• 2 days ago
The Senate Committee on Armed Services held a hearing on Tuesday on stabilizing the military health system.

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Transcript
00:00:00Okay, the hearing will come to order. The committee has convened this hearing to discuss the state of the military health system.
00:00:07We hope to shine a light on the challenges facing that system and begin working towards solutions.
00:00:13Our witnesses are experts in the field of military medicine.
00:00:17Dr. Douglas Robb is a retired Air Force Lieutenant General and the former director of the Defense Health Agency, DHA.
00:00:25Dr. Paul Friedrichs is a retired Air Force Major General and the former
00:00:31joint staff surgeon, and Dr.
00:00:33Jeremy Cannon is a retired Air Force colonel and trauma surgeon who currently serves on the faculty at the University of Pennsylvania
00:00:40School of Medicine. I look forward to their testimony.
00:00:43I want to hear their recommendations about what Congress and the Department of Defense should do to provide
00:00:51long-term stability to the military health system.
00:00:55Military medicine often follows a familiar but regrettable cycle. During peacetime,
00:01:01medical teams focus on the treatment of ordinary illnesses. When conflict erupts, military medicine is
00:01:08frequently caught unprepared,
00:01:10resulting in unnecessary casualties. This interwar erosion of our unique military medical skills is known as the peacetime effect.
00:01:19To disrupt the peacetime effect,
00:01:21Congress enacted sweeping reforms of the military health system.
00:01:25These reforms, now nearly a decade old, were designed to refocus military medicine on its primary purpose,
00:01:33combat casualty care and medical readiness.
00:01:44We elevated the Defense Health Agency to a combat support agency and tasked it with
00:01:50administration of all military hospitals and clinics, relieving the military departments of that mission.
00:01:54The goal was to have the military services focus exclusively on the medical readiness of their forces.
00:02:00These ideas were recommended by an independent bipartisan commission embraced by Pentagon leadership and signed into law in
00:02:082017. Unfortunately, opponents of these reforms have delayed
00:02:13implementation and
00:02:15undermined the effectiveness of the legislation. For example, in 2019,
00:02:19the military departments implemented drastic cuts to military medical personnel on the
00:02:25faulty assumption that it would be easy for DHA to hire civilians to take their places.
00:02:31This assumption was misguided, which became evident during the COVID pandemic. During that crisis, the existing national physician
00:02:38shortage accelerated. To this day,
00:02:41private sector health systems seek out and hire away doctors from the military, not the other way around.
00:02:48We've all seen this in our states. In 2020, Congress ordered a halt to any additional military medical reductions,
00:02:56but it was too late. A
00:02:58significant number of reductions had already occurred,
00:03:00severely reducing the capability of military hospitals. In many locations,
00:03:05the private sector was unable to handle the additional patients, sending more service members to private sector care.
00:03:12This has proven more expensive and has sapped the military doctors' experiences
00:03:19that are vital to maintaining proficiency. Even worse,
00:03:23DOD has refused to request
00:03:26adequate funding for DHA, which would allow DHA to staff adequately and
00:03:31equip its hospitals and clinics. Since 2015, the budget for military hospitals has decreased by nearly 12 percent.
00:03:39The water damage at Walter Reed this January is an example of the antiquated
00:03:44infrastructure that military medical teams work with around the world. In addition to the problems
00:03:50I've just explained, I would like our witnesses to highlight how
00:03:54bureaucratic delays within the Department of Defense have prevented the military health system from preparing for the next potential conflict.
00:04:02Combat casualty care is the primary purpose of the military health system. When service members are exposed to danger or are injured,
00:04:10they need to know that they will receive the best care possible.
00:04:15We know that troops in combat are more comfortable taking the risks necessary
00:04:20to accomplish their mission if they have confidence in military doctors. We cannot go back to the way things were before
00:04:272017. We must stop scapegoating the Defense Health Agency. The Department of Defense must request
00:04:35adequate resources to ensure the department's hospitals and clinics are properly staffed and equipped.
00:04:41This is the best way to ensure the military health system is ready for the potential demands of large-scale combat operations in the future.
00:04:49I thank the witnesses for being willing to testify and I now recognize Ranking Member Reed for his remarks.
00:04:55Well, thank you very much, Chairman Worker, and welcome to our witnesses.
00:05:00General Douglas Robb,
00:05:02General Paul Friedrich, and Colonel Jeremy Cannon each bring important perspectives from their extensive careers in military medical fields.
00:05:11We are fortunate to have such a distinguished panel before us.
00:05:15Throughout history, military medicine has often represented the leading edge of modern health care.
00:05:20Many of the life-saving practices common in today's emergency rooms and clinics were born out of
00:05:26necessity from the battlefield hospitals of the Civil War, World War I and II,
00:05:31Vietnam and the wars in Afghanistan and Iraq.
00:05:35Professional expert health care, both in combat and peacetime, is a vital component of our military.
00:05:41Our servicemen and women and their families deserve nothing but the best in this regard.
00:05:47I am concerned that our military health care system will be challenged to meet the demands of a potential large-scale future conflict,
00:05:55particularly in the Indo-Pacific.
00:05:56We have seen the terrible challenges of health care in austere environments like the frontlines of Ukraine,
00:06:03where supplies and medics are often cut off from the troops in contact.
00:06:07These risks would be compounded in the Indo-Pacific, where contested logistics and the tyranny of distance would be major factors.
00:06:15Congress has dedicated considerable attention to reforming the military health system in recent years,
00:06:21with an eye toward any potential future large-scale conflict.
00:06:25The primary objective of these reforms have been to improve combat casualty care,
00:06:30assure quality medical care for servicemembers and their families, and
00:06:34ensure that military medical professionals are able to deliver the world's best care on the battlefield, at field hospitals,
00:06:42and at medical centers and clinics.
00:06:45However, until relatively recently, the military health system was inadequately designed to meet these missions.
00:06:52For decades, the individual military branches managed their own military treatment facilities, and the Defense Health Agency, or DHA,
00:07:00was tasked with managing Defense Department health care via civilian providers.
00:07:06This system was hampered by unnecessary complexity, a lack of standardization,
00:07:11inefficiency, and redundancy in the system, and inflated costs. The military health system was too focused on
00:07:18beneficiary care, while insufficient attention was paid to combat casualty care.
00:07:23To address this, the Fiscal Year 2017 National Defense Authorization Act
00:07:28included provisions restructuring much of the system. This legislation transferred responsibility for operating the military treatment facilities
00:07:37entirely to DHA.
00:07:39This change was intended to allow the military services and surgeons general to focus on medical readiness for the force and its
00:07:47health care providers.
00:07:49Unfortunately,
00:07:50implementation of this legislation has been difficult.
00:07:53The military services have not implemented the changes readily, and they have failed to staff the treatment facilities with the military personnel
00:08:01needed to provide
00:08:03timely care. The Department of Defense made progress to break through the inertia in
00:08:092023, when it issued a memorandum with specific directions to stabilize and improve the military health system,
00:08:16to include adequate manning of military treatment facilities, and
00:08:20this effort marked a major milestone in modernizing the system.
00:08:24More work remains to be done, and I hope that the Trump administration will continue the momentum in this area.
00:08:31During today's hearing, I would ask for our witnesses' views on the key challenges remaining for successfully
00:08:37reforming the military health system, and how Congress can help equip the Department and our war fighters with the medical support needed for any
00:08:45future conflicts. Thank you again to our witnesses, and I look forward to your testimonies.
00:08:50Thank you, Mr. Chairman. All right, we'll begin with five-minute
00:08:54testimonies from each of our distinguished witnesses.
00:08:59Lieutenant General Robb, you are recognized.
00:09:04Chairman Wicker, Ranking Member Reed, and distinguished members of the committee,
00:09:08thank you for this opportunity to testify on the urgent need to restore and sustain our military medical readiness in the face of
00:09:16large-scale combat operations, and thank you both for your, what I would
00:09:22believe is spot-on comments, so thank you very much.
00:09:25Just a little background on where my perspective of the military health system originates from. I started my military career as a boots on the tarmac
00:09:33operational flight doc, both stateside and overseas. I've served at the Air Force squadron, hospital, clinic, and medical center commander positions,
00:09:40and at the headquarters level.
00:09:42I've also had the honor and privilege to serve our joint forces as a U.S.
00:09:47Central Command Surgeon, Joint Staff Surgeon, and as a First Director of the Defense Health Agency.
00:09:53Moving forward, a refocus on our ability to support large-scale combat operations,
00:09:57I believe will require a recalibration of current and future resources to support large-scale
00:10:03casualty flow from the battlefield or the sea battle to definitive care,
00:10:09rehabilitation, and eventually reintegration. All this in the face of incremental pressures from OSD,
00:10:15OMB, and the military departments, resulting in a decade-plus of flatline, actually declining, Defense Health Program budgets,
00:10:23personnel reductions, erosion of our mission-critical military treatment facilities, and
00:10:29intense competition for quality health care professionals with the private sector.
00:10:33One of the key military health system organizational elements in support of the military health system strategy is the evolving and maturing
00:10:41Defense Health Agency,
00:10:43designated as a combat support agency, that was established over a decade ago.
00:10:47Recently, the DHA's justification, and specifically the DHA's designation as a combat support agency, has been challenged and questioned.
00:10:56In 2011, the
00:10:59Deputy Secretary of Defense issued a memo titled Review of
00:11:03Governance of Model Options for the Military Health System that was driven by the department's significant growth in health care costs.
00:11:11Fast forward a decade later, sound familiar?
00:11:15The Task Force on Military Health System Governance Reform was then established,
00:11:20and this is key, that included co-chairs from the Joint Staff, OSD, and FLAG and SCS
00:11:27representation from the Joint Staff, OSD, PNR, CAPE, and Comptroller, and the Service Surgeon General's for a total of nine
00:11:35voting members. And I think it's also too important to recall the Task Force overwhelmingly recommended a Defense Health Agency
00:11:42organizational model with a final vote of seven for the Defense Health Agency,
00:11:47one for a unified medical command, and one for what then was called a single service model.
00:11:52The recommendations were briefed through both Joint Staff, and actually through two chairmen's, and
00:11:58Office of the Secretary of Defense, and actually through two
00:12:03Deputy Secretary of Defense's, with the Defense Health Agency
00:12:06construct signed off by the DEPSECDEF with the chairman's support.
00:12:11Another decision that has come into question in recent years was a designation of the Defense Health Agency as a combat support agency.
00:12:18This designation was initiated by the director of the Joint Staff with the chairman's concurrence
00:12:25when reviewing the proposed DHA organizational structure and the relationships with both the chairman and the OSD.
00:12:33The CSA designation was then codified.
00:12:36Now a decade later, do I still believe the original analysis and the
00:12:41recommendation to stand up a Defense Health Agency as a combat support agency remain valid? In the short answer,
00:12:48is yes.
00:12:50But does a recalibration of the Defense Health Agency's supporting relationship with its combat support agency
00:12:57responsibilities to the supported entities of the military departments and the joint forces need to be
00:13:03readdressed? And again, I would say yes.
00:13:06I share with you several lines of effort that I believe are essential as we strive to further achieve a more tightly integrated
00:13:13military health system to support our national military strategy and our national security strategy. Number one,
00:13:21reemphasizing with clear articulation and execution of
00:13:25the Assistant Secretary of Defense's of Health Affairs authority, direction, and control of the Defense Health Agency.
00:13:33Number two, I believe we need to establish a direct
00:13:37organizational linkage at the defense health
00:13:40organizational structure level
00:13:42with the chairman of the Joint Chiefs of Staff and the combatant commands through the Joint Staff Surgeon to ensure that the
00:13:50responsibilities are prioritized with the DHA's execution. And
00:13:54finally,
00:13:55NDA 19 directed the department to establish joint force medical requirements process to synchronize the military health systems
00:14:02already established joint operational requirements governance process.
00:14:06And I think that's key that the medics need to play with the Joint Staff's
00:14:11process for determining requirements. In closing,
00:14:14I would like to thank you and look forward to support you in assisting the military health systems
00:14:20ability to accomplish our mission of ensuring a medically ready and a ready medical force in support of our military departments and
00:14:27combatant commands through the provision of care to our 19, excuse me, 9.5 million beneficiaries. Thank you.
00:14:35Thank you very much, Dr. Robb. Major General Friedrichs.
00:14:40Chairman Wicker, Ranking Member Reed, and members of the committee, thank you so much for the opportunity to be here.
00:14:45I had the opportunity in my very last briefing to some members of this committee in May of 23 to give you a classified
00:14:53assessment of MHS readiness, and I will start with a recommendation that if you've not had an update since May of 23,
00:15:00I would implore you to schedule that so that the Joint Staff Surgeon can give you the most current classified assessment,
00:15:07because what we will provide today is an unclassified assessment. Second,
00:15:11I'll give a disclaimer that the views that I express are my own, not those of any organization with which I've been affiliated.
00:15:18I've provided a detailed written statement to you,
00:15:20and I would respectfully ask that that be entered into the record of this hearing. All of the statements will be
00:15:26added to the record at this point, without objection. Thank you very much, Chairman.
00:15:31I have two disclaimers. The first, this is my family business,
00:15:35so I will speak both from my experience and because my dad served in the Navy,
00:15:4198, still alive at the end of World War II,
00:15:44multiple other relatives in the Navy. My wife is a former Army physician who now works for the VA.
00:15:49We're very proud that one of our children is a Marine.
00:15:53I care about this not only because of all of the others,
00:15:56but because this is what my family has done for generations.
00:15:59My second disclaimer, like General Rob, is I've had the privilege of serving our country now for 39 years, and the majority of
00:16:07those years I've spent in joint roles.
00:16:10Congress got it right in 1986 with the Goldwater-Nichols Act, but the one thing I wish you would change is
00:16:16to include medics as part of the military. As long as we preserve this false narrative that the military health system is separate and
00:16:24not covered by the same expectation of jointness as the rest of the military, we're going to continue to have these fruitless,
00:16:31bureaucratic, buffoonery actions that distract us from taking care of patients.
00:16:35I encourage you to treat the military health system like a part of the military.
00:16:42We've had tremendous accomplishments over the last 20 years with the lowest rate of deaths among injured ever seen in conflict,
00:16:50and we should be incredibly proud of that. When I deployed, I had what I needed when I needed it,
00:16:55ARAVAC available. I flew ARAVAC missions. I operated on casualties. I never lacked for what I needed.
00:17:03I cannot offer you the assurance that my successors will have that same environment in the next conflict.
00:17:09I am grateful that you're holding this hearing today. I have several very specific
00:17:15recommendations. First, as I touched on before, we must prioritize the patient over the patch.
00:17:21Put a nail in the heart of this discussion about
00:17:25reorganizations and what the role of the military health system actually is.
00:17:30We need to commit, and we need your help in the next NDAA, to clearly
00:17:35articulate, just as both the Chairman and the Ranking Member said, the military health system exists as part of the military to ensure that we deter
00:17:42those who might seek to harm our nation and defeat them if they try to.
00:17:47The military's role is to take care of the human weapons system.
00:17:51The health care benefit delivery is part of how we do that and part of a commitment that we make, but I implore you to
00:17:57address that in the next NDAA.
00:18:01As I said before, I think that you got it right with Goldwater-Nichols,
00:18:05and I would encourage you in the next NDAA to clearly articulate that you view the military health system as part of the military and
00:18:11not exempt from the requirements that the rest of the military faces. A joint
00:18:17casualty stream requires a joint casualty care team.
00:18:22That seems relatively straightforward, and yet that is still something that we are arguing over. Whether medical units should be interoperable,
00:18:29whether they should have the same equipment or the same training, the answer is yes.
00:18:33Look at Israel. Look at almost every other country with a large military.
00:18:37They've already made those changes, which you rightfully began and appropriately began in 2017.
00:18:43We don't need another reorg. What we need is execution of the vision that you laid out.
00:18:49The next point that I bring up is resourcing, and both the Chairman, the Ranking Member, and Dr. Rob touched on this.
00:18:55Healthcare is not cheap.
00:18:56The mistaken belief that somehow military medicine can be done at a lower cost
00:19:02than in the civilian sector and be ready for conflict is just that. It's a mistake,
00:19:08and it's a discredit to those who state that they care about our patients.
00:19:12Finally, I'm deeply concerned about our growing vulnerability to biological threats. The decisions to take down our overseas
00:19:20partnerships to build better biosurveillance, the decisions to take down research and biological threats, the decisions to take down
00:19:27multiple other programs that we had built as a result of the 2018 National Defense Strategy,
00:19:34which President Trump signed in the first administration and President Biden updated,
00:19:39put us at greater risk, and we must continue to address those risks of the evolving biological threats, both naturally occurring and
00:19:48deliberate threats. The confluence of AI,
00:19:51biotechnology, and compute is dropping the bar dramatically for biological threats.
00:19:56We should be working on mitigating that. I thank you again for the opportunity to be here and for your interest in this.
00:20:02Thank you, Dr. Friedrichs. Colonel Cannon.
00:20:07Chairman Wicker,
00:20:08Ranking Member Reed, and distinguished members of the committee,
00:20:11thank you for the opportunity to testify.
00:20:14These comments are my own and do not reflect an official position of my employer, Penn Medicine, or of the Hoover
00:20:21Institution, where I currently serve as a veteran fellow. As a practicing trauma surgeon,
00:20:26I've cared for injured warfighters in both Iraq and Afghanistan.
00:20:31I've directed the DOD's only level one trauma center, and
00:20:35now I lead a Penn Medicine Navy partnership for trauma training.
00:20:39I know firsthand what it takes to save lives on the battlefield, and
00:20:44what happens when we fail to sustain medical readiness.
00:20:48I want to start by sharing the story of the unexpected combat casualty survivor that I took care of in 2010.
00:20:55Note, I'll use a pseudonym throughout my comments for patient privacy.
00:21:00U.S. Army Sergeant Eric Ramirez was on patrol in Afghanistan when a sniper's bullet
00:21:06tore through his chest just above his body armor. His injuries were truly catastrophic,
00:21:11but thanks to decades of investment and innovation in combat casualty care, a
00:21:16military trauma team pulled him up out of his certain death spiral by placing him on heart and lung bypass
00:21:23on the battlefield. Days later,
00:21:26I had the honor of caring for Sergeant Ramirez in the U.S. as he reunited with his family.
00:21:33This unequivocal display of medical supremacy was not accidental.
00:21:38It was built on years of research, training, and policy reforms,
00:21:42but I fear that if Sergeant Ramirez suffered this same injury now, he would die a preventable death on the battlefield.
00:21:50Today, only 10% of military general surgeons get the patient volume, acuity, and variety
00:21:56they need to remain combat ready. We're actively falling into the trap of the peacetime effect.
00:22:04Meanwhile, as the MHS struggles, our enemies continue to grow stronger.
00:22:08Projections estimate a peer conflict could produce as many as a
00:22:13thousand casualties per day for a hundred days straight or more, a scale not seen since World War II.
00:22:20Neither the current MHS nor the civilian sector can absorb this impact.
00:22:25What's more, many of these patients will have survivable injuries, yet one in four will die at the hands of an unprepared system.
00:22:34How can we meet this looming threat? First, we must clearly articulate the root problem of our failed readiness efforts.
00:22:42No one in DOD truly owns
00:22:45combat casualty care. In
00:22:482017, the Joint Trauma System, or JTS, was codified in law.
00:22:53This committee must now strengthen the statutory language to affirm the JTS
00:22:58owns combat casualty care and to provide this precious resource with both top-down
00:23:05authority and bottom-up support.
00:23:08Then we must push the MHS to refocus on forward deployed care, the one thing that only
00:23:14military medicine can do.
00:23:17For this, I recommend three lines of effort. First, clinical training.
00:23:21In order to train the way we fight, we must establish five to six high-volume
00:23:27military treatment facility centers of excellence for both trauma and burn care.
00:23:32These centers must undergo civilian accreditation and fully integrate into a national trauma and emergency preparedness system.
00:23:40We also need to strengthen and expand our military-civilian partnership sites where military trauma teams
00:23:46manage critically injured patients on a daily basis, like my partnership program at the University of Pennsylvania.
00:23:53To do so, Congress must reauthorize PAPA and fully appropriate the Mission Zero Act.
00:24:00Second, combat casualty research. To succeed on complex future battlefields,
00:24:05DOD medical research must refocus on pre-hospital care, team training,
00:24:11bleeding control,
00:24:13battlefield blood transfusions,
00:24:16regenerative medicine, and
00:24:18long-term outcomes. In order to fully understand the effects of battlefield treatments,
00:24:23we must link DOD trauma registry data with VA records.
00:24:27Finally, we need a unified military trauma system strategy.
00:24:31We must urgently develop and implement a whole-of-society roadmap aligning military, VA, and
00:24:38civilian systems for both peacetime readiness and large-scale combat operations.
00:24:44The bottom line, if we maintain the status quo and enter a peer conflict unprepared,
00:24:50we will condemn thousands of warfighters to preventable death.
00:24:55Without urgent intervention, the MHS will continue to slide into medical obsolescence.
00:25:00To restore the medical supremacy that saved Sergeant Ramirez, we must act now.
00:25:06Mr. Chairman, members of the committee, our warfighters and our nation deserve medical supremacy.
00:25:14Thank you for your time. I look forward to the comments. Thank you, Dr. Cannon, and I commend
00:25:19each of you for your excellent testimony.
00:25:21Let me just get a quick answers here from all three of you.
00:25:25I think what I'm hearing from all three of you is that this is going to require more than
00:25:32simply good management of what we have on the books now. Each of you is
00:25:38recommending
00:25:39changes in the statute that need to come in this coming NDAA. Is that right, Dr. Robb?
00:25:45Yes. And Dr. Friedrichs? Yes, sir. And Dr. Cannon? Yes, Mr. Chairman.
00:25:49Okay. Now, let's talk about military surgeon readiness for combat care.
00:25:55There was a study out in 2021. It found that the population of military general surgeons
00:26:02meeting necessary readiness standards
00:26:05decreased from an already low 17 percent in 2015 to about 10 percent in
00:26:132019.
00:26:16We'll let all three of you take a brief
00:26:20chance at answering this. Why is this happening and
00:26:24what specifically can DOD do to reverse this trend? And we'll just start with Dr. Robb and go down the table.
00:26:31I'll take a, we'll try to share different perspectives here. I think it comes back to
00:26:38the system to be able to resource the requirements that we need. And so, for example, if you want to look at,
00:26:47Dr. Cannon referred to the five to eight, what we call
00:26:51critical military treatment facilities, in order for us to provide a higher volume, high acuity care,
00:26:57they need to be resourced. And I think that's the challenge that we all face right now is,
00:27:02what's that strategic reserve with our military treatment facilities?
00:27:05And then how you augment that with the VA and the Department of Defense
00:27:10partnerships, and then how do you augment that with the military? Is that what he called this, the Centers of Excellence?
00:27:16Sir, I would call them, that's one way to call them, but what I,
00:27:22coming from the airlifter world,
00:27:25in fact, General Friedrichs and I will say, follow the casualty flow.
00:27:30And the casualty flow comes in from Indo-PACOM to,
00:27:34primarily will become in the two or three military treatment facilities. From SouthCOM,
00:27:39they will be coming into the National Capital Region. And then from Europe,
00:27:43CENTCOM, and AFRICOM, they will be coming into primarily National Capital Region and with a pop-off at Portsmouth. Okay, Dr. Friedrichs,
00:27:50is this 10% number a concern? And why do we have a
00:27:5810% of
00:28:00eligible, 10% of military surgeon readiness?
00:28:05Mr. Chairman, it absolutely is a concern. When I did my training in the military, I trained at the old Wolford Hall.
00:28:10That was a level one trauma center.
00:28:12I took care of trauma patients because it was a 36 on 12 off schedule every other night.
00:28:17Or I took care of vascular surgery patients, or I took care of cardiothoracic patients.
00:28:22We've de-scoped our facilities to the point that they take care about, of
00:28:26low acuity community hospital patients, not trauma patients.
00:28:29So I would reiterate the point that you've heard all three of us make.
00:28:32We need our key hospitals to be level one trauma centers in partnership with the American College of Surgeons and the communities in
00:28:39which they're located. But to do that, we must address the elephant in the room, and that's resourcing. The medical inflation rate, on average,
00:28:46since 1938, is 5.1% per year. And the military has seen a net 12% reduction in funding.
00:28:54There is no way to fix these problems if
00:28:57the military health system is viewed as a bill payer and not something worth investing in. The second point that I would make is we've
00:29:04got to
00:29:05reiterate the intent that you and the ranking member mentioned. I spent four years as the joint staff surgeon.
00:29:12Almost every meeting in which I participated in that role focused on roles and responsibilities and patches,
00:29:19not on patients. Please, again, I implore you,
00:29:23kill this narrative that somehow there's a belief that we can unwind things and go back to the good old days.
00:29:30We need to go forward
00:29:32towards a more integrated system that focuses on patient care and, as you said, on readiness, not continuing to focus on bureaucratic buffoonery.
00:29:40Dr. Cannon.
00:29:43Mr. Chairman, it's shocking, astonishing, and awful, and it has to be reversed.
00:29:49That 10% number results from
00:29:52inadequate,
00:29:54actually,
00:29:55grossly inadequate patient numbers, volume. They're not doing the cases. They're not doing the procedures.
00:30:00They're not doing what they were trained to do, and that's because they don't have the patients in the facilities.
00:30:05They're, in many cases, not
00:30:08designated or verified trauma centers,
00:30:11so they're scrounging around trying to get cases, and it's been, frankly, an uphill climb.
00:30:16So we've got to provide them the patients, the cases, the experience to
00:30:21write that 10% number. Thank you very much, gentlemen. Senator Reed, you're next.
00:30:26Thank you very much, Mr. Chairman and gentlemen. Thank you for your excellent testimony.
00:30:31In the
00:30:332023 memorandum by the Deputy Secretary of Defense, one of the key points, I believe, is the
00:30:40direction to
00:30:42re-attract beneficiaries to the MTFs,
00:30:47which would increase the patient flow,
00:30:50increase the demands on
00:30:52physicians, etc., and also save money, they believe.
00:30:56Dr. Fredericks, your total response to this approach?
00:31:02I strongly support the vision that Deputy Secretary Hicks laid out,
00:31:06which is very similar to the vision that Deputy Secretary Norquist laid out in the previous administration, and almost every administration
00:31:13prior to that. Again, to do that, we must have resources.
00:31:16I'll offer one other option, which I think you've heard all three of us touch on briefly.
00:31:22Every single patient in the Veterans Health Administration started in DOD.
00:31:26I had the great privilege of commanding the DOD VA Joint Venture Facility in
00:31:32Anchorage, and I can tell you that when the patient walked in the door, they were taken care of by a joint team.
00:31:38It was far more efficient than building duplicative adjacent facilities. Instead, we built integrated
00:31:45adjacent facilities. There's a $10 billion
00:31:49unfunded recapitalization bill in the DOD, a $100 billion unfunded
00:31:54recapitalization bill in the VA. There are real opportunities to bring those higher acuity patients from the VA
00:32:01into the DOD facilities or bring DOD
00:32:05medical personnel into the VA facilities so that we are not wasting money on
00:32:10duplicative buildings and instead focusing our resources on the patients who need our care. Thank you.
00:32:16General Rob, or Dr. Rob, or both,
00:32:23do you think the military healthcare system is adequately focused on the combat related medical capabilities?
00:32:29I've heard comments by all the panels suggesting that they're diverted into
00:32:34things that are not effective in the combat situation.
00:32:39Well, I think,
00:32:42in fact, I would kind of like to challenge the misnomer that there's a separation between care
00:32:49beneficiaries and
00:32:51medical readiness, and I would argue the way that we get our skills,
00:32:58primary care,
00:32:59specialty care, and just as important, our allied health, pharmacy, x-ray techs,
00:33:06logistics, we get that by taking care of our
00:33:10beneficiaries, and so what I think is so, so important is
00:33:15that we use our, not use, but we care for our patient population
00:33:20to best achieve a medically ready and a ready medical force, and what I think is really important
00:33:27is that, again, we have to create a capability, has to be an enterprise approach,
00:33:32and when we talked about, again,
00:33:34I'll go back to the point of follow the casualty flow, and you look at those critical hospitals that we believe are important,
00:33:39we must staff those, and we must staff those to the fullest extent possible.
00:33:44You can't reattract patient care into our MTFs
00:33:48unless you staff them, and I think that is what is key. If I can't get an appointment,
00:33:54then I can't get an appointment, and so, so that's what is key, and so if you talk with Walter Reed, for example,
00:34:00they may have enough surgeons, but for various reasons, the support staff doesn't exist,
00:34:05so they don't have the throughput that they need for surgical cases. The caseload is there,
00:34:10so what I think we need is an enterprise approach on how do we resource,
00:34:14okay, the full spectrum of support for our critical care hospitals, and they make up the Delta
00:34:20with our military VA partners and with our military civilian partnerships. Thank you. Dr. Cannon, your comments, please.
00:34:26Senator, I think it's vitally important to have highly functioning premier medical centers that we can be proud of, that our surgeons and
00:34:35other specialists and allied health members want to be a part of. Right now, many of these facilities are
00:34:42shells of what they used to be. You heard about Wilford Hall. That was an amazing
00:34:47facility that did so much good for so many decades.
00:34:50The new incarnation, Brooke Army Medical Center, the San Antonio Military Medical Center, is also amazing,
00:34:57but it's sort of out on the vanguard by itself. We need other premier flagship centers,
00:35:05and I think we can do it. We've got the, we've got the pieces in place,
00:35:09but we've got to commit to keeping the combat casualty at the center of our focus and make it happen. Thank you.
00:35:16My time has just about expired, but
00:35:19a yes, no, or perhaps answer.
00:35:22I am concerned about the ability to mobilize medical professionals for a
00:35:27all-out fight.
00:35:30Is that a valid concern? Yes or no, please. Yes.
00:35:36It is the billion-dollar
00:35:38concern. The Israelis have proved that, and we are, we have a shell game right now with our Garden Reserve and civilian facilities.
00:35:45We're going to pull them out,
00:35:47deploy them, and assume that civilian facilities, which during COVID
00:35:52required 70,000 military medics to take care of a surge in demand,
00:35:57instead lower their staff and then take care of a surge in demand. The math doesn't work, even for a Louisiana public school grad.
00:36:06Dr. Kennedy, go ahead and answer the question. Yes. Take the time. I agree. It's a concern. All right, Senator Fischer.
00:36:13Thank you, Mr. Chairman. Thank you all for being here today.
00:36:18I really appreciate the information that you're giving us, and also the concern you have with the direction
00:36:25that we aren't headed yet.
00:36:28In the
00:36:30NDAA for FY2020
00:36:34pilot program was established to assess the National Disaster Medical System, the NDMS, and
00:36:42hopefully that it would increase not just capability,
00:36:46but also capacity within that. In a conflict, you know, we've touched on that already.
00:36:52We have to be able to quickly disperse and absorb
00:36:56casualties throughout the United States. Dr. Friedrichs, why is it so important for the
00:37:03NDMS to maintain this surge capacity?
00:37:07Senator Fischer, first, thank you for the role that you and your colleagues from Nebraska played in championing this and highlighting this.
00:37:15It's important because the military health system does not have the capacity to care for every casualty coming back.
00:37:21We don't have the capacity to care for the people in peacetime right now.
00:37:25So to think that somehow we can do this on our own is another mistaken belief. During the Cold War,
00:37:31we recognized that if our nation went to war,
00:37:34we would go to war together and that we would do it with an integrated system with the DOD, the Veterans Health
00:37:41Administration, and civilian partners. We must rejuvenate the NDMS, not let it continue to atrophy.
00:37:48So what's the next step in this pilot program?
00:37:52So the next step is to make this not a pilot program,
00:37:55but to reiterate that this is indeed the intent of Congress, that the NDMS is
00:38:01the framework in which we integrate our ability to deal with either surges in military patients or,
00:38:08in the event of a natural disaster, surges in civilian patients.
00:38:12But that is the framework. A subset of that are the RESPECT centers,
00:38:16which you're very familiar with, the Regional Emerging Special Pathogen Centers that are designed to take care of patients exposed to or treated,
00:38:25infected with high-consequence infectious diseases. And another subset of that is the trauma
00:38:30system that Dr. Cannon so nicely described.
00:38:35We need your help to articulate in law that we must work as a nation and as a team.
00:38:41We're short 300,000 nurses nationally. The projections are we will be short
00:38:47130,000 doctors by 2035.
00:38:50There is no way that we can do this individually.
00:38:53We must do it together, and I urge you to codify the NDMS pilot and make that the intent moving forward.
00:39:00Dr. Cannon, Dr. Robb, anything to add on that?
00:39:04Senator, I would just advocate for what my colleague General Friedrichs just said, but we need to put our foot on the gas.
00:39:11We don't have five years, ten years, twenty years. We need the solution really now.
00:39:18Dr. Robb? Yeah, I concur with both their comments, and going back, the fact that we
00:39:25we dual-purpose
00:39:27these assets, these expensive assets, to solve
00:39:32problems both on the military and the civilian sector, but they're mutually synergistic, so absolutely we need to press forward. Thank you. Dr. Friedrichs,
00:39:39you mentioned the University of Nebraska Medical Center and working with
00:39:44an academic
00:39:47institution.
00:39:48Can you explain to the committee the benefits of those partnerships with academic
00:39:53institutions in particular and what that can yield for the military health system?
00:39:59Thank you very much, Senator Fischer. So the first benefit is we share and exchange information.
00:40:05You know, University of Nebraska has established,
00:40:08without a doubt, one of the premier programs for treating
00:40:11casualties or patients who are exposed to highly contagious infectious diseases, and they've got remarkable on-site training,
00:40:18which they built in partnership with the United States Air Force.
00:40:21This is a great example of a military-civilian partnership in which the exchange of ideas
00:40:26improves care, both for military and civilian patients.
00:40:29But the other thing that we can learn from our civilian partners is something that I
00:40:34offered to the committee to consider. The CHIP-IN Act,
00:40:36which was originally passed to allow for blending of funding to build new VA facilities,
00:40:42should be expanded to include the DOD.
00:40:45We cannot afford to keep building duplicative facilities, and the CHIP-IN Act was a great way to allow the blending of federal, state, local, and
00:40:54philanthropic funds so that we can most efficiently care for this diverse patient population. Again,
00:41:00I commend the University of Nebraska for the pioneering work that they've done in showing what a good military partnership looks like.
00:41:06Thank you for the shout-out on the CHIP-IN Act. That bill was written in my office, so thank you very much.
00:41:13Dr. Cannon, as a professor of surgery, do you have anything to add on that?
00:41:19I would just comment that these mil-civ partnership sites can be incredible assets for forced generation.
00:41:25We're building up that next generation, those future leaders in surgery and other combat relevant specialties,
00:41:32and these are epicenters of academic excellence where we can truly inspire that next generation.
00:41:40Thank you. Thank you, Mr. Chairman.
00:41:42Thank you, gentlemen. It seems to me that
00:41:44the state of Nebraska must have excellent
00:41:48representation in the U.S. Congress.
00:41:51Senator Shaheen.
00:41:53Thank you all very much for being here today.
00:41:57Dr. Robb, you discussed the impact of declining budgets on
00:42:02the Defense Health Agency. As a former director,
00:42:05can you talk about how late budgets and operating under continuing resolutions, continued budget uncertainty,
00:42:12affects the readiness of the military health system?
00:42:19When I look back at, in fact,
00:42:22I'll go back in history because I was part of that, when we initially stood up the Defense Health Agency in response to
00:42:28the perception that we had a 10% of the
00:42:32DOD's overall budget, and then we moved, and then I fast forward to 12 years later,
00:42:37now we're actually less than 10%. And I look at, we were meeting most of our, not quite,
00:42:43but most of our demands back then, but as I watch, we've had increasing combatant command requirements with a decreasing
00:42:50defense health program. And what that has forced us to do is, we've seen a couple of
00:42:56challenges, and there are multiple things going on, but the military departments have, their end strength has gone down.
00:43:03And the way we man those hospitals is with a certain percentage of
00:43:08military members. And as Dr. Friedrich said, you just can't buy health care professionals off
00:43:14the streets. And so what, because when we cut the end strength,
00:43:18okay, then we portion this care downtown, and then that
00:43:23increased tri-care budget, but then we have to pay with bag one money, which is direct care money, to pay direct care.
00:43:29So now we actually have a
00:43:31internal shrinking of our budget.
00:43:33So it has been challenging for the Defense Health Agency to manage a set of military treatment facilities
00:43:39with that to be the current business process.
00:43:42And is it fair to say that budget uncertainty
00:43:46exacerbates that problem?
00:43:48Continued resolutions exacerbate that problem. Absolutely. Yes, ma'am. Yes, ma'am. Thank you.
00:43:52Dr. Friedrichs, you mentioned the National Guard, and
00:43:56one of the things that I know, the National Guard as we all know, is assuming a greater role in
00:44:04actual deployments and
00:44:06picking up work
00:44:08for the regular military.
00:44:13I could probably say that more eloquently, but they're taking on a much bigger role than
00:44:19they did 30 years ago. And
00:44:22yet the National Guard
00:44:25doesn't have the same coverage for health care that our regular military does. Despite the challenges that you all have identified,
00:44:32it's even a greater problem for the National Guard.
00:44:36Can you speak to what we ought to be thinking about as we're thinking about how do we ensure that the Guard
00:44:41actually has the health care they need so that they're ready to go if they're called to deploy or called into combat?
00:44:49Thank you, Senator Shaheen. And I'll start, if I may, first with your premise that there's an increasing demand signal.
00:44:56The decision to take down the United States Agency for International Development and most of its capabilities is almost
00:45:03unquestionably going to drive more demand on the Department of Defense.
00:45:08USAID provided countless services for disaster response and for work with allies and partners around the world.
00:45:15And for global health. And for global health and for biosurveillance and many other roles. In the absence of USAID,
00:45:23we either agree that when Americans are caught in a disaster,
00:45:26they're on their own, or we're going to turn to the only other organization that has those kind of capabilities, and that's DOD.
00:45:32So we should, I'm afraid,
00:45:33expect to see more demand on DOD as a result of those changes. To your point about health care preparedness, when we look back at
00:45:40why people, shortly after deployment, have to be pulled off the line, interestingly,
00:45:45it's dental care, primarily among the Guard and Reserve, who don't have ready access to that.
00:45:50I think if we are serious about a smaller force that must be ready on a moment's notice,
00:45:56we are going to have to address how to ensure that force is ready, when needed, to go forward.
00:46:02And that's medically ready, as well as ready and proficient with whatever their assigned task is.
00:46:07And
00:46:09we're learning a lot of lessons on the, on our industrial-based side, from the war in Ukraine right now,
00:46:15and a lot of lessons about the conduct of war today.
00:46:20Are we learning anything about the health care system and what we ought to be thinking about from what's happening in the war in Ukraine?
00:46:28Anybody?
00:46:30If I may, I'll just quickly say, having just been with the Ukrainian search in general,
00:46:35absolutely. So what they have found, first and foremost, is
00:46:38they're in the kind of conflict we will likely be in. In the absence of air superiority,
00:46:44contested logistics, you must have a functioning system that's integrated.
00:46:48And this gets back to Senator Fischer's question about the national disaster medical system.
00:46:53They're also learning the importance of supply chains. When we looked at this at the Joint Staff,
00:46:57we found that a significant percentage of the
00:47:00pharmaceuticals in our deployable assemblages actually rely on ingredients from countries
00:47:05that may or may not be willing to continue to provide those in the next conflict. Same song next verse with medical equipment.
00:47:11I urge you, as I said in my written statement, to require the department to give you an accounting for our
00:47:17vulnerabilities in that area and a plan to address them. There are ways to do that.
00:47:21We need a strong push, I would submit, to actually accomplish that. Thank you very much. Thank you all.
00:47:28Thank you, Senator Sheehan.
00:47:30Dr. Cannon and Dr. Robb, do you want to elaborate on what Dr. Friedrich said about USAID?
00:47:41That's right, that's out of my
00:47:43domain, so I don't have any specific comments. Very well then, yes. I would concur,
00:47:49one, with his comments, but number two, it's again, it's mostly out of my domain currently. All right. Thank you very much.
00:47:55Senator Cotton.
00:47:56Dr. Friedrichs, I'd like to continue with the answer you just gave to Senator Sheehan about our dependence on other countries for drugs and
00:48:05precursors, specifically Communist China.
00:48:07The United States relies heavily on Communist China for basic drugs and so-called APIs, active pharmaceutical ingredients.
00:48:15Providers obviously need this, not just in the civilian world, but in the military world, especially to treat combat casualties.
00:48:22China, for instance, has 80% of the global supply chain of antibiotics.
00:48:27How could Communist China use this dependence of ours to its advantage if there were a major conflict in the Pacific?
00:48:37Thank you very much, Senator Cotton, and I think we've seen examples of this with rare
00:48:42minerals and other things that China
00:48:46largely controls the supply chain for, in that they will choose to titrate that supply chain based on their satisfaction or
00:48:53dissatisfaction with those trying to purchase those items.
00:48:56I had the great privilege in my last role of working with India, the EU, Japan, and Korea on
00:49:04a consortium in which we began to identify ways to leverage new technologies to change and to
00:49:12broaden our supply chains, and
00:49:14I encouraged this committee to direct the Department of Defense, in
00:49:19partnership with the Department of Health and Human Services, to continue exploring those options. What we found was, in many cases, as in the case of
00:49:28antibiotics that are based on penicillin, the Japanese have already made a tremendous investment
00:49:34in the ability to produce those APIs within Japan. We should be partnering with them and
00:49:41creating an environment in which at least the DOD and the VA
00:49:44purchase from Japan to help sustain that production base and ensure that we have the access that we need.
00:49:50There are many more examples. I touched on some of them in my written statement,
00:49:53but there are ways to mitigate this. And your answer, Senator Shaheen, said that
00:49:58Congress should push the Department of Defense to catalog all of these dependencies.
00:50:02It sounds like you're saying that we also need to push to
00:50:05eliminate, or at least significantly curtail, these dependencies as well. Is that right? Absolutely. And you mentioned four different sourcing options,
00:50:15South Korea, Japan, the EU, and India. Those first three are
00:50:19advanced industrial democracies, just like ours.
00:50:22If they can produce these items, like acetaminophen or ibuprofen or penicillin, at a reasonable cost,
00:50:29surely the United States could do so as well, right?
00:50:32I believe that is the case. And what we found is that particularly in these countries,
00:50:37they've created an environment in which it was financially possible for companies to produce these items within their country.
00:50:44We have not done that here in the United States.
00:50:46But a thoughtful industrial policy that was focused on resilience and national security, as well as economic security and health security,
00:50:55could do that for us as well.
00:50:56It's fair to say that between the two of them, the Department of Defense and the Department of Veterans Affairs
00:51:02sure does have a lot of purchasing power to create a domestic market for the production of these fairly basic and
00:51:10long-standing medicines, right?
00:51:12Absolutely.
00:51:14About 8% of the market, and it gets back to Senator Shaheen's point about continuing resolutions and predictability.
00:51:21If companies know that they have a predictable demand signal,
00:51:24they'll build to it. If they have an episodic or random demand signal, they'll let somebody else deal with that.
00:51:30General Rob, I've noticed you nodding your head vigorously, so please get off your chest everything you wanted to add to General Friedick's answers.
00:51:39Yes, I also,
00:51:42and I know I'm sure you're aware, and this has been in the direction from questions asked by our Congress,
00:51:48you know, the Center for Health Services Research at the Uniformed Services University has been tasked with, along with the Defense Logistics
00:51:56Agency, to catalog and specifically look at what, and define the problem,
00:52:00what is the Department of Defense's reliance on
00:52:04the medicines that we have talked about that are primarily sourced from China and from India, and which would then help
00:52:12what I would call inform the decisions a way ahead of whether you, what I call it, ally shore,
00:52:19you know, or near shore or onshore, as Dr. Friedrichs
00:52:23discussed in looking at a way forward, but they are creating that, you know, what's the data to drive the decision in the investment?
00:52:32Thank you, gentlemen, both for your answers. It's long been the case that the Department of Defense, acting at congressional direction, has
00:52:38mandated the domestic purchase of many uniform items,
00:52:42so I think surely we should make sure that our troops have the medicines
00:52:47they need to stay healthy or to recover as needed.
00:52:53Thank You, Senator Cotton. Senator Cain.
00:52:56Thank You, Mr. Chair, and thank you to the witnesses. I want to particularly recognize Dr. Cannon.
00:53:00I know you're very well prepared for this hearing today because one of the
00:53:03leaders that's with you, Krista Malloy, used to be on my staff,
00:53:06and she made sure I seemed a lot smarter than I was at any hearing that I attended.
00:53:11You know, I think I want to focus all of your attention on the
00:53:15workforce issues because I'm on the health education labor pension, too, and if I go to my
00:53:20hospitals and health care providers, they're singing the blues about
00:53:23workforce, tight labor market, difficulty hiring and retaining folks.
00:53:28I went to the grand opening of a new VA clinic in the Fredericksburg area two Fridays ago,
00:53:34and we built it to the tune of about $350 million, and we built this state-of-the-art clinic with one step down from a hospital
00:53:42because there were multiple clinics in the area and
00:53:44veterans were having to go from pillar to post to get care rather than a single place.
00:53:49But when we opened it, and I was there for the opening, I had staff say,
00:53:52we're on a skeleton crew. The three VA hospitals in Virginia, Salem, Richmond, and Hampton are laying people off.
00:54:00There's hiring freezes. There's plans for even more layoffs.
00:54:03And so the estimates I was getting at that grand opening is they're probably 20 to 50 percent staffed.
00:54:10There's another sizable clinic similar that's going to open in Chesapeake, supposed to, on April 11th. If it does open on time,
00:54:17I'm suspecting that it will be a similar thing, and you saw the announcements about more cuts coming in the VA.
00:54:24What is your vision for how we, you've talked a little bit about
00:54:29the need to be more integrated between DOD facilities and VA facilities, but then also on the civilian side,
00:54:36what is your vision for how we
00:54:38equip our civilian system to provide a surge capacity or backup capacity
00:54:45when we need it to perform well in combat situations?
00:54:50Please, Dr. Cannon.
00:54:53Senator, thank you for your very insightful comments and questions.
00:54:58I am a veteran. I get my care at our VA in Philadelphia.
00:55:02My wife is a primary care physician and takes care of veterans.
00:55:07So I can speak to your comments about the VA from that perspective.
00:55:11I do have a role at Penn Medicine as the Assistant Dean for Veteran Affairs for Penn Medicine,
00:55:17but I'm quite new in that role and still learning the ropes. So I'll speak more from my end-user experience. I would say that
00:55:26certainly there are opportunities for synergy.
00:55:30The partnerships between VA facilities and academic medical centers, I think, have been
00:55:36partially realized, but in this sort of urgent situation we find ourselves in, we need truly a
00:55:43whole-of-society approach, and where there can be
00:55:47market synergy, where there can be economies of scale, we should aggressively pursue that. I know that our CEO, Kevin Mahoney, has
00:55:55made overtures to the VA, and there have been agreements signed between the VA.
00:55:59I don't have detailed knowledge about that and where that stands,
00:56:04but I think there is an opportunity, and we should push for that. And as a veteran who receives my care, I
00:56:10hope that we can continue to deliver excellent care through better synergy. How about Dr. Friedrichs and Dr. Raab?
00:56:17Thank you, Senator Koehn, and that is a beautiful facility.
00:56:20It'll be tragic if it sits there empty while veterans are unable to access care because of shortages of medical
00:56:26professionals in the VA, in the DoD, and in the civilian sector.
00:56:30We're in a less-than-zero-sum game right now, and that is both a health security issue,
00:56:35but also a national security issue. The first recommendation I would make to this committee
00:56:40direct that the Department of Defense does not close any more of our military training programs. For decades,
00:56:45the military training programs have been one of the pipelines that, when people eventually left the military, which all of us do,
00:56:52they go to the civilian sector.
00:56:53We cannot afford to close any more training programs when we have so many shortages of doctors and nurses and dentists and other things.
00:57:00The second, I implore this committee in the NDA,
00:57:04direct the DoD, and in partnership with the appropriate VA oversight committees, the Veterans Administration, to come back with a plan
00:57:11starting with the DC market to integrate the two systems. We've talked about this since I was a major.
00:57:17I moved here in 1997, and we were talking about this.
00:57:21It's time to stop talking and start doing it.
00:57:24We can't afford to keep talking about this problem. That hospital in the VA here is ancient.
00:57:31It's got to be replaced. We just finished a billion-dollar upgrade at Walter Reed.
00:57:35Why in the world are you not demanding that we come back with a plan to do that?
00:57:40It is more efficient, and it helps to pool the resources.
00:57:43The third point, and the most important one in your health committee role, is we must address these pipelines as both a
00:57:50health security and an economic security and a national security concern.
00:57:56As long as the pipelines continue to be insufficient to need,
00:58:00there's no way that any of these problems are going to get fixed, and I think you have a unique opportunity
00:58:05to help bring that into both committees. Thank you, Senator. Thank you, and Dr. Rob,
00:58:09I'll ask that question for the record because I'm now out of time. I yield back to the chair.
00:58:16All right.
00:58:19Actually, these witnesses will not be taking
00:58:27questions for the record, but
00:58:31I'll let you follow up for 45 seconds.
00:58:36Dr. Rob, then could you approach that workforce integration question, too? Thanks.
00:58:41Yes, and I'll go back to where
00:58:45we can share resources, and I will foot stomp. We have very many successful
00:58:52joint DOD and VA
00:58:54partnerships.
00:58:56Travis Air Force Base is a great example where the actual VA is inside of David Grant Medical Center, share staffs,
00:59:03but more importantly, share patients. We have other where we're co-located
00:59:07community-based outpatient centers that feed patients into like Anchorage, Alaska.
00:59:11We see that down there at Naval Pensacola.
00:59:14So those opportunities, because usually what happens is we want access to critical care patients
00:59:21for our proficiency, and the VA wants access to resources,
00:59:26which is either excess capacity on space or in staff, and so I think that
00:59:32continued movement forward, not always one-size-fits-all,
00:59:35but that is very, very important, much like the VA is all the academic health centers.
00:59:40I think the Department of Defense, especially in our six or eight strategic places, need to have
00:59:46strategic VA and strategic military partnerships, sharing staff.
00:59:49And I will quickly say, not only do we learn from the military,
00:59:54I mean the military learned from the civilian opportunities, during OIF and OEF,
00:59:59actually, the American College of Surgeons made sure that they were with us so they could learn
01:00:04firsthand, real-time, on how we were treating. So it is a mutually synergistic
01:00:09relationship. Thank you, Dr. Rugg. Senator Rounds.
01:00:14Thank you, Mr. Chairman, and I'm going to follow right along that same line, because I think
01:00:18what you're laying out is basic common sense when it comes to the integration of these two systems.
01:00:24My question is, why is it that when we have
01:00:27what is considered to be excellent care with the military system, the MHS involved,
01:00:33and then we have to transition these young men and women as they leave the
01:00:39armed services into a VA facility, in which we start all over again.
01:00:43We have different ways of communicating, and in fact, let me just ask this, in
01:00:48your experiences, how well do we integrate the transfer of information from the MHS back into the VA systems today?
01:00:57Senator, I can take a crack at that. I believe you're spot-on.
01:01:06My experience in transitioning from the DOD to the VA was more of a lukewarm handoff than a warm handoff.
01:01:14I had to sort of navigate my way to the VA. I now have
01:01:19closed that gap, and I get my care there, as I mentioned, but it's not a smooth process. So
01:01:25why is it still the case that the two
01:01:31healthcare delivery systems are so partitioned? I think you have to go back to ancient history almost in our country.
01:01:38And if you look at Secretary Gates'
01:01:41comments about his experience as Secretary of Defense, he said the one department that gave me the most fits was the Department of the VA.
01:01:49So there are
01:01:51historic challenges. The VA wants to do it their way.
01:01:55Understandably, most of us do want to do it our way,
01:01:57but I think there are clear opportunities and a clear demand signal to break down those barriers and realize
01:02:04opportunities for synergy.
01:02:05So I think we can do that. I think the focus should be on whether or not we're delivering for the veteran and not necessarily the
01:02:10survivability of the VA itself, and I think that sometimes gets mixed up. I'm just curious, gentlemen.
01:02:17We've talked about trauma centers. We've talked about the integration or an integrated health care system and so forth.
01:02:23We're not right now in a
01:02:28we're not at the same degree of
01:02:31activity and intensity with regard to battlefield casualties as we were just a few years ago, and therefore the
01:02:37opportunity for these surgeons, these battlefield surgeons and others to actually learn right now is probably not as great.
01:02:44How do we keep the intensity or the capabilities, the
01:02:48the
01:02:50you know, the training, how do we keep that up to date when we don't have those
01:02:55those
01:02:57opportunities? And I'm not going to say that they're good opportunities.
01:03:00I'm glad that we're not in them,
01:03:01but how do you allow that surgeon to keep those skills up to speed when you don't have
01:03:06the types of casualties that you have on a battlefield that we were experiencing for a number of years?
01:03:12Take care of sick patients, sir.
01:03:14I mean, there's an analog between taking care of a patient who has bladder cancer, needs to have their bladder removed, and
01:03:22taking care of a patient who's just had a gunshot wound to the abdomen, needs to have their bladder reconstructed.
01:03:28We need our
01:03:30military medics taking care of sick patients.
01:03:33They do that at hospitals that are well staffed and well resourced to take care of sick patients, and so, you know,
01:03:39that's what we have done historically to maintain the proficiency of surgeons or of critical care nurses
01:03:46or of medical logistics staff, is keep them busy during peacetime, taking care of sick patients.
01:03:51It's not a perfect analog, but that is the best surrogate, and that requires resourcing the system,
01:03:57making sure that sick patients can get in the door and get the care they need.
01:04:01And to your point about the VA, I would just say I applaud the VA for accelerating the process.
01:04:07I applaud the VA for accelerating moving forward with their electronic health record,
01:04:11because that is going to be the secret sauce that enables greater sharing between the two departments and will enable us to track patients
01:04:18from the day they join the military to the day they take their last breath and really learn how to improve both systems.
01:04:24Is the current system that you use
01:04:28integratable with the VA's new proposed
01:04:32medical records health care system? So, I am not an expert on the VA system.
01:04:38When I left the movie, they were looking at purchasing the same system that the DOD had purchased.
01:04:44I hope that those with oversight responsibilities will insist that the two systems are
01:04:51integratable, because technologically there's nothing to prevent that. I mean, civilian health care systems integrate
01:04:57Epic and Cerner all the time, or McKesson and Epic.
01:05:00There should be no technological reason why we can't do that. Thank you.
01:05:06General Rob, anything to add to that?
01:05:09I would share what Dr. Friedrich said. In fact, what I was excited about is I've had the
01:05:17opportunity for family members to be in civilian hospitals,
01:05:20and they are able to reach into it and see Genesis now.
01:05:24And so, they know the health care that my family members have been getting in the military.
01:05:27I know that has absolutely been the vision
01:05:30between the Department of Defense and the Department of VA, and I believe that is still
01:05:35what I would call the true north. Thank you. Thank you. Thank you, Mr. Chairman. Thank you, Senator Rounds. Senator King.
01:05:42Thank you, Mr. Chairman. First, I want to thank you for having this hearing, very timely and important. Secondly,
01:05:47I want to associate myself with Senator Cotton's comments about a sort of Barry Amendment for drugs, the idea that we have to buy
01:05:55Made in America shirts for our troops, but we're worried about the availability of crucial drugs.
01:06:02It seems to me that's something that should be pursued. We could even call it the King-Cotton Amendment, but I'll pass on that.
01:06:12Also, Mr. Chairman, before getting into the questions, and these witnesses wouldn't have the answers, but I think in light of this
01:06:19hearing, the committee should make an inquiry about whether there have been firings or early retirements encouraged within the medical
01:06:28facilities at the Defense Department,
01:06:32because we know there's a lot of that going around, and I'd like to know whether that's happening in the Defense Health Agency.
01:06:40Secondly, there's the impact of the continuing resolution.
01:06:43That's certainly not going to help this situation in terms of maintaining demand signals, continuity,
01:06:49pilot programs, all of that is gone in a continuing resolution. For the first time in my knowledge,
01:06:54I think the first time in American history, we're faced with a year-long continuing resolution, which basically vitiates the entire budget process.
01:07:02Okay.
01:07:04What we're really talking about, it seems to me, is surge capacity,
01:07:08and it's impractical to maintain a
01:07:12capacity within the Defense Department, or even Defense plus VA,
01:07:16for the kind of
01:07:18casualties that would be generated in a significant conflict.
01:07:22Therefore, I see no other alternative than a
01:07:27cooperative surge agreement with the private sector.
01:07:31That's where the
01:07:34that's where capacity is, even though that's fairly limited, but Dr. Friedrichs, isn't that really what we're talking about here?
01:07:40How do we deal with a conflict way beyond what we're seeing now
01:07:47within the current capacity?
01:07:50Defense Health Agency couldn't do it, VA couldn't do it.
01:07:53It's got to be relationships, and shouldn't we have those relationships in advance,
01:07:58so this isn't something that we scramble to do as we did during COVID, for example.
01:08:04Senator King, I could not agree more strongly.
01:08:10Thank you, sir. So, in the Cold War,
01:08:13we had what was called the Integrated CONUS Medical Operation Plan, which it was essentially what you just described.
01:08:19It was our shared commitment as a nation to care for our nation's casualties if and when our nation went to war.
01:08:27That depended on the National Disaster Medical System as part of the integrating function between the federal and the civilian health care system.
01:08:34The NDMS has been allowed to tread.
01:08:38I echo the recommendations to reauthorize the Pandemic and All Hazards Preparedness Act because that in part
01:08:45enables the NDMS, but I implore you to go further.
01:08:50The Integrated CONUS Medical Operation Plan needs to be updated, and we started that work when I was the Joint Staff Surgeon,
01:08:56and it's continuing today.
01:08:57Having the NDMS in name is not sufficient.
01:09:01We actually have to build out the numbers by community of what beds would be available,
01:09:06with pre-existing conditions and analysis of deaths.
01:09:11I just wonder if the Pentagon has war-gamed this issue.
01:09:19Absolutely, sir.
01:09:19We actually did a war game on this that we hosted first when I was the Transportation Command Surgeon,
01:09:24and again when I was the Joint Staff Surgeon, and what we found was just as you said,
01:09:29it can't be done unless it's a whole of a nation effort, and the only way to get to that point is if we do
01:09:35much more detailed planning.
01:09:37Taking down funding for state and local readiness officials, for example, is not going to help them do more planning or preparing.
01:09:45We need to work together to build and flesh out that plan,
01:09:49and we must bring industry into that. The Defense Industrial Base provides the equipment. The Health Industrial Base
01:09:55addresses the points that you make.
01:09:57And we have an analog in Transcom,
01:09:59which has agreements with the private sector, both in terms of airplanes and ships, in the case of an emergency.
01:10:05That's where our surge capacity is, so it seems to me, I mean, here we are talking about it,
01:10:11but I think there needs to be some very specific
01:10:15good new looks at this relationship in order to be ready, so again, we're not scrambling.
01:10:21Dr. Rob, you're nodding. I take it you agree.
01:10:24Yes, I would absolutely concur, and again,
01:10:26I keep going back to the same theme, is we've got to build up those six to eight to ten strategic military treatment facilities.
01:10:33We have to resource them, and then you create the already established civilian,
01:10:38excuse me, military VA partnerships, you know, and then you just keep expanding that ring,
01:10:43but you have to have those
01:10:47relationships codified and in place, and that's what Dr. Friedrichs is talking about.
01:10:51You can't just, all of a sudden, when it kicks off, pick up the phone and say, how's it going?
01:10:55You've got to have them in place before the crisis hits. Absolutely.
01:10:59Thank you, gentlemen. Appreciate it. Thank you, Mr. Chairman.
01:11:04Thank you very much, Senator King. Senator Budd.
01:11:11Catch your breath.
01:11:25Major General, in your opening statement, whether here or able to watch it on the closed circuit,
01:11:32you identify the importance of the relationship between the military health system and the defense logistics enterprise.
01:11:41So, should deterrence fail and the war break out in the Indo-Pacific, there are undeniable logistics constraints,
01:11:49particularly given the geography of Indo-Pacom.
01:11:52The logistics of replenishing medical supplies and evacuating wounded service members could make all the difference in reducing service member casualties.
01:12:01You provide a number of recommendations in your opening statement to address these concerns, including a number of reports and studies.
01:12:07So, thank you for that. So, what can our military health system do in the short term, like immediately, to address logistical constraints, and
01:12:15how can DOD leverage medical innovation to address some of those constraints?
01:12:21Thank you very much, Senator. I think that the most immediate recommendation that I included in my written statement was
01:12:27that whenever we contemplate an operation or we're updating plans,
01:12:33we do a medical feasibility assessment, very similar to the medical logistics or to the logistics feasibility
01:12:40assessment that the Joint Staff J4 does.
01:12:42We need to ensure that we are informing our combatant commanders about what is and is not possible.
01:12:48That is something that can be done very easily.
01:12:51The longer answer to your question gets back to the discussion that we were just having about partnering with industry,
01:12:58both on the equipment and pharmaceutical side and on the health care delivery side.
01:13:03We have the civilian reserve air fleet that allows us to commit money to ensure that we have industry partners willing to provide
01:13:11aircraft and support when we need it.
01:13:13We have no such analog in the health care space, even though we know, as multiple senators pointed out this morning, that there's
01:13:20insufficient capacity in the DOD and in the VA to care for our casualties.
01:13:24The NDMS currently is a voluntary system in which hospitals can say, yeah, okay.
01:13:30And then when we call them, they say, I'm busy today. I'm not going to participate.
01:13:33We actually need to codify a system, as we've done with other industrial partners, in which there's a commitment and an
01:13:41understanding of how the reimbursement would work.
01:13:43The last point that I would make on that going forward is in supplemental planning for future operations,
01:13:50we have to build in that cost.
01:13:52There is no question if we're bringing back thousands of casualties, as Colonel Cannon described,
01:13:57that that is going to displace care and it's going to increase cost at hospitals. We have to plan for that.
01:14:03That's why this whole planning effort, the integrated CONUS medical operations plan, for which NORTHCOM is the lead, in
01:14:09partnership with industry, state, local, and HHS officials, is so important,
01:14:14so we can bring back the requirements for funding and the challenges that we'll need congressional help to address.
01:14:22Following up on that, you said we need to codify that.
01:14:24Do you have the language ready, or has that been written in a way that we could review, either individually or as a committee?
01:14:32Senator, I took the liberty of including an attachment with suggested language, just in case anyone wanted to do that.
01:14:39We'll read it in a few moments. Thank you. Mr. Rob,
01:14:43as you know, the department relies on a mix of military personnel, federal civilians, and
01:14:49contractors to carry out its mission. Talk to me about the roles of physician extenders, such as registered nurses,
01:14:55and what role do physician extenders play in ensuring the readiness of the broader force, and what challenges do you see to
01:15:02retention of physician extenders?
01:15:04Thank you for that question, Senator. I think it's key that what we are just,
01:15:12the same issues of what I call proficiency in currency that exists for physicians, exists for our
01:15:21physician extenders. And the Army does a great job, especially in the way they've manned
01:15:27and equipped their fighting forces of using those
01:15:31physician extenders, all the way down to the corpsman, to the fullest extent of their capabilities. And so I
01:15:38would argue, as we have these discussions about medical readiness and about
01:15:44our ability to care for what we call critical wartime specialties, we must remember
01:15:50trauma is a small percentage of that, but the majority of the care that is applied to our
01:15:57fighting forces comes from our primary care providers, which would be PAs, nurse practitioners,
01:16:04general practitioners, family physicians.
01:16:06So we must ensure that they also have the critical thinking skills and the opportunity to practice at the top of their gate.
01:16:16Thank you all for the whole panel. Chairman?
01:16:20Senator Budd, yes, indeed,
01:16:23in looking at the
01:16:26statements, which have all been
01:16:30admitted to the record by unanimous consent, I see on page 14 of Dr. Friedrich's
01:16:37prepared testimony,
01:16:39attachment one, suggested National Defense Authorization Act language. So we do appreciate
01:16:46him
01:16:47acting as an uncompensated
01:16:49legislative
01:16:51staffer for this committee. We appreciate that. And thanks for the question.
01:16:57Senator Kelly. Thank you, Mr. Chairman.
01:17:01General Friedrichs,
01:17:04good morning, and thank you, all of you, for being here today.
01:17:08General Friedrichs, in a recent war game brief to Congress in November of 2024, a
01:17:14hypothetical conflict in the Indo-Pacific resulted in 3,000 U.S. casualties in three weeks, and
01:17:2110,000 across the entire conflict. And I'm kind of following up on Senator Budd's line of questioning here.
01:17:28These numbers are higher than anything we've seen since the Korean War. And
01:17:34as severely injured service members transition through the care system and make their way back to
01:17:40the United States for treatment, I'm concerned that the number of
01:17:44DOD providers capable of handling trauma
01:17:48will be grossly insufficient. So given that, we're going to need to surge capacity,
01:17:54potentially
01:17:55found in the U.S. hospital system and
01:17:59VA hospitals, so meaning civilian hospitals, VA hospitals.
01:18:03What concerns do you have with relying on U.S. civilian and VA
01:18:09hospitals to provide this trauma care to our service members?
01:18:14Thank you very much, Senator Kelly.
01:18:16And I'd start by saying even before we get patients back to the United States, in the past,
01:18:21we've relied on our allies and partners to help care for our casualties. And I am deeply concerned if we
01:18:29sever or degrade those relationships,
01:18:32we will need to rewrite our plans and the demand on the U.S. health care system will be even greater.
01:18:37To your point about the U.S. health care system, the integrated CONUS medical operations plan that we updated in
01:18:441998 and then didn't look at
01:18:47until 2020
01:18:48is the plan that describes how we will surge capacity.
01:18:52But a key part of that gets back to some of the discussions we've had earlier.
01:18:56There have to be doctors and nurses and
01:18:58pharmacists and all the other staff to do that. And I implore that we continue to look at the pipelines that produce those medics as
01:19:05well as the facilities in which they work.
01:19:09We had briefly chatted about the opportunity for a medical equivalent to the civilian reserve air flight
01:19:16that that we use to ensure access to civilian aircraft when needed.
01:19:21I believe we need some similar construct in the health care system where we partner with industry and recognize that during surge
01:19:29moments, there's a plan and there's money available for us to be able to leverage their staff and their facilities.
01:19:35Is there a plan?
01:19:37There is a plan. We wrote the first version of that before I retired and they are working on an update to that.
01:19:44But it would benefit from additional congressional oversight to ensure that it's on track and it does not get diverted by bureaucratic buffoonery.
01:19:51Are there current efforts in the relationship building with these hospitals?
01:19:56The Defense Health Agency is tasked to
01:19:59to have that outreach and as I've met with
01:20:02hospital CEOs and system owners, there's certainly an opportunity to do more in that space.
01:20:08We must view the health care industry the same way we view the aviation industry or the missile producing industry as our partners.
01:20:15We cannot take care of America's casualties without those partners.
01:20:19Can you talk to
01:20:21the value in the two Navy hospital ships?
01:20:24I don't know if anybody here is prepared to talk about because I think I think there's enough effort underway to
01:20:30replace those.
01:20:32There's also the
01:20:35training ships for the
01:20:37state maritime
01:20:39academies that I think also could serve a role.
01:20:43I visited one at the Philly shipyard a few weeks ago,
01:20:48had an operating room on board. Is that part of the system as you envision it?
01:20:54Yes, absolutely. The hospital ships are integral to our plans for a large-scale combat operation.
01:21:01And the two ships we have are some of the oldest ships afloat. They have to be replaced.
01:21:07I think there's a plan to replace them now.
01:21:11Can you speak to how that is going if you know?
01:21:15So I pushed incredibly hard for that plan as the Joint Staff Surgeon against intense
01:21:20opposition that we should spend the money in other places.
01:21:22I would defer to the Navy for the latest update on it because they can give you the most current plan.
01:21:28But my understanding is that we're still years away from having the replacement ships available.
01:21:33So we'll have to extend the current ships. And I believe the last update I received, which is dated, was through 2035.
01:21:41But we do need that additional replacement funding to replace those aged ships.
01:21:47All right. Thank you. And thank you, Mr. Chairman.
01:21:50Thank you, Senator Caley. Senator Warren.
01:21:53Thank you, Mr. Chairman. So we need a medical health care system that works in wartime,
01:21:58but the one we have is failing us in peacetime.
01:22:02And I think we need to do better on this. Fixing TRICARE's prescription drug benefit is part of that.
01:22:09Since 2009, TRICARE has outsourced to Express Scripts a
01:22:15massive pharmacy benefit manager, PBM. The Defense Health Agency, DHA, pays
01:22:21Express Scripts to negotiate with pharmacies deciding where service members can pick up their prescriptions and what price they're going to pay.
01:22:30But Express Scripts also owns Acredo, a
01:22:35massive pharmacy that participates in TRICARE. And
01:22:39DHA has been allowing all kinds of self-dealing between these two entities.
01:22:44Here's one. DHA used to require Express Scripts to maintain a network of
01:22:5150,000 pharmacies. But in 2021, Express Scripts negotiated that down to
01:22:5735,000 pharmacies. Then they turned around and told thousands of pharmacies that they don't own
01:23:04either to take money-losing terms or get kicked out of TRICARE. General Robb,
01:23:09you used to oversee the TRICARE network before this gaming started.
01:23:14Do you have any idea how many pharmacies have left just since 2022?
01:23:24And I have been out, Senator Warren, I've been out of that business since 2016.
01:23:28Okay, so I just wonder if you happen to know how many had left. No, ma'am. No, ma'am. I do not. Well, it's over
01:23:3513,000 pharmacies have left this network and most of them are
01:23:39independent pharmacies,
01:23:40community pharmacies. That has forced
01:23:44400,000 service members and their families to find new pharmacies and many of them have been pushed to the
01:23:51Express Scripts-owned
01:23:53Accredo.
01:23:55Even worse, Express Scripts has set up Accredo as the primary off-base pharmacy, where military families can fill
01:24:04specialty drug prescriptions. You know, these are the really expensive
01:24:08cancer drugs, rheumatoid arthritis
01:24:11drugs, that make up over half of the eight billion dollars in TRICARE prescription drug spending.
01:24:18So it's a lot of money here. It doesn't end there. As we speak, Express Scripts is facing a whistleblower
01:24:26lawsuit that alleges the company
01:24:29systematically overfilled TRICARE prescriptions at Accredo,
01:24:33saddling DoD with, quote,
01:24:36billions of dollars in excess dispensing fees and drug resupplies. And this isn't a surprise.
01:24:43Express Scripts has been found to massively overfill and overpay for
01:24:49prescriptions at Accredo, which they own, in other government programs.
01:24:55So, General Rob, since last year an audit uncovered that Express Scripts
01:25:00was leveraging its contract with the West Virginia Public Employees System
01:25:06to send inflated payments to Accredo for expensive specialty drugs. In some cases,
01:25:13inflating the price by a hundredfold
01:25:16more than the cost of dispensing exactly the same drug at a competing pharmacy.
01:25:21I imagine you think this kind of taxpayer overcharging is unacceptable. Is that fair,
01:25:28General Rob?
01:25:29I would agree with that. It would be unfair. Yes, ma'am.
01:25:33Okay. DHA is supposed to audit Express Scripts pharmacy data to make sure that that same thing
01:25:40isn't happening at TRICARE. But DHA said it hadn't completed an audit because DHA had, quote,
01:25:48no concerns about data accuracy.
01:25:52You know, talk about being asleep at the wheel here. In just the first quarter of
01:25:592023, Express Scripts dispensed
01:26:0370,000 specialty drug prescriptions at Accredo, but the company only reported about
01:26:1140,000 to DHA. In other words, Accredo failed to report nearly half of the expensive specialty drugs
01:26:18dispensed at its own pharmacy, which were paid for by DHA.
01:26:24So they get the money, but they don't tell DHA what's going on here.
01:26:28General Rob, after completing their investigation, GAO sensibly recommended that DHA
01:26:35periodically audit Express Scripts reported data for accuracy, which, by the way, is already required in the contract.
01:26:43So this is telling them basically to follow through on the contract. Do you agree with GAO's recommendation?
01:26:52I would agree that they need to follow what is the business
01:26:56policy and what is the
01:26:59contractual
01:27:00requirements. Yes, ma'am. You know, I just want to say, and I'll close up here,
01:27:04DHA is paying Express Scripts
01:27:07billions of taxpayer dollars to manage the TRICARE benefit and negotiate with itself, and
01:27:14DHA isn't even bothering to check the books.
01:27:16I think that everyone in this room agrees that Express Scripts ought to pass an audit and that ought to be required in this year's
01:27:24NDAA. Thank You, Mr. Chairman.
01:27:27Thank You, Senator Warren. Mr. Chairman, may I add a comment to that? Is there time? You certainly may, yes.
01:27:33Thank you very much. I would hold up the Veterans Health Administration's
01:27:38exemplary mail-order program, which has worked for years, as
01:27:42an opportunity, again going back to this concept of how do we deliver better care and where possible do it more efficiently.
01:27:50There's a real opportunity for this committee, in partnership with the appropriate VA Oversight Committees, to direct the comparison of the two systems
01:27:57and then bring back recommendations for the best practices between the two.
01:28:02Pharmaceuticals are growing in cost and that is not going to change,
01:28:06but this is an area in which the Veterans Health Administration actually has done this well for years with high patient satisfaction and,
01:28:13more importantly, the patients get the meds they need when they need them. There's a real opportunity to learn from the VA here.
01:28:20Thank you very much. Thank You, Senator Warren. Mr.
01:28:26Ranking Member, anything more?
01:28:28Just let me commend the witnesses and
01:28:32you've given us lots to think about and lots to do and so we appreciate that. Thank you very much.
01:28:38We are indebted to you and grateful to all three of you. Thank you very much and this concludes the hearing.

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Ted Cruz Fires Back At Dick Durbin Over 'False Charges' Against Key Trump DOJ Nominee
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3:03
DelBene Slams House GOP Colleagues, Claiming They ‘Seem Fine’ With ‘The Damage They’re Causing’
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1:48
Ami Bera Floats Democrats Going To Red Districts For Town Halls
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2:20:16
The Senate Armed Services Committee Holds A Hearing On The Readiness Of The Joint Force
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1:29:40
The Senate Armed Services Committee Holds A Hearing On Pending Defense Nominations
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1:48:16
The Senate Health Committee Holds A Hearing On The Shortage Of Minority Health Care Professionals
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54:33
Richard Blumenthal Leads Senate Homeland Security Committee Confirmation Hearing For Nominees
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2:13:26
BREAKING NEWS: Jim Jordan Leads Weaponization Committee Hearing To Probe ATF Overreach
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2:09:30
Senate Commerce Committee Holds Hearing About Major Broadband Affordability Programs
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1:22:44
Mike Lee Leads Senate Energy Committee Hearing To Consider Pending Legislation
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1:01:28
Senate Appropriations Committee Holds A Markup On Pending Legislation
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1:18:36
Veterans Affairs Secretary Denis McDonough Testifies Before Senate Appropriations Committee
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1:29:51
CBO Director Phillip Swagel Testifies In Front Of The Senate Budget Committee
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1:41:20
BREAKING NEWS: Boeing Airline Whistleblower Testifies Before Senate Homeland Security Committee
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1:21:48
Ron Wyden Leads Senate Finance Committee Hearing On Youth Residential Treatment Facilities
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1:44:25
Pete Sessions Leads House Oversight Committee Hearing About Improper Payments And Fraud At Agencies
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1:40:41
Dick Durbin Leads Senate Judiciary Committee Confirmation Hearing For Pending Nominees
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9:34
John Thune Issues Warning To Senate Dems They'll Cause Shutdown If They Don't Back CR
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2:34:04
House Homeland Security Committee Holds Hearing On Cyber Security Workforce Shortfalls
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3:43
‘Is The President Concerned About This?’: WH Pressed On Polls Showing Declining Support For Israel
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54:22
Senate Judiciary Committee Considers Nominations Of D. John Sauer, Harmeet Dhillon
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1:52:47
House Judiciary Committee Probes The NCAA And Antitrust Policy | FULL HEARING
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2:46:11
Mark Green Leads House Homeland Security Committee Hearing On Artificial Intelligence
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