In the book Retribution: The Battle for Japan, 1944-1945, Max Hastings described how ships’ crews took on the characteristics of their commanders. One captain was not well liked but was respected because “he had a mind like a slide rule.” Most good commanders took care of their sailors.
One characteristic of all effective commanders was that they communicated all that they knew about the strategic situation to their crews. In December 1944 the US Navy had 1100 warships and 5000 support ships. Most sailors never saw the big battles and instead spent the war shipping cargo between ports. For example, it is 5100 nautical miles from Honolulu, Hawaii to Darwin, Australia. Cargo ships took 21 days each way to make the trip. Temperatures in these all-metal ships reached 110 degrees, the odor of fuel and sweat was ubiquitous, and the noise was deafening. Men swabbed, repaired, ate, slept and repeated the process endlessly. They saw nothing but the sea, the sky, their ship, and each other. Few knew how their part, no matter how small, fit into the overall plan for victory.
How many of you feel like one of these sailors, endlessly repeating the same tasks with no idea of the impact of your labors?
Good sea captains in the Pacific in World War II told their sailors how their ship, their section, and their own work contributed to winning the war. The leaders in the Military Health System, (MHS), including the JTF Cap Med, are dedicated to telling our warriors and civilians how your work contributes to our mission.
The MHS consumes $50 billion dollars per year, 10% of the entire defense budget of the United States. In 2001 the MHS consumed $18B, 5.9% of the defense budget. These skyrocketing costs are unsustainable. The United States must find a less expensive way to provide health care, and a system for health, to its military beneficiaries and others.
The key question before Congress, the White House, and the American people is: “Is the Nation’s commitment to the Warriors and their families a military health care system or a health insurance plan for the military?” If the latter, there is little reason not to contract out beneficiary direct care services. If the former, then military medicine must better align under the Joint Strategic Capabilities Plan (JSCP) and take its military duties very seriously. The MHS’ mission under the JSCP includes provided beneficiary care, with active duty as first priority. It also includes defense against Chemical, Biological, Nuclear, Radiological, and high Explosive threats (CBRNE), whether intentional or not. Finally, the JSCP mission for the MHS includes Defense Support of Civil Authorities (DSCA), Stability Operations and Humanitarian Assistance.
Of that $50B about $32B is spent providing garrison patient care (not including salaries for active duty medical personnel, field medical care, etc.). Of that $32B, over $16B is spent on purchasing care from the private sector and the other $16B is spent for direct care in the MHS. Civilian medical providers in the national capital region and throughout the country would love to get more of the $16B spent on direct care in our area. That will happen if we have no space for our patients, or if they choose civilian care instead of choosing military care.
Many patients were forced out of the MHS by the needs of war wounded and are not coming back. Some cannot get military health care because of inefficiencies in our own system. Others leave because of inability to get appointments, poor customer service, too long a drive from home, or no parking.
We have a duty to our service members and their families. We are honor-bound to fulfill the promise of Abraham Lincoln when he said “With malice toward none, with charity for all, with firmness in the right as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation’s wounds, to care for him who shall have borne the battle and for his widow and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.”
The MHS is not fulfilling this duty, or even competing successfully for our patients. It is increasingly difficult to get care in the military system, and many recent investigations suggest that our quality is average. We do well at public health, combat casualty care, and medical evacuation. However we struggle at the basics of low cost, high access, and high quality.
What if the MHS shrinks, or even goes away?
If America loses the MHS, we lose:
- A vital combat force multiplier
Consider the history-making survival rates among wounded warriors in Iraq and Afghanistan. No civilian organization (or other military) can come close to the MHS in saving and restoring our wounded, ill and injured service members.
- A source of soft national power
When serving as vice Chief of Naval Operations (VCNO), ADM William J. “Fox” Fallon suggested that the Navy get rid of hospital ships because they cost too much money. When later serving as PACOM commander and coordinating US relief efforts after the 2004 Southeast Asia tsunami, he noted that “in the Global War on Terrorism, a hospital ship is more cost effective than a carrier task force.” Carrier task forces can rain terrible destruction, but medical care can win the hearts and minds of the people. The response to the Ebola outbreak in Western Africa has demonstrated the successful use of medicine, as well as engineering, as an element of national power.
- Education and research
Other institutions can train doctors, nurses and medics, but only the MHS can train these professionals to be leaders and warriors as well. America needs civilian trained clinicians, but it also needs outstanding medical professionals who are also excellent in military skills.
No civilian or other academic institutions can duplicate the research of the MHS. Combat injuries are often significantly different than civilian trauma, and the MHS is located in areas with high concentrations of these patients. Further, civilian facilities often do research on diseases Americans care about (such as cancer) but not on diseases that are not common at home (such as malaria, schistosomiasis, and African sleeping sickness).
- America’s ability to respond to manmade and natural disasters and national security special events (NSSE) with military-unique medical resources.
No one in the world has the deployable medical capability of the military health system. Medical warriors have responded to civil wars, terrorist attacks, earthquakes, tornados, and a host of other disasters and NSSEs with resources and expertise that no one else could. Countless lives have been saved and suffering averted by the men and women of military medicine.
What must the MHS do?
The Military Health System is already getting smaller, and that is probably a good thing. We have demonstrated that we cannot consistently provide better access, higher quality and lower price for routine medical care than our civilian colleagues. Should we choose to, we could compete better, but often we don’t choose to. Many of our patients are going to civilian health care, and that means that many of our jobs will be going to the civilian sector as well. If that is the best for our patients, our families, and our nation, so be it.
The MHS must focus on what we can do well, and maintain a good infrastructure to support the nation in the future. This should include:
- Institute a unified medical command, US Medical Command, which will align and provide command and control to the entire MHS, regardless of service affiliation. The Defense Health Agency is duplicative and would be made obsolete.
- Close organizational and planning alignment of military medicine with their parent service.
- A single major military medical center in the main metropolitan areas of Washington DC, the Tidewater area, San Antonio, Puget Sound, Hawaii, and Landstuhl.
- Moderate sized hospitals in areas of large troop concentrations, including San Diego, Fort Bragg, and Fort Bliss.
- Outpatient clinics, including primary care, behavioral health care, and public health, in all other areas when significant numbers of troops are present.
- Military medical education and research facilities including the Center and School in San Antonio, the Walter Reed Institute of Research.
To improve military medicine, we must do the following:
- Each person in military medicine must be convinced of the indispensable work of caring for warriors and their families.
- Each worker in military medicine must understand our vital role as individuals and as teams.
- Each of us must do our part to the best of our abilities and top of our competencies.
- Each of us must hold ourselves and others accountable for excellence.
- Each of us must place our primary focus on the needs of the patients, met within resource limitations.
- We must work together, escaping every snare that entangles and divides us and laying aside every weight that slows us.
Together we must move from a health care system to a system for health, including implementing certain programs such as patient centered medical homes, behavioral health, public health, and others.
From the days when Dr. Jonathan Potts cared for Washington’s patients at Valley Forge, military medicine has served our warriors and our nation. Our private sector colleagues will take care of more and more of our military patients and their families. Current leaders in the MHS must position military medicine to move into the future. It is a challenge, but no more than that faced by Dr. James Thacher at Saratoga, or Dr. Jonathan Letterman at Antietam.
America owes its warriors and their families a military health plan, but also a powerful military health system. Nothing less can provide the quality and scope of care, and of health, that America and the world needs. It must be excellent, be available to all of our beneficiaries, be an agile element of national power, and be affordable to our nation. The task falls to the professionals of military medicine to make this happen.