opening statement and any other statements we'll put in the record or let you say a few words. And we'll put your full statement in the record; if you will summarize it for us.

MS. EMBREY: Mr. Chairman, Mr. Dicks and Mr. Moran -- I'm sorry I have a froggy voice today too, so I'm sorry. (Off mike.)

Well, I'm honored to be here today to present the priorities of the Military Health System in its Fiscal year 2010 budget. America's armed forces are our country's greatest strategic assets. And apart from defending the nation, DOD has no higher priority than to provide the highest quality health care and support to our force and its families.

Secretary Gates has said that at the heart of the all-volunteer force is a 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 to -- of 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. And we wholeheartedly agree.

Indeed the MHS has one overarching mission to provide optimal health services in support of our nation's military mission anytime, anywhere. Today, the Military Health System serves more than 9.4 million beneficiaries. In addition to ensuring force health protection and delivering the full range of beneficiary health services, the Military Health System provides world class medical education, training and research; and support to military and humanitarian assistance operations at home and abroad.

In addition to sustaining a fit and healthy protective force, our goals include achieving the lowest possible rate of death, injury and disease during military operations. Deliver superior followup care that includes smooth transition to the Department of Veterans Affairs. And to build healthy and resilient individual, family, and communities; and improve access to high-quality, cost-effective care.

I want to especially thank this committee and you Mr. Chairman for your leadership and support financially and otherwise, as we strive to provide the best possible care for our forces and their families. Your support for them and especially for our combat wounded, ill and injured is greatly appreciated. While there is always much more to be done, I believe we have made significant progress towards our goals. I have provided this information in some detail in my formal statement, which is submitted for the record.

I'd briefly like to discuss a broad summary of the unified medical budget request for 2010. DOD's total budget request for health care in 2010 is $47.4 billion. This includes the Defense Health Program, Wounded, Ill and Injured Care and Rehabilitation, Military Personnel, Military Construction, and Medicare Eligible Retiree Health Care. The largest portion of the budget request $27.9 billion is requested for the Defense Health Program, which includes $27 billion for operations and maintenance, $300 million for procurement, and $600 million for military relevant, medical research and development.

For military personnel the budget request includes $7.7 billion to support more than 84,000 military personnel, who provide health care services to our forces around the world, including those involved in aeromedical evacuation, shipboard and undersea medicine, and global humanitarian assistance and response. Funding for military construction includes $1 billion for 23 medical construction projects in 16 locations, including two of the department's highest construction priorities. Phase 1 of a hospital replacement project in Guam and Phase 1 of a new ambulatory care center at Lackland Air Force Base, Texas.

The estimated normal cost for the Medicare Eligible Retiree Health Care fund in the budget request is $10.8 billion, which includes payments for care in MTFs to provide health care providers; and to reimburse the services for military labor used in the provision of health care services. For wounded, ill and injured service members, the budget request includes $3.3 billion for enhanced care, new infrastructure, and research efforts to mitigate the effects of traumatic stress and traumatic brain injuries.

The secretary funded all FY 2010 medical requirements identified by the service medical departments and the TRICARE management activity. It is important to note that the budget does not include any benefit reform savings; and beneficiary enrollment fees and copays remain unchanged. MTF efficiency savings previously assumed have been fully restored to the services medical departments. And previously programmed MIL to CIV conversions are being restored in accordance with the FY 2008 NDAA. Pursuant to this restoral, the services have submitted memorandums (sic) of agreement to restore 5,443 billets in FY 2010.

Mr. Chairman, the MHS is 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 their sacrifices on our behalf.

We can and will continue to do all that we can to protect and strengthen their health, heal their wounds, and honor their courage and commitment to our nation. I look forward to answering your questions.

GEN. SCHOOMAKER: Mr. Chairman, ranking member Young, distinguished members of the Defense Subcommittee, thank you for the opportunity to discuss Army Medicine and the Defense Health Program. Army Medicine in the past few years due in no small measure to this committee and your leadership, sir, serves -- and in general this year is well funded in FY '10.

The president requested sufficient funding to support the growth in Army end strength, wounded, ill and injured care, traumatic brain injury and psychological health programs and specialized casualty care. The Medical Treatment Facility or efficiency (uncertain?) wedge as it was called was fully restored. And as Ms. Embrey has commented, all military to civilian conversions were reversed. We received partial re-basing for the workload increases we've achieved since 2003, but expect the balance to come in this year of execution.

Facilities sustainment is funded at 100 percent. We've added significant funding to the human capital programs to include our civilian hiring incentives -- the three Rs, recruiting, retention and relocation. Our Health Professions Scholarship Program and loan repayment, and continuation of civilian nursery loan repayment and special civilian salary rates. While the president's budget is adequate, FY '10 may present some financial challenges for Army Medicine as new and expanded missions emerge to meet the increasing health care requirements of the Army at war.

I strongly believe that we must focus on building and maintaining health and resilience and in conducting science-driven, evidence-based practices focusing on the ultimate clinical outcomes when bad things happen to good people, and they fall off the balance medium (uncertain?) of good health, such as with combat wounds, injuries, serious illnesses and the like.

Sir, before the meeting we were talking about the utility for example of scanning procedures for say colon cancer. And good evidence-based practices would always look at whether that procedure when applied to patients really does truly extend life and find disease earlier or if it's just technology that has not added value. And that's what we talk about when we talk about evidence-based practices and optimal clinical outcomes. I believe that this approach will ultimately lead to the best results for our Army and military community, and the most cost effective system of health and health care delivery.

I'd also like to comment upon the efforts to prevent, to mitigate, to identify, manage and treat behavioral health consequences of service and uniform, and those arising from frequent deployments, from long family and community separations, and the exposures to the rigors of combat. Army leaders at all levels recognize that combat and repeated deployments are difficult for soldiers and stress our families, especially the short dwell times between deployments. We are making bold, sustained efforts to improve the resilience of the entire Army and family; and to reduce the stigma associated with seeking mental health care.

We want to provide multi-disciplinary care that addresses specific behavioral health care needs both promptly and expertly. We're resolved to prevent adverse social outcomes associated with military service in combat, such as driving while intoxicated and family violence. Suicides are unaccepted -- unacceptable losses of our soldiers, realizing that the loss of even one soldier to suicide is one too many. We're looking closely at the factors involved.

Rather than post-traumatic stress disorder, as one might expect, we continue to see that fractured relationships and work-related stressors are the major factors in soldier suicides. We have numerous coordinated and integrated initiatives in place to help soldiers and their family. Key among them are the -- is a new comprehensive soldier fitness initiative, which is being led by the chief of staff himself and is being implemented by Brigadier General Rhonda Cornum, an Army Medical Department general officer. This improves the resilience of the soldier and the whole family really by focusing on five areas of fitness and resilience -- physical, emotional, spiritual, social and family. I believe that your leadership here has heard about this and I certainly will expand upon that today, if you desire.

In closing, I want to thank one of my colleagues here at the table -- we mentioned it, sir, informally. This is one of the -- a wing men, Jim Roudebush's last hearings. He's been a terrific partner in military medicine; and we certainly admire his service. He is leaving behind a soldier in uniform in a striker brigade in Fort Lewis for which we are very grateful; and we wish him the very best.

I want to thank the committee for their terrific support of the Defense Health Program and Army Medicine. Thank you again for holding this hearing and for your continued support of Army Medicine and the entire medical force. Thank you.

ADM. ROBINSON: Chairman Murtha, Congressman Young, distinguished members of the committee, since I testified last year we have seen the emergence of impressive changes and unique challenges to this nation and the global community. 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 families while supporting the CNO's maritime strategy. Our Navy Medicine teams are flexible enough to participate in Overseas Contingency Operations, homeland defense missions, humanitarian civil assistance missions, disaster relief missions; while at the same time providing direct health care to our nation's heroes and to their families and those who have worn the cloth of the nation.

In spite of all of the missions we are currently prepared to participate in, we are continuously making the necessary changes and improvements to meet the requirements of the biggest consumer of our operational health support efforts, the Marine Corps. Currently, we are realigning medical capabilities to support operational forces in emerging theaters of operation. Our Navy humanitarian efforts have continued to grow; and this year we will visit sites in the U.S. Pacific and Southern Command's areas of operation. We will not be deploying the USS Dubuque because of an outbreak of H1N1 in the past several weeks. We are however working on other alternatives; and in fact, a USNS ship has been named the bird to replace the Dubuque.

Our nation's humanitarian efforts serve as a unique opportunity to positively impact the perception of the United States and our allies by other nations. So this is a critical part of the CNO's strategic initiatives. We continue to make improvements to meet the needs of sailors and marines who have become injured while serving in theater or training at home. Over the last year, Navy Medicine significantly expanded services so that the wounded warriors would have access to timely, high-quality care. In addition, Navy Medicine's concept of care is always 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.

At our military treatment facilities, we recognize and embrace the military culture and incorporate that into the healing process. The Bureau of Medicine and Surgery, Wounded Warrior Regiment medical review team and the returning warrior workshop supports Marines and Navy sailor 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.

Much attention has been focused on ensuring service members medical conditions are appropriately addressed on return from deployment. The pre-deployment health assessment PDHA is one mechanism that is used to identify physical and psychological health issues prior to deployment. The post-deployment health assessment PDHA and the post-deployment health reassessment PDHRA identify deployment- related, health-care concerns on return to home station and 90 to 180 days post-deployment.

Navy Medicine's innovative deployment health centers currently in 17 high fleet and Marine Corps concentrations areas support the deployment health assessment process and serves as easily accessible, non-stigmatizing portals for mental health care. The centers are staffed with primary care and mental health providers to address deployment-related, health issues such as traumatic brain injury, post-traumatic stress, and substance misuse. Navy Medicine's partnership with the Department of Veterans Affairs medical facilities is evolving into a mutually-beneficial partnership. This coordinated care for our warriors who transfer to or are receiving care from a Veterans Administration facility ensures their needs are met and their family concerns are addressed.

Working closely with the chief of naval personnel, medical recruiting continues to be one of the top priorities for 2009. In spite of successes in the HPSP medical and dental corps recruitment, meeting our direct accession missions still remains a challenge. I anticipate increased demand for medical service corps personnel with respect to individual augmentation missions supporting the current mission in Iraq and Afghanistan; and the planned humanitarian assistance and unexpected disaster relief missions that we will certainly have.

These demands will impact the medical service corps' specialties linked to mental, behavioral and rehabilitative health and operational support such as clinical psychiatrists, social workers, occupational therapists, physician's assistants, and physical therapists. For the first time in five years, Navy nurse corps officer gains in 2008 outpaced losses. Despite the growing national nursing shortage and the resistance of the civilian nursing community to the recession, the recruitment and retention of nurses continues to improve.

It is important to recognize the unique challenges before Navy Medicine at this particularly critical time for our nation. 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. The military health system continues to evolve; and we are taking advantage of opportunities to modernize management processes that will allow us to operate as a stronger innovative partner within the military health system.

Chairman Murtha, ranking member Young, I want to express my gratitude on behalf of all of Navy Medicine -- uniform, civilian, contractor, volunteer personnel who are committed to meeting and exceeding the health care needs of our beneficiaries. I'd also like to take a moment to thank General Roudebush, sitting to my left, who has been a wonderful partner. He's been a wonderful professional to work with; and most of all, he's been a great friend to have. And we will miss him as General Schoomaker has already alluded to. So, happy retirement to you and thank you very much. He's been an excellent wing man.

Thank you again for providing me this opportunity to share with you Navy Medicine's mission and what we're doing today. It has been my pleasure to testify before you; and I look forward to answering your questions. Thank you.

GEN. ROUDEBUSH: Thank you.

Chairman Murtha, ranking member Young, distinguished members, it is a pleasure to be here before you today. This is my last time. It has been a privilege to be part of this process, to have the opportunity to share issues, concerns, opportunities with you. And to invariably receive your full attention, your full support and the unflagging intent and vector to assure that every soldier, sailor, airman and marine has the care that they need as well as their family members. And we truly thank you for that, sir.

Air Force Medicine contributes significant capability to the joint war fight. In combat, casualty care, war time surgery and aeromedical evacuation. On the ground of both the Air Force Theater Hospital at Balad and the Craig Joint Theater Hospital in Bagram, 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, endovascular operating room at Balad, the only DOD facility of its kind.

Their use of innovative technology and surgical techniques has greatly advanced the care of our joint war fighter and coalition casualties. And their work with their Army and Navy brothers and sisters, have truly rewritten the book on combat casualty care in our theater of operation. To bring our wounded warriors safely and rapidly home, our critical-care, medical-transport teams provide unique ICU care in the air within DOD's joint enroute medical care system. We continue to improve the outcomes of the CCATT wounded warrior care by incorporating lessons learned into clinical practice guidelines and modernizing the equipment to support the mission.

This Air Force unique expertise pays huge dividends back home as well. When Hurricanes Katrina and Rita struck in 2005, Air Force active duty, Guard and Reserve medical personnel were in place conducting life-saving operations. Similarly, hundreds of members of this total force team were in place September 1, 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 unit patients from Texas area hospitals to Dallas medical facilities. I'm truly proud of this incredible team effort.

The success for our Air Force mission directly correlates with our ability to build and maintain a healthy, fit force at home and in theater. Always working to improve our care, our family health initiative establishes an Air Force medical home. This medical home optimizes health care practice within our family health care 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 critically important as well. To mitigate their risks 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 to recognizing risk factors in themselves and others, along with the willingness to seek help is the key to effectively functioning across the deployment cycle and reuniting and reintegrating with their families.

Likewise, we screen carefully for traumatic brain injury at home and at our forward deployed medical facilities. To respond to our 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 psychologists and psychiatrists 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 specialties. And we thank you for your support in this critically important endeavor.

For your awareness, over time we are seeing an increased number of airmen with post-traumatic stress disorder; 1,758 airmen have been diagnosed with PTSD within 12 months of return from deployment from 2002 - 2008. As a result of our effort at early PTS identification and treatment the vast majority of these airmen continue to serve with the benefit of support and treatment. Understanding that suicide prevention 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 help seeking behavior 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 medicine and the VA to assure 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 today and tomorrow. At the center of our strategy is the Health Professions Scholarship Program. HPSP is our most successful recruiting tool, but we're also seeing positive trends in retention from our other financial assistance programs and pay plans. Again, thank you for your unwavering support in this critical endeavor.

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. And as we look to the way ahead, I see a great future for the Air Force medical service built on a solid foundation of top notch people, outstanding training programs and strong partnerships. It is indeed an exciting, challenging and rewarding time to be in Air Force Medicine and indeed in military medicine.

I couldn't be more proud of my Air Force and joint medical team. We join our sister services in thanking you for your enduring support; and I look forward to your questions.

REP. C. W. BILL YOUNG (R-FL): Mr. Chairman, thank you very much. First let me apologize for being late for the beginning of the hearing. But for me to get to work, I've got to travel on probably the heaviest trafficked highway in the world. And there were three accidents on that highway this morning. So -- anyway, Mr. Chairman and I want to welcome the surgeons general.

MR. : (Off mike.)

REP. YOUNG: Well, he's only half, not even half as far as I am away from the city.

MR. : (Off mike.)

REP. YOUNG: At one of our previous hearings with the surgeons general, I made the comment that -- complimented the witnesses for the really outstanding medical care that our military troops and their families receive in the military hospitals. And I'll tell you I took a couple of really tough blogger hits because it was right at about the time that there were some negative stories about one of our hospitals; but I'm going to do it again today. I'm going to tell you that. Now Mr. Murtha and I have visited your hospitals so many times. And I think he would agree that we have -- we have actually seen miracles take place at your hospitals, miracles at least from the laymen's perspective.

And I just want to compliment you for the military medical care that you provide for our troops and for their families. No one is perfect, we certainly aren't perfect, but you just do a really good job. But General Roudebush, you know, the last time I saw General Roudebush, Admiral Robinson, was out at your hospital at Bethesda about three weeks ago. And he was in his flight suit. I don't know if he was getting ready to fly off somewhere, but I tell you what that flight suit fit him just like it did 30 years ago when he first put it on.

General, the Air Force will miss you, military medicine will miss you.

Military medicine has done a really good job promoting the United States and the generosity of the American people around the world. And one of the early projects of this committee was the creation of the hospital ships, the Mercy and the Comfort. But I have learned some interesting information because we send the Mercy and Comfort around the world to natural disasters that are not related to any military operation, but we still do it. And I think it speaks well for the United States, but it also helps those who have been injured and who will become sick because of those natural disasters. But I'm getting some word that maybe the Navy has to pick up the cost of even those non-Navy, non-military operations.

And Admiral, I wonder if you might explain that to us. In fact, are you -- does that come out of your regular budget that you would use for treating military troops?

ADM. ROBINSON: Congressman Young, humanitarian and civil assistance is actually funded out of Fleet and Forces Command in Norfolk. So the missions are funded in that regard. What I have testified to before is a nuance of that, and it goes something like this. As we staff the humanitarian and civil assistance missions, and over the course of the last year we've done approximately 130,000 outpatient visits and about 1,400 inpatient visits from around the world.

The workload of those visits isn't captured by any of the data systems that we use in DOD. And so, as my men, women, corpsmen, nurses, and physicians, medical service corps, dentists leave the medical treatment facilities, go do those missions, as we then backfill with contractors which is also paid for, the workload often doesn't reflect the additional work that those men and women are doing. And therefore, as we get into our pay-for-performance systems how we will calculate monies back to the MTFs. Often I'm -- actually end up being taxed for those humanitarian civil assistance. So I have previously testified to that; and that is, I think what you are alluding to in terms of the impact on the military health system and specifically on Navy Medicine.

REP. YOUNG: Well Admiral, explain the effect as to what you are maybe not able to do for the troops in our military -- in the Navy hospitals.

ADM. ROBINSON: Well, I would say that in fact we're not negatively affected by our ability to do the care and do the missions that we have. But what I would suggest is that as we look at, as we look at workload and as we look at metrics that help explain the efficiency of our -- particularly our hospitals, our military treatment facilities, what you'll find is that instead of not being as efficient, which often is reflected in the workload data, because the workload data, as I said, that is being done on Mercy, Comfort and other humanitarian assistance missions isn't being captured.

Instead of being less efficient, I actually think we're more efficient. But specifically, as we look at the inefficiencies that can occur; we not only get graded as not being as efficient, but we also get taxed by not being able to participate in the compensation of pay for performance. So the PPS becomes an issue. So we send people, we do missions and we still get taxed for that. And I just bring that up because I think that's a real factor in Navy Medicine.

REP. YOUNG: Well let me direct this question to all three of you or all four of you. The budget -- I personally think that the budget is a little -- the budget request is lacking in some of the needs for military service-wide. Are there any things that you all really need that are not in the budget request that would become an unfunded requirement?

MS. EMBREY: As you know, sir, I'm performing the duties. I am not currently an appointment of the current administration. So I'm serving in an acting capacity, they call it performing the duties. I think I won't be performing the duties much longer if I identified anything other than the needs of the president's budget. (Laughter.)

REP. YOUNG: Now I understand that, but we're not going to tell the president what you tell us.

GEN. SCHOOMAKER: Well, sir, I will echo Ms. Embrey's comments. As I said in my opening statement, Army Medicine is sufficiently funded in the FY '10 budget now. But I think you're asking us to give you an assessment, our gut check on where we think we're taking risks. And I would say that probably -- if there is an area that I am concerned about, it's that you all have been extraordinarily generous in helping us to reverse several decades worth of under-capitalization of our physical plants, our hospitals, our clinics. You heard the list from all of us of what you all have done for us.

But our initial outfitting and transition costs associated with that -- we call them IO&T costs, are funded in the budget year. So with the increased use of -- that is, more users coming into our system, more unique social security numbers, more unique individual patients. And with our patients who are enrolled in our system using it more frequently.

That's a good thing in the sense that people are -- have reduced stigma to go to the -- to get mental health. So they are coming in and using it more. Wounded, ill and injured soldiers much like Vice Admiral Madison -- oh excuse me, Robinson commented about the military unique missions of the Navy, in Army Medicine we are caring for close to 10,000 wounded, ill and injured soldiers. They take a significant larger amount of care. And so, with this growth in care competing with initial outfitting, I think that there is some risk there, sir. But I would have to say at this point in time, we are sufficiently budgeted.

REP. YOUNG: Thank you.

ADM. ROBINSON: I would echo what Ms. Embrey has said already.

I would also suggest that -- and Navy Medicine is fully funded also. I would suggest that as we look at the DHP though, the private sector care monies, I'm not suggesting that they're not fully funded, but that is a risk area because we on the MHS, we in the active duty side don't really have visibility of those amounts of funds. So those are types of issues that come to play. I don't know that that's going to be an issue. It's just that the visibility is lacking from my point of view so I can't see that. So that would be my only comment.

GEN. ROUDEBUSH: Sir, I would agree we are adequately funded, but I think it's also going to be challenging this year, challenging next year. We're operating at a very high ops tempo with the MIL to CIV billets coming back on our books as we work to fill those with military personnel, we are working to be sure that we keep those gaps filled by other means, whether it's just short-term over-hires, whatever the methodology. But we want to assure that we maintain ready access and that we are in fact able to provide that care. So, it does provide a challenge.

I would like to offer an observation, however. I think you and we are especially well served by your staffers who really engage with us at a variety of levels. Quite often is that early warning radar to pick up the issues as they are emerging and working through. So we find that as we do deal with items that come about, I believe we're well served on both sides. But I believe we will get there this year and continue to deliver the care that our beneficiaries and men and women so richly deserve.

REP. YOUNG: Well again, thank you very much for being here. Thank you very much for the good job that our military medical professionals provide for our troops.

And Mr. Chairman, I have additional questions but I'll wait for another turn. Thank you very much.

REP. NORMAN D. DICKS (D-WA): Well, I want to compliment all of you for the incredible job that's being done. I mean, just the survival rate I think is an amazing feat; and it's improvement over years is quite impressive.

I wanted to go back -- this is the question I asked before when we had an earlier hearing. With regards to the hyperbaric oxygen therapy treatment, Ms. Embrey, the text of your testimony is nearly verbatim from your previous testimony before the committee in March. Has any progress been made in getting this trial underway?

MS. EMBREY: Yes, sir. I wish Laurie Sutton was here so she could give you exactly the details. But we have worked with the services and with our outside experts to develop a protocol. We have three different sites where we're planning to do that. Because the FDA has identified oxygen in the hyperbaric chamber as an investigational new drug for this kind of treatment, we need to seek their authority to use that in this protocol. When FDA gives us that authority, then we can begin to execute --

REP. DICKS: Would you tell the committee again how this -- in what circumstances it would be utilized? Or maybe one of the admirals, generals could do it.

MS. EMBREY: I'm sorry?

REP. DICKS: When would you use this? Under what circumstances would this be used?

MS. EMBREY: Well the Navy uses it routinely for diving issues. But for the purposes that you're talking about, we're talking about this as a treatment for traumatic brain injuries and other mental health symptoms.

REP. DICKS: And its been prescribed -- you can do a, it has been utilized and its been quite effective I'm told.

MS. EMBREY: Doctors have the ability to identify because of their personal relationship with their patients anything that they believe in their judgment would assist them in achieving a better outcome. And so, they have the authority to use and prescribe alternative therapies. Even if they're an off-label use -- hyperbaric chambers are safe for certain things. The challenge is is that we don't know -- there is no evidence currently that indicates that putting a person who has had a traumatic brain injury in a hyperbaric chamber may or may not have and do harm evidence wise. And so the reason why we are doing these studies is to make sure that we do know --

REP. DICKS: Are the studies underway yet?

MS. EMBREY: In one site, I believe they are, sir.

GEN. ROUDEBUSH: Sir, if I can comment. We initiated a study at Wilford Hall beginning back in February which will be completed within a year's time, which uses hyperbaric oxygen with pre- and post- neurocognitive testing to see if in fact there is a beneficial effect. The -- I think the more definitive study is the study that Ms. Embrey refers to wherein the FDA has identified hyperbaric oxygen as an investigative -- as a new drug, if you will. And we are just on the verge of getting their approval and moving forward with this study.

True there have been anecdotal reports of the benefits of hyperbaric oxygen, but there has not been a thoroughly prepared and conducted study to see if in fact that is the case. And that's precisely what we're doing, and actually doing it in a very aggressive manner to get this done as expeditiously as we can.

REP. DICKS: Admiral, do you have any comment on this? The Navy is kind of the reservoir of expertise on this.

ADM. ROBINSON: The Navy helped to facilitate a meeting in which many of the professionals who have contributed to the hyperbaric oxygen therapy literature came together with other professionals who have been doing a great deal of work with neuroscience and with the effects of different modalities, treatments, medications and also oxygen on neural and brain tissue. We did that in the January - February time frame. We spent two days. It was widely attended by these professionals. It was very informative.

From that we have gone out with Air Force, the Wilford Hall study, also with Louisiana University, LSU, and others to in fact try to find the best method of doing a prospective randomized trial that we could utilize to make sure that if we say that hyperbaric oxygen is a therapy for traumatic brain injury, that we can prove that. And that we can write clinical practice guidelines that can be utilized across the United States, actually across the world. Because to put the imprimatur of success on a therapy that has not been proven in the standard medical methodology. It has been proven in terms of anecdotal information.

There are many patients --

REP. DICKS: Let me just ask you on that point. Has there been any -- ever any adverse consequence where this was prescribed and utilized?

ADM. ROBINSON: None that I have --

REP. DICKS: Has there been any adverse consequence?

ADM. ROBINSON: None that I have ever heard of Congressman Dicks. But that doesn't necessarily mean that it hasn't been -- it hasn't occurred. It just means that I don't know about it. People who tend to give anecdotal information often don't necessarily tell all of the story, which is the reason that in medicine, which is the prospective randomized, multi-disciplinary and also multi-centered, evidence-based trials are necessary to make sure that we can get the best evidence to go with the clinical practice guidelines.

The end result is whatever I say is going to work for a sailor, an airmen, a marine, a soldier, a Coast Guardsman, or their family member. But whatever I say works from a Navy perspective or from an Army or Air Force perspective, we really base that on randomized prospective, reproducible data that we can live with and build practice guidelines on. That's what we don't have yet. (Off mike.)

ADM. ROBINSON: I would anticipate -- this is going, I know this seems slow. This is going very rapidly. I would say probably in the next 18 - 24 months, we may have some evidence of how hyperbaric oxygen therapy is working in the trials that we have going, but that is a guess.

I'm not quite sure.

MR. : And I would have to -- I'll add to that. Everything that has been said by my colleagues is exactly our position on this. I think one of the frustrations here is that hyperbaric oxygen has been around for many, many years. It's used in -- (off mike).

GEN. SCHOOMAKER: Sir, this is pressurized, this is putting a patient with staff support, because it is fairly labor intensive into a high pressure environment where the oxygen pressure around the patient and what is breathed in their lungs is higher than here at sea level. And so, when you are recovering, for example, from a deep diving problem in what we call the bends, you have to be put back into an environment where you push literally air and oxygen and nitrogen back into the body to then slowly decompress them and then reverse the problem.

In cases of resistant infection, where we have bacteria that are growing deep in wounds, where we think if we raise the oxygen tension, we may encourage wound healing. It has been used in that setting as well. But in this setting, sir, it has never been demonstrated to be effective in a standard way where we know number one -- who are we treating? We're already having difficulty separating mild traumatic brain injury from post-traumatic stress because the symptoms are so overlapping. And then, what are the total outcomes of that -- positive and negative?

As Dr. Robinson said, I agree totally. Unless you do a careful study, you don't know if you're doing harm. And there are potentials for harm. One of the frustrations we've had with this is a technology which has been around for decades; and concussions which have occurred on sports fields and on highways for decades has never been studied by this group. And when we offered, through your generosity, money to do careful studies, nobody came forward with credible research proposals that we do. Finally, the military services said enough. We're going to conduct the research. And that's what's doing.

REP. MURTHA: (Off mike.)

REP. TODD TIAHRT (R-KS): Thank you, Mr. Chairman. We have -- I was recently up at Fort Riley and not long after that I went pheasant hunting with some soldiers that were in the Wounded Warrior Unit. We had a great day. I spent all day with them. And some of the things that they're going through I wasn't aware of; and I think most Americans aren't aware of especially in the area of TBI where I'm not sure we really understand the long-term impact of having their brain jostled around.

And the good thing about the MRAPS for example is that we have a lot more -- or lot higher survivability rate. One of the down sides is though that these soldiers going through three or four major explosions like that can impact their brain because of the impact to it. And would you explain so that we better understand what a Wounded Warrior Transition Unit is like the one that they have at Fort Riley?

GEN. SCHOOMAKER: Yes, sir, the Army today has 35 such units across the Army and nine, what we call community-based warrior transition units. These are special units we developed after the problems that were highlighted earlier of the transitional care that takes place from inpatient to outpatient and beyond into the VA system and back into either private medicine or VA medicine or back into uniform.

What we realized was that we had world class even cutting edge inpatient care and we had established outpatient practices, but very, very rudimentary. In fact, we had forgotten many of the lessons of earlier wars where we transitioned soldiers successfully from inpatient to outpatient care and then back into uniform or into private life for continued care required. So we stood up a series of units -- they are actually staffed by non-medical soldiers from all backgrounds. Young officers and enlisted, we train them how to do that. We've put nurse case managers in place and primary care managers, physicians, nurse practitioners, physician's assistants who provide primary care services.

And that triad then is responsible for carrying the soldier in a sense with family along the transitional pathway. Currently, we have 7,700 roughly soldiers in the Warrior Transition Units -- wounded, ill and injured soldiers. About 15 percent are combat wounded; about 15 percent are evacuated with other medical problems. About 30 percent identify problems like concussive injury or post-traumatic stress after they return. And about 30 percent are frankly injuries -- illnesses that are not associated with the deployment, but may be training injuries or cancer or heart disease or other problems that soldiers are prone to, or motor vehicle accidents.

That's the construct and it's working quite well. Our focus this year now that we've set these units up and have staffed them successfully and standardized their practices, is to focus on what we call the comprehensive transition plan, which is a soldier and family developed plan for what they want to do, where they're going to go with this injury or illness, how we're going to recover them and get them back into uniform. And that's our highest priority is to try to get them back in uniform if possible or transition back into private life, into the VA system, if necessary.

Does that answer your question, sir?

REP. TIAHRT: Yes, it does. Thank you it was a very good explanation.

There are some instances around the country where there is a high discipline rate for these wounded soldiers that come back. And some bases have a different rate than others. Fort Drum, New York has every month one out of 76 soldiers are going through Article 15 (ph). In Kansas where we have this Wounded Warrior Transition Unit, it's only one out of 309. And I think it's because they have focused on working with these folks that come back.

And I -- in my personal experience in meeting one of these soldiers, a young sergeant, who had been through six explosions. He told me that he has trouble with simple reasoning things that he didn't have before. You know, just like small calculations. He now carries a calculator around in his pocket because a small addition problem is just one of the evidence.

There is an article done by the AP back in March. I don't know if you are familiar with it or not, but it highlights how some bases are not working with these soldiers as well as others. And I would like you to -- it's called Disciplined Wounded Warriors, I'd like you to check out that article. Because I think there is a problem by being consistent in the military and helping these folks transition back to either active duty full time or back to civilian life.

The last thing I wanted to ask you about in both the military medical records and in private sector health care records, we're moving towards electronic medical records. But I notice that in the VA and certainly in the private sector there is no standard interface for these different electronic record programs that are out there. So you can have within the VA somebody's military records or health care records, excuse me, not being read in a -- except when they change to a different facility. They may be working at one of our remote clinics. And then, when they come into the VA hospital, there's not always a connection that is useable. In the private sector it's the same thing.

Now, in any government program they always have an interface control document that manages all the interfaces between the working systems. Yet, I don't think we have one in any of the services when it comes to medical records. And yet, we are seeing services develop these electronic medical records. So I would suggest that somewhere inside the services; and I think you guys would be the logical initiator in this, develop an interface control document so that when medical record software is developed, it has the ability to interface with other softwares (sic) that are trying to do the same tasks.

GEN. SCHOOMAKER: Yes, sir, if I could -- let me comment real quickly, first on - (inaudible) - rates. We're very concerned about insulation focused allegations that we are not sensitive to medical problems of soldiers who may have been brought up for administrative or non-judicial punishment. We have very active policies that soldiers not undergo administrative actions or non-judicial punishment without a very thorough incorporation of their medical history and problems. And Brigadier General Gary Cheek, who commands the Warrior Transition Command overseeing all of these units and their standard practices, has just completed a review of non-judicial punishment at nine different installations.

While we don't direct and can't direct that installation commanders or warrior transition commanders employ a kind of standard approach, because every case stands on its own. He's very reassuring that in fact our policies are working out there. Commanders are taking into account the medical conditions and problems of soldiers before implementing or taking administrative and non-judicial action.

Quickly on the electronic health record, sir, we do have with the VA system a standard interface. In fact, we have Bi-directional Health Information Exchange now it's called BHIE. It isn't to where we want it to be right now. We have very good exchange of information to the four polytrauma centers where the most severely injured and ill soldiers are doing -- are being sent.

But you're absolutely right. We do not have with the private sector to include our purchased care partners that were referred to by my colleagues earlier. We do not have a standard interface with the thousands of practices and hospitals out there. And this is a national problem.

REP. TIAHRT: Thank you, Mr. Chairman.

REP. MURTHA: (Off mike.)

REP. JIM MORAN (D-VA): Yes, yes, except that what happens, Mr. Chairman as you particularly know, in the national capital region affects the ability of this panel to carry out its mission. There is a relationship here. And thank you, Mr. Chairman.

And I'd like to ask Ms. Embrey and I understand the constraints you've already explained that you -- I don't think you really ought to be worried about your job. You're doing a fine job. But what if we don't make the deadline for Walter Reed in time? I know we're going to talk about it with another panel, who is focused on the weeds in this garden. But I want you to look at the larger picture. Because many of us feel that there is some very serious problems that need to be addressed if we are not able to achieve what needs to be achieved in what is now a pretty short period of time.

We're talking really a year and a half. And as far as I can see, you're not going to meet that deadline. So that's going to have a major impact on all the operations you are responsible for. What are your contingency plans, Ms. Embrey?

MS. EMBREY: Officially, I think my contingency plan is to press harder and faster with the current program. But truly, the contingency plan is when we get close and we realize that as a department we really can't -- we understand what the negative and positive effects are of where we are. At a point in time, we need to inform people about, you know, what they are and how we can come together to work through those problems.

But right now we have a plan; we're committed to meeting it. And we're working it very hard.

REP. MORAN: Well, I know you're working hard. I know you have a plan. I know you're committed to meeting it. And in fact, when we tried to inject some judgment into the process, somebody over at DOD threatened to veto the whole bill if we suggested that you might extend the deadline so that we can actually achieve this transition in a reasonable period of time. That was probably Chu or somebody like that, but he's gone now.

So now, we're going to find out who reports to who --

MS. EMBREY: We recognize we report to you.

REP. MORAN: There you go. Now we're getting back onto -- to our link to the chairman at least. Certainly, Vice Admiral Carney understands that -- behind you there. Some of the problems here at Walter Reed we're going to get into the nitty gritty with the next panel. But we love these Centers for Excellence. You're doing a great job. But the space that you've provided for the Centers for Excellence in the new facilities are considerably smaller than the space you have now; isn't that right? How is that going to affect Centers for Excellence, which we like which are undoubtedly going to need to expand to deal with the needs?

MS. EMBREY: Centers of Excellence Institutes and centers and the concept of how we're going to implement that across the department is actively being discussed now. A Center of Excellence may not necessarily need to have brick and mortar. A Center of Excellence by its terms implies that if you have a Center of Excellence the other places aren't excellent. And we don't want that, we certainly want to have a mechanism by which to ensure --

MORE that the whole system is apprised and kept current on the best possible practices, and to deliver the best possible care anywhere.

So the physical location and the brick and mortar location at Bethesda right now for the Defense Center of Excellence for Traumatic Brain Injury and Psychological Health, the location of the Defense Center of Excellence for Vision, I believe, is also going to be there. But there's going to be other locations and hubs throughout our system.

REP. MORAN: I understand that but I have a suspicion that you're, in order to meet this arbitrary deadline you're trying to stuff stuff into Ft. Belvoir and the other new hospital that you're building, and instead of looking for the most excellent design you're just trying to figure out the expedient way to meet again the deadline, but I won't argue about that, I just want to raise it as an issue.

But apparently the Surgeon General wanted to comment on that, so --

GEN. SCHOOMAKER: The only comment I'd like to make is that, in addition to the fact that we, in every forum where we jointly go out, for example, the new Belvoir or the new Walter Reed national military medical center. And this is true throughout the BRAC process. We take a pause and say, no kidding. Are we on track? Are we going to run into problems? And in every one of those fora, sir, we have been ensured by engineers, by designers, by the people building these things, that we're going to meet the deadlines.

Second point I'd like to make, and I hope it's developed in the next panel, is that there's a lot of focus been on this new Walter Reed national military medical center at the Bethesda campus, but in fact the beauty of the JTF CAPMED, and with apologies, Vice Admiral Mateczun, I hope I'm not putting words in your mouth here, but is that we have 500,000 beneficiaries in the greater metropolitan Washington area, in 37 facilities, from Carlyle barracks, Pennsylvania to Quantico, and Belvoir, the National Military Medical Center, Meade, and others. And it's the coordination of care across this very dynamic metropolitan area, and to follow the movement of our families and soldiers, and sailors, airmen, Marines, to the places where they live and they can come.

So, frankly, I'm as excited, or almost more excited about the new Belvoir, which has got tremendous capacity, and which is going to take some of the capacity and some of the functional elements of the centers for breast cancer, prostate cancer, heart disease, amputee recovery, and the like, and distribute those to where we can best serve the public. So this is a coordinated plan for the entire metropolitan area. We are too focused on one institution within that bigger plan.

REP. MORAN: We want you to do it right, Mr. Surgeon General, and to do that you ought not to have an arbitrary timeline that fits an arbitrary decision of September 2011. That's the whole point. And we're up against people who say, well you may be right in terms of judgment. It's just that I've been given a job, so I'm going to do the job come hell or high water. So that's our concern.

Let me ask a more general issue here, and you've touched on it, and so I've got to obviously get into the Walter Reed stuff in a more specific way, but one of the problems we are facing is that a lot of our soldiers and families, after they return, they go back in the field but we have long-term responsibility for their medical care, there's a high level of diabetes, obesity, a lack of physical fitness once they get out of the military. And we wind up paying for that through military health care programs, particularly TRICARE.

So what are you doing in terms of preventive efforts to save us money to deal with some of these almost endemic problems with families and particularly the soldiers who just don't maintain their physical fitness regimens?

MS. EMBREY: In 2003, we developed a system to track the individual medical readiness of folks across the force, active duty and reserve component. And we measure whether or not they've been assessed, on a both physically and dentally and mentally, on an annual basis.

We assess peoples' health status through screenings, pre-deployment, and post-deployment, twice. We also have engaged in campaigns based on information and trends in utilization of alcohol, substance abuse of various types, tobacco principally. We have looked at obesity as an issue, and we've stepped up campaigns through the line, who owns those programs for us and runs them for us.

Each service has significant programs that are addressing those issues. Some are more effective than others. We still do have an obesity problem, but frankly it's because we recruit folks who have these issues, and part of it is addressing, you know, cessation of those bad and risky behaviors.

We also have introduced, and will be introducing, in the next 60 days, pilot programs to incentivize people to engage in more healthy behaviors, paying people to go to the gym and to not smoke and to do different things. It's a pilot. It's detailed in my testimony, and I outline some of the highlights of it, and I can give you more information about those, but that's a pay for, you know, it's incentivized pay for outcomes that we are trying to achieve.

REP. MORAN: It's just what I was looking for. You didn't mention it in your summary, so I didn't realize it's in your testimony. That's exactly what we ought to be doing. It's a small fraction of the cost of taking care of them, obesity and all kinds of other problems that are behaviorally related onto TRICARE. TRICARE is going through the roof. And a little bit of money to incentivize them to be healthy now is going to save us billions in the long run.

Thank you, Ms. Embrey.

GEN. SCHOOMAKER: If I could just comment quickly. I think, at the execution within hospitals and clinics, we have to incentivize commanders and clinics to do that too. This is a problem in American health care. What we've been doing in Army medicine for the past four to five years is to shift the paper performance towards population health and toward preventive measures.

I mean in the last two years, we have 50,000, roughly, over-65 patients we care for. When we started this campaign, 25 percent of them, roughly, had their vaccination for common pneumococcal vaccine complete. We started incentivizing commanders and clinics that if you can raise the vaccination levels higher, we'll pay you for it. We pay generously, handsomely if they're brought to the emergency room with pneumonia or admitted. Why don't we pay better if you prevent it?

And now we're at 85 percent vaccinated. So these kinds of programmatic improvements need to be done too.

GEN. ROUDEBUSH: And sir if I might add, Congressman Murtha has been instrumental in helping us establish diabetes outreach with UPMC and Wilford Hall, and in fact, we've identified a cadre of folks. We are employing strategies and methodologies, and we are starting to see beneficial outcomes. So there is, I think, an active program to improve the health, improve the outcomes, and ultimately certainly cut costs, but most importantly improve the health.

REP. MORAN: Great. Thank you.

REP. MURTHA: Mr. Rogers.

REP. HAROLD ROGERS (R-KY): Mr. Chairman, I know you're wanting to get to the next panel, so I'll be brief. I don't know who can answer this, but let me ask you about the vision center of excellence that I understand is in the works. What can you tell us about that?

MS. EMBREY: It's a very high priority for us. We have appointed a director. We have found temporary location. We have five employees from the VA who are joining us. They've just visited the spaces. They've been in effect for a short time, but they haven't really gotten off the ground too well, primarily because we were authorized a considerable amount of money but not appropriated any for that purpose. And so we took some money out of (hide ?) this last year to try to get it started, but we have a full complement of funds to expand and engage more fully an operating center.

REP. ROGERS: When will that be in operation?

MS. EMBREY: Next year.

REP. ROGERS: Next year?

MS. EMBREY: Yeah, I mean, it's operating now, but next year we're going to have it fully operating.

REP. ROGERS: Now would you integrate with the VA?

MS. EMBREY: Yes, five -- actually we just brought over five VA folks to actually staff the current temporary location in Skyline, and they are going to be moving over in the next couple of weeks, so we have five VA folks working in the center with the DOD folks.

REP. ROGERS: Here's a problem. A constituent of mine, a young soldier, who was injured about his head and face by an IED but got out and had some vision in his right eye but none in the other, enrolled in school, college, and then developed a problem. He had had operations in Germany and at Walter Reed with head injuries, went to the VA hospital in Lexington, Kentucky. And they, because he had an infection and swelling, bad, and the VA hospital there could not operate because they did not have the records of what they had done to him in Walter Reed and Germany. And he lost his eye, what was left of his eye. So he's blind now because they apparently could not get access to the military records of his previous treatment at the Army hospitals.

Will that be remedied in this process?

MS. EMBREY: Sir I think the access to records and, you know, images particularly, we are working on a standard with the VA to ensure a standard exchange of imaging so that people can see, you know. Because right now there is no standard for medical imaging in any health care environment. And so what we are trying to do -- and by this Fall we intend to have a standard that will enable rapid sharing of imaging anyplace in our system, but in the meantime, we had been working around, you know, by sending information, FedExing and other kinds of things, but I am not familiar with this particular case, so if you'd like to follow --

GEN. SCHOOMAKER: Yes sir, I'm very familiar with this case. I've spoken to the patient. We've reviewed all the records involved, and not to in any way discount the challenges of exchanging information between different systems, I have to say, sir, that our review and the VA's review concluded that this was not a problem of exchange of medical records. In fact the physician involved in the VA hospital had the entire medical record at his disposal. It happened to be a hard copy record.

So I think, I don't want to back away from the problem that was raised earlier about the bi-directional exchange of information and a digital record. That is our goal, and we do continue to work through problems there. But in this particular case, that young soldier's continued problem with vision, despite how the media has depicted it, frankly did not revolve around the exchange of medical records.

REP. ROGERS: Well I'm glad to hear your report. But let me conclude by saying that it just seems incomprehensible to me that the VA hospitals and the military hospitals have not had their records shared a long time ago. I mean, that seems a basic, elementary problem. Do you not agree?

GEN. SCHOOMAKER: Yes sir, I think that all of us are frustrated by the pace at which this is taking place. I do also know that we're probably, in terms of the national landscape of this problem, at the leading edge of solving problems for the nation in this exchange of information, and if it's problematic for us, its too big, large federal systems, we have no trouble within the military side, then out there in all of the practices and all of the different mom and pop operations around the electronic health record, it's truly problematic.

So we're trying to solve some of these problems to demonstrate how it can and should be done.

REP. ROGERS: What can we do to help with that problem?

GEN. ROUDEBUSH: Sir, if I might comment, and go back to Congressman Tiahrt's question about interfaces, Secretary Gates and Secretary Shinseki have taken a personal and very active interest in this, in terms of mandating and driving us towards a common solution, not down-selecting to Vista or down-selecting to Alta, but going to a service-oriented architecture that gets to those interfaces, the architectures, and the basic taxonomy that allows you to link these systems to get to a truly transparent and interchangeable health care record that just has one record, wherever that patient finds themselves.

Now, we live in the greater context of American medicine. So as we move this along, we do need to do it with policy, processes, and practices that are consonant with what we see in the private sector. And it is slow, it's frustrating, but I think, in terms of the last probably two to three months, we've seen more focus, the right focus in my view, moving us towards that common solution. In the meantime we'll continue to work the day to day interfaces, but we're getting there.

REP. MURTHA: (Off mike.)

REP. SANFORD D. BISHOP, JR. (D-GA): Mr. Chairman, can I ask the next panel the questions I wanted to ask this panel? (Laughs.)

(Off mike.)

REP. MURTHA: Welcome, gentlemen. We appreciate your patience. Next year I think we'll separate the panels because there is nobody more involved in health care than this subcommittee. Bill Young, his wife, myself, we've been to, I was just out at Bethesda the other day, only a couple of patients. I'm glad to hear that, I mean it's -- But we can take a lot of credit for what has happened in health care, and we certainly do. But we appreciate and are gratified by the results. But of course here we're talking about the region.

And Mr. Moran, I guess, has left, but -- (cross talk; laughter) -- Oh is he here?

(Cross talk, laughter.)

REP. MURTHA: No, no. I appreciate it. I appreciate it.

REP. DICKS: Don't get him started on -- (inaudible) --

(Cross talk.)

REP. MURTHA: If you could abbreviate your statements and let us get right to questions, because the members obviously have all kinds of concerns about what's going on here in the region. And we depend on Mr. Moran to make sure he takes care of those problems, so we appreciate your coming before the committee. And Mr. Young, do you have any comments for these gentlemen?

REP. YOUNG: No, Mr. Chairman. I'm anxious to hear the statements.

ADM. MATECZUN: Thank you, Chairman Murtha, Ranking Member Young, committee members. Thank you for the opportunity to share with you the Department's progress on realigning medical assets in the national capital region to create an integrated delivery system, a fully integrated, jointly operated and staffed health care region. It's transformation will allow DOD and the services to capitalize on their collective strengths, maintain high levels of readiness, provide second-to-none world-class health care to service members, retirees, and their families.

To be responsible for delivering this integrated world-class health care in the national capital region joint operating area, JTF CAPMED will operate two jointly manned treatment facilities comprising nearly 10,000 individuals, more than 3 million square feet, clinical and administrative space, providing 465 beds of in-patient capability. To achieve this we must oversee the transition of operations from the current Walter Reed Army Medical Center and National Naval Medical Center to the new Walter Reed National Military Medical Center, and to the Ft. Belvoir community hospital.

Our primary mission is the delivery of health care services, including casualty care. The national capital region is currently our nation's primary casualty reception site, and we have significant and world-class capabilities. At Walter Reed Army Medical Center, the prosthetic capabilities are second to none in the world, and are leading the world, as is the capabilities at the National Naval Medical Center today, to provide care for open traumatic brain injuries that are returning to our country;

The Aeromedical Staging Facility at Malcolm Grow is an extraordinarily capable facility, the best aeromedical staging facility, I believe, today. And together they comprise a seamless reception capability for those patients that are returning on C-17s from across the world.

Fortunately, as the chairman points out, casualty rates for complex trauma care are significantly down in the NCR. However, the number of psychological health cases is increasing at the same time. So we've seen a switch in the emphasis of the care that we need to deliver, but not in the need to be able to provide care for the wounded warriors that are returning here.

REP. MURTHA: Does that include in-patient and out-patients?

ADM. MATECZUN: Yes sir, it does.

We will continue to have capability to maintain this capability to receive casualties in the national capital region during transition to these new facilities and throughout the entire BRAC operation. We will in fact have significant new capabilities, including a comprehensive cancer center which puts together many of the centers of which this committee in particular, members of this committee have been so helpful in making sure that we maintain these capabilities. It will bring together the ability for the trauma registry, Congressman Young, that you have -- I'm sorry, the bone marrow registry -- to bring those together with the comprehensive cancer center in a way that's never been done before within the military health system.

There are also significant new capabilities at the Ft. Belvoir community hospital. In fact, out of those 500,000 beneficiaries that live in the region, about half of them live in the southern half of the region, and that Ft. Belvoir community hospital, a sleepy community hospital today, will grow to a 120-bed facility with significant new capabilities, including linear accelerators for oncology care, for radiation oncology, and cardiac catheterization. So significant new capabilities there.

I'll abbreviate my statement, Mr. Chairman. I would be remiss, as we near Memorial Day, if I did not remember the 221 service medical members who have made the ultimate sacrifice in their service to both their country and their fellow soldiers, sailors, airmen, Marines, Coast Guardsmen. Your support, your extraordinary support pays great honor to their service. And I'll conclude my statement.

GEN. VOLPE: Chairman Murtha, Ranking Member Young, committee members: Good morning. Thanks for giving us the opportunity to share with you the great effort that's being made by the department to enhance the health care in the national capital region. As we forge a new frontier in military medicine in the national capital region by leveraging joint solutions and initiatives, we are committed to ensure a more effective and more efficient delivery of health care.

For the first time in history, the department will deliver health care in a fully integrated region, and JTF CAPMED will oversee through operational control the first two truly joint hospitals at the Walter Reed National Military Medical Center at Bethesda, as well as the Ft. Belvoir community hospital in Virginia. The two hospitals will be jointly staffed, jointly operated, jointly led, and jointly governed. Service members, veterans, and their families will be better served by being able to receive their health care in a regional system, which leverages the outstanding capabilities that each service has to offer.

We at JTF CAPMED are very mindful that the massive transformation in the national capital region comprises more than BRAC alone. It is a conglomerate of numerous complex initiatives.

While BRAC provided the initial stimulus to realign the military health system resources within the national capital region, the department utilized and will continue to utilize it as an opportunity to transform, integrate, and re-engineer how we deliver health care in the region.

I will abbreviate much of my opening statement, but I would like to mention finally that the real beauty of JTF CAPMED is that it is a mechanism to integrate health care across the three services' medical systems to leverage the common capabilities that each service has to offer while still respecting the unique requirements that each service must maintain. And we're very proud to have an open working relationship with the three services and the assistant secretary of defense of health affairs, those on the joint staff at OSD, and there are procedures in place for us to work through the challenges that we face and to capitalize on the opportunities to improve the delivery of health care.

The fact is that we all have a very common goal and culture, providing warriors and their families the world-class health care that they deserve.

Again, thank you for allowing us to share in the progress and the transformational efforts in the national capital region. And I've submitted the rest of my comments in the written statement and look forward to your questions.

REP. MURTHA: General, you didn't mention the committee. You mentioned all the work you guys are doing. I mean this is the first time that I remember that you stepped up to the table and put enough money in the budget. I mean this committee has been at the forefront of health care, and you just gloss over that like we weren't even there.

GEN. VOLPE: Sir, we are greatly appreciative of all the support by you the chairman, the ranking member, and all the committee members, through the years in the military --.

REP. MURTHA: -- Bill Young and Beverly Young. Did Beverly Young ever talk to you about any of this health care?

GEN. VOLPE: No sir.

REP. MURTHA: (Inaudible.)

REP. YOUNG: She probably -- if we give Beverly his name, I'm sure she'll -- (laughter) --

REP. MURTHA: Mr. Bishop.

REP. BISHOP: Thank you very much, Mr. Chairman. Let me, may I just mention from the previous panel some concerns that I had for the record.

With regard to Lieutenant Schoomaker's, Lieutenant General, excuse me, Schoomaker's testimony, he stated in his opening testimony that the fractured relationships and not PTSD account for, are related to many of the suicides. And what, I found that a little bit incredulous because many times the suicides relate to relationships that became fractured as as result of PTSD, and I was wanting, for the record, the department to submit any studies that have been done to track the relationship and to test the relationship between fractured relationships and PTSD.

Because there is, I think, a great deal of likelihood that the underlying causes of the suicides relate to the PTSD as well as the multiple deployments that strain those familiar relationships. And also, Ms. Embrey stated that the doctors may prescribe whatever treatment they want if they think it will help the service member. And I think that for the most part, folks have done that.

Witness, there was a three-star general who got the hyperbaric oxygen treatment for injuries that he sustained and swears by it, anecdotally I might add, and I know there's a need for the establishment of medically and scientifically proven studies, General Schoomaker, but if, in fact, these anecdotal studies document some benefit from the hyperbaric oxygen treatment, it would appear that if the doctors, if it's made known to them that they do, in fact, as Ms. Embrey suggests, have leeway to recommend and prescribe some of these treatments, it perhaps would help the thousands of our Army and Marine soldiers who are suffering from PTSDs, the spinal injuries, and other nerve damage injuries which anecdotally suggest can be cured, definitely treated with the hyperbaric oxygen treatments.

Now, getting to the subject of this panel. I would just like to ask -- I think it was in the appropriations report, in the language titled, Medical Care in the National Capital Region, the committee expressed concern that in spite of the significant cost increases at the new Walter Reed, funding still had not been included for a number of facilities that already exist at the current Walter Reed center. And the planners hadn't solved the ingress and the egress problems and how that would be accomplished for patients and staff, given the fact that the patient and staff population would virtually double in a little more than two years.

Has the report been completed with regard to that? Have those ingress and egress problems been solved? Do you have a plan that speaks to that? When will the construction be completed for each of the two facilities? And, when can the staff at Walter Reed be notified of their future employment and vice-versa I guess with Bethesda?

There are a number of these issues that we are concerned about, and if you would sort of address those, I would be appreciative.

ADM. MATECZUN: Thank you, Congressman Bishop. There is a 27-21 NDAA '09 report which was due and delivered two days ago, which includes an integrated master schedule of over 10,000 line items on tasks that must be accomplished to coordinate and finish these moves. That report, that integrated master schedule will lead to a master transition plan, which we will be completing this summer, which will have all of the steps outlined. And that will be in fulfillment of the 16-74 requirement of the NDAA '08 --

REP. BISHOP: It was delivered to the committee? It was delivered to the secretary? To whom was it delivered?

ADM. MATECZUN: To the committee, sir.


ADM. MATECZUN: And so that may answer some of those questions.

In terms of being able to reach to the -- with 10,000 individuals that we have, and a fair number of them moving, primarily out of Walter Reed and into both Bethesda and Ft. Belvoir, we have significant resources devoted to try to make sure that we are letting them know in a timely way where they might be going. There is a guaranteed placement program available under the BRAC. We do need all of the workforce that we have today to be distributed amongst those two hospitals of the future.

The demanding documents themselves, we're in the process of finalizing coordination within the department. And so once those two documents are finalized, we will know each of the positions at those hospitals, and then we will be able to start the process of working through who will fill each of those positions.

REP. BISHOP: What -- how much -- what about the equipment? How much of the major equipment at Walter Reed is going to be utilized at the new Walter Reed and/or at Ft. Belvoir, and how much additional equipment is going to be required, have to be procured for both of those transitions?

ADM. MATECZUN: The Army's (JGTRRA ?) team did a review of all the equipment in the national capital region. About $50 million of the equipment that exists at Walter Reed today, of the major equipment, will be reusable within the new facilities. There's about a $400 million item --

REP. BISHOP: You said $50,000 worth?

ADM. MATECZUN: Fifty million dollars.

REP. BISHOP: Fifty million dollars, I'm sorry.

ADM. MATECZUN: Yes sir. There's about a $400-million initial outfitting and transition cost for these two new facilities. Those are included in the budget, the president's budget that was just submitted.

REP. BISHOP: So that 400 million includes the movement of the existing equipment that you will be able to continue to use, as well as the acquisition of the procurement of new equipment for the new facilities.

ADM. MATECZUN: Yes, our strategy is to have a single contractor that does all of that, which is the norm out in the civilian world today.

REP. BISHOP: What is the planned disposition for the existing facility there on Fourteenth Street?

ADM. MATECZUN: Sir, I'd have to go to the department and get an answer. I believe that the BRAC law requires that they be, the facilities be turned over to the General Services Administration, and that the General Services Administration make disposition.

REP. BISHOP: Okay, will you have -- will it be a part of your budget to do the cleanup and disposition, or that will be totally under BRAC. We've got to do some cleanup I guess, and that's under the military construction bill. And usually there's a significant lag time for the cleanup, but it's got to be budgeted, it's got to be implemented, of course, and it's got to be paid for.

ADM. MATECZUN: Yes sir, the business plan details on that, I don't know. I'm not responsible for executing the closure of Walter Reed. The move out, I'm responsible for. But we will take that and come back with an answer for you.

REP. BISHOP: Thank you. Thank you Mr. Chairman.

MR. MURTHA: Mr. Hinchey.

REP. MAURICE HINCHEY (D-NY): Thank you, Mr. Chairman.

And I want to thank you both for all the important work that you do and the way in which you oversee all the work that a lot of other people do. But as we know, no matter what we do and how focused we are on it, nothing is perfect. There are a lot of issues that come up and a lot of problems that result. And I know that, particularly over the last couple of years, you've really been doing a lot of very good work.

We've all had experience within the last few years of constituents of ours coming back from situations in Iraq and elsewhere, and the consequences that they faced. And in one particular case, but more than one, but I have one in mind, particularly, because of the very dire circumstances, the guy was almost killed. But because of the very good medical attention he got instantly in Iraq and in Germany, and then over here it declined, but nevertheless, he's improved significantly. But there's been a declining attention that has been focused on him. And I think that the circumstances there are that somebody who is no longer going to be functional in the context of the military, or maybe not even particularly functional in any context, may not be getting attention.

And so I think that that's something that we really need to look at. There's another aspect too that I just wanted to draw attention to, and that is, I think it was back in the 1950s, maybe it was '53 when the issue of medical malpractice was dealt with in a way that made or eliminated responsibility, frankly, for medical malpractice. So we know that in the human context, no matter what we're doing, even in military and maybe even more so in military situations because of the, you know, tough circumstances that we have to experience in the military from time to time, that it may be more likely for military people to get disease, get normal, you know, kinds of things that anybody is subject to.

And whether or not that's true, we know that at least it's going to be average for human beings, for normal people. And what I've seen happen is that people who get sick, and including specific dire elements like cancer, are not attended to effectively. And in some cases even, as I've seen, the presence of cancer in people, even though the evidence of it is so apparent, has not been dealt with, not been admitted to, not been addressed in any way.

So I'm just wondering what you might be thinking about this. I think that there are some things that we have to do here in the Congress to deal with this more effectively, and I just wonder what you may be thinking, particularly with regard to trying to, as much as possible, eliminate medical malpractice. Now we have not been able to do that, eliminate medical malpractice, in the normal medical circumstances for citizens in normal hospitals anyplace across the country. And I'm from New York, and we haven't been able to do it there.

But this is something, I think, that needs attention, and I think that the situation of medical malpractice may be worse in the military than it is out in the general public. And I'm just wondering what you think and what might be needed to do to address that problem?

ADM. MATECZUN: Mr. Hinchey, congressman, I'll respond, and just in some background ways tell you what we're doing in the national capital region, and what's happening in the military.

Malpractice, the malpractice rates I think in the military are not higher than they are out in the civilian world. There are good statistics that go back years that take a look at the denominator of all the malpractice and the number of cases where we have actually made a settlement or reported somebody in the national practitioner data bank.

I think the route to quality, the route to improvement is by reducing variation, and in particular in the way we practice in elevating the standards. So that here in the capital region, for instance, as we take a look at working across all of the hospitals and clinics that we have, I'll just take a procedure. Conscious sedation, which you get when you go to the dentist or when you are getting a colonoscopy or other procedures, can be done in 37 if not 57 different ways just in a couple of facilities.

And so one of the ways to improve is to make sure that we're doing it all the same way, in an evidence-based way, across all of those clinics that we have within the NCR. Just as a quick example of how we might be able to, in an integrated delivery system, provide the care that these beneficiaries need. Also, we need to integrate that care consistently across them. So cancer care needs to be the same no matter where you, what your entry point is into the system.

So just a couple of examples on how to improve care.

General Volpe?

GEN. VOLPE: Yes sir. Thank you for that question. There's a few things that I think are fairly inherent to our military health system in all of the services, and that is, between our fairly strict recruiting standards, our graduate medical education programs are second to none, and that is pretty much shown out on national board examinations in various specialty areas. And all of our physicians and clinicians do a magnificent job in leading the nation in those scores. And our credentialing process and procedures and maintenance of certification is also second to none throughout our system.

So from a quality aspect of the clinician that's in the military, we believe this is the best quality system there is. And I believe that's one of the reasons why Admiral Mateczun mentioned that our malpractice rate is less than what it would be in the general population.

REP. HINCHEY: So do you think that -- (off mike) --

ADM. MATECZUN: They are held accountable for medical malpractice as clinicians.

REP. HINCHEY: They are not held legally accountable.

ADM. MATECZUN: The providers have the same actions taken against them. You may be referring to the Ferry's doctrine? Okay, well Ferry's doctrine -- I'm beyond my expertise in answering questions to it. I think we'd be glad to take that and get a written response back to you.

REP. HINCHEY: We need to be clear about it. The fact of the matter is that they somewhat -- (off mike) --

ADM. MATECZUN: Yes sir, we, I think, looking at it from our side, on the provider side, the compensation that they get, I'm not an expert on. I can tell you that as providers we do hold them accountable. If they've had malpractice they are reported to the national practitioner data bank and their privileges are removed or changed.

(Off mike.)

REP. MORAN: Thank you very much, Mr. Chairman. As the panelists know, you required a comprehensive report to be delivered to this subcommittee so that we could have some confidence that the move from the three medical facilities into the two medical facilities would be done, not just on time, which is not our major concern, but would be done right.

Now we got late, very late, the report, yesterday, within the last couple of days. Was it yesterday? Anyway, it was just a short while ago. But nevertheless our superb staff, particularly Mr. Horner, has gone through it.

But it's not adequate. It's not a comprehensive plan. What we were looking for is what steps need to be taken by when so that you can get this done without our warriors being adversely impacted by the move. And you gave us this broad picture without adequate specificity. I think you may want to have your staff talk to Mr. Horner and he will tell you what it is that we envisioned. We thought it was clear.

But, for example, we'd like to know how much it's going to cost. One of the things that concerns us is that BRAC in 2005 had a number of cost estimates, costs saved, and what it would cost us, and all of those estimates have been wrong. All of them. It said that it would cost 20 billion, and now we're told it's 32 billion. It said that we would save 36 billion, and now we're told we're lucky if we save 4 billion annually.

That was the broader picture. There are 230 locations as a result of BRAC that have to be completed, and we're being told they're all going to be completed within the last two weeks of September 2011, including the realignment of Walter Reed hospital. So you're going right up to the deadline. There's no plan B, and that's the concern of the committee and has been all along.

Now you can first of all respond, were the original savings and payback period for the transition to Walter Reed, are those numbers still accurate? The cost and the savings?


REP. MORAN: No, they're not. Do you have new numbers?

ADM. MATECZUN: Yes sir. We can provide those to you. The Cobra estimates were not anywhere near what this project is going to cost.

REP. MORAN: Well, Mr. Chairman. So here we are again. The BRAC estimates were nowhere near what it's actually going to cost us. And what savings are going to be achieved? But again, we asked for a report. Those numbers are not in the report, and, you know, I don't want to give you a hard time. Because I know you were given an impossible mission and to some extent you are the messenger of what we expected would be bad news in terms of adequate implementation, but that report was supposed to include cost estimates.

So now, yes we do need those cost estimates to be provided. This is the committee that provides the money, and we don't want to be told at the 11th hour, unless you give us all this extra money we can't get it done. So yes we need those estimates. Can you tell us?

REP. MURTHA: Let me reinforce what the gentleman's saying. I went to the BRAC hearings. I very much opposed closing down Walter Reed. Well I lost that battle. But I remember distinctly they said it would cost $232 million to close it down. That was the figure that they gave. Principi, who was the chairman, said the same thing. He was concerned about it. All of us were concerned about it.

But we, over and over from the defense department we get inadequate figures and then the taxpayer has to pay. Something happens, you come to us, representing the taxpayer, we do, and then we have to fork over money which we didn't anticipate, which then makes it very difficult to solve our budget problems.

So you need, and I told the secretary of defense this yesterday, you need to go back and start to get accurate figures for us so that we have a better estimate of how we can put a budget together. For instance, there was a two-and-a-half billion dollar shortfall in personnel costs. We had two or three hearings, two or three meetings in addition to the hearings, about the military shortfall, mostly in the Army. We couldn't get it until the last minute exactly what those figures were.

Now, we have 15 people on our staff. It's impossible for us to have oversight. So we depend on you to give us that kind of information so that we can put together a logical budget. So with that I yield back to --

REP. MORAN: Thank you Mr. Chairman. We have some problem -- I know you're supposed to be looking at this, but I know they seem minor.

The personnel, the employees at these facilities. One thing, for example, it's at a Metro stop at Bethesda. There is no Metro stop where they are going, at Ft. Belvoir. But have any of them been notified as yet where they will be going within a year and a half?

ADM. MATECZUN: No sir. Until we have the actual manning documents themselves, which are 3,000 people, 32-hundred people out at Ft. Belvoir, 6,000 at Bethesda, we can't say, this is the spot that you're going to.

I can tell you in general that the vast majority of the civilian personnel will be accommodated where they would like to be. We've surveyed the workforce at Walter Reed. Approximately 10 to 15 percent of them plan on taking retirement or some other BRAC-related eligibility, which would remove them from the workforce. And we estimate that in our last run-through, and this is a preliminary number, 90 percent of them would be able to stay north where they needed, if they wanted to stay north, i.e., at the Bethesda campus.

We need to incentivize the other personnel, if we need to, to go down to Ft. Belvoir, although Colonel Callahan has been doing a great job in recruiting people to come down there as part of the workforce.

REP. MORAN: I appreciate that, but I need to underscore this issue again. We've got a year and a half. None of the people have been told where they are going. Most of them are going to Ft. Belvoir, but most of the ones at Bethesda want to stay in Bethesda, and you're telling them they can. You are also telling us that 15 percent of them are going to drop out; they're going to take retirement. Well we have expanded facilities, we have a greater need for personnel, and yet 15 percent of them are going to leave, and again our concern is the quality of care provided to the residents, the patients.

So, I don't know how you're going to get the new people to staff these expanded medical facilities when 15 percent have already notified you they are leaving, and the majority at Bethesda are going to stay at Bethesda when most of them are supposed to be going to Ft. Belvoir.

I know my time is up, but these are issues that we need resolved. And you've been given an impossible task. The problem is, the subcommittee made it clear. This is impossible. And if the highest priority is the care of the patients, then we are going to fall short. And now we've got a year and a half, and we are very much concerned that inadequate planning, and certainly the estimates we demanded, have not been provided. And they need to be.

Thank you, Mr. Chairman.

REP. MURTHA: Mr. Young.

REP. YOUNG: Mr. Chairman, thank you very much.

In following the same line that Mr. Moran has initiated, General Volpe you said that when you have the two hospitals -- you don't have to respond to this, but my question is, is one of them a Navy hospital, or is one an Army hospital, or are they both hybrid?

GEN. VOLPE: Sir we have the approval from the department that both of these facilities will be joint. They'll be placed on a joint table of distribution, which is a document that allows the commander of that facility to be responsible for all the people that are working in that facility, regardless of what service that they are in. So we are able to get unity of effort through unity of command in those facilities and have one person responsible for the good, the bad, the ugly that occurs in that facility.

REP. YOUNG: Okay, but you said, General, that two hospitals are jointly staffed, jointly managed, and jointly governed. Somebody's got to be in charge. When its jointly, who is in charge?

GEN. VOLPE: Yes sir. There will be a commander that's selected. It will either be by a rotational basis or a nomination basis. That is yet to be determined, but we have to work with the services on that process to do that, and they will be under the operational control of JTF CAPMED.

REP. YOUNG: Will there be a super commander that would be in charge of both facilities? Ft. Belvoir and Bethesda?

ADM. MATECZUN: Yes sir, that is the joint task force.

REP. YOUNG: Do we know who that is?

ADM. MATECZUN: That's me, sir.

REP. YOUNG: That's you, sir?


REP. YOUNG: And then, each hospital will have a commander.


REP. YOUNG: And I assume, will the Army and Navy share those roles?

ADM. MATECZUN: That's one of the options, yes sir. Either to do it on a rotational basis or a nominative basis, like all other joint positions.

REP. YOUNG: Outside of the normal grumbling that takes place at any kind of a merger, whether it's military, civilian, political, whatever, and I'm sure you've heard some of that, Mr. Moran, as indicated some.

Is the merger going well? Is it on track?

ADM. MATECZUN: Yes sir, it is, and I'd like to say that our concern is, our primary concern is and will always be, the health care that we deliver. If we were not able to meet any of the deadlines that we think are out there, I would have no hesitancy about telling you about that and asking for your help.

REP. MURTHA: Let me just interrupt, Mr. Young. We need you to give us a plan. The first time I heard we're going to have 35 different installations. My wife told me the other day, look over there, that's going to be part of the new Walter Reed. I didn't know that. I mean, I had no idea. It's along (Interstate) 95.

She may be wrong. She's not wrong very often, but you know the wives talk to each other, but I don't say she's wrong. She's probably right. (Laughter.) But the point I'm making, we need to see what you're going to do here, and what it's going to cost. That's what we need. Now we shift money to military construction in many cases, because they need the money. So give us a plan so that we can live with it and figure out in increments what needs to be done.

Because what Mr. Moran is worried about is not going to happen -- I mean it's going to happen as he predicts -- unless you have the funding that's necessary in order to implement this. And all of us want to do the same thing. All of us want to have the money that it's necessary for the troops to make sure there's no care for not only the troops coming back, the troops that need care that have been back, and also the retirees who, there are so many of them in this general vicinity.

Okay, that's it. Without objection, the committee adjourns until after the recess.