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system. In my opinion, with a few unhappy notable exceptions which we have all read about, the doctors and nurses, the corpsmen, the other support staff, have done and continue to do herculean tasks under the most difficult of circumstances.

Now, the problem has not been, was not and is not the people in the system. The problem has been and I believe remains the system itself. The system simply was not designed to perform the tasks which, as a result of existing laws and the rapid increase in beneficiaries, it has been required to perform.

Now, I am hopeful that we are on the road toward overcoming the system's problems. After 3 years of congressional debate, the Department has been able to sign a contract to demonstrate the CHAMPUS reform initiative. After 4 years of congressional debate, the Department has been able to sign a development contract for a long needed comprehensive data management system.

The services are now searching for innovative means to provide the services that are required, to provide care to beneficiaries which simply could not be provided using the old and outmoded approach to military medical care.

But there remains much to be done. I am a strong supporter of greater use of private sector resources through the CHAMPUS reform initiative, but that by no means means—and I want it clearly understood that it does not mean-that that allows us in some way to neglect or to dismember our uniform health care services.

I am afraid that, because of the turmoil resulting from the reevaluation of the entire system and because of the declining defense resources over the recent years, our existing uniformed medical infrastructure has been unintentionally allowed to decline.

Now, while we probably could provide for many of our peacetime health care needs relying only on the private sector, if we were to do so it would be a terrible mistake because we could not have our military medical system ready to go to war by relying exclusively upon the private sector. In order to be prepared in the event of war, we must have a military medical program with a balance between its Active component, its Reserve component, and its private sector component.

We are on the way to properly involving the private sector and now I think we need to turn our attention back to rebuilding the uniformed part of the system. We must work to ensure that we have sufficient numbers of personnel on active duty with the appropriate mix of skills so that our military medical facilities can be used to the optimum.

This means we need enough doctors to use efficiently the operating rooms and surgical equipment in our inventory. We must have enough nurses, enough anesthesiologists, and enough technicians to support those doctors. And additionally, we must ensure that we have adequate numbers of qualified providers so our military hospitals can continue to remain fully accredited by the Joint Commission on Accreditation.

Mr. Chairman, there are problems with our treatment facilities. Some of the facilities are inadequate. Some of them are not staffed. Some of our most qualified physicians and support staff appear to be quitting in frustration over these problems.

And we just cannot allow that to happen. We cannot allow some of the best and the brightest to leave the services. There is a minimum level of facilities and staffing which must always remain in the Active forces in order for us to be ready for emergencies.

I am not sure where that level is. That is part of our inquiry today. I fear, though, that we had better determine it quickly and act so that we do not reach it, because it appears from statements of the kind that you just alluded to that we are rapidly approaching that level.

Mr. Chairman, I know not only by your statement today, but by all the hard work in the past, that you are concerned, that you feel, as you have indicated, that this is a critical problem, to use the phrase you used, a potential war-stopper.

And as we have worked closely for a number of years on these issues, I am grateful to you today for continuing this work. We have got to continue to work together, with Dr. Mayer, and with the distinguished surgeon generals to make certain that we are able to meet that challenge and assure ourselves that the entire medical military system is in sufficient health so that it can discharge the responsibilities that it has, and it is one hell of a challenge.

So I thank you and I thank them, and I apologize for taking that much time. But I share your feelings.

Senator GLENN. Thank you very much, Senator Wilson. That was a good statement.

We will have a vote at 2:30, I am told, a rollcall cloture vote. So we will have to take a break at that time. But we will proceed until the vote goes off.

The committee welcomes our witnesses today. At the table we have: Dr. William Mayer, Assistant Secretary of Defense for Health Affairs; Lt. Gen. Quinn Becker, Surgeon General of the Army; Vice Adm. James A. Zimble, Surgeon General of the Navy; Lt. Gen. Murphy Chesney, Surgeon General of the Air Force.

Admiral Zimble, this is your first appearance before our subcommittee as Surgeon General of the Navy, and we welcome you. We know of your previous accomplishments, especially your report on medical shortfalls and the problems in Europe following the bombing of the Marine Corps barracks in Lebanon. And so we look forward to working with you.

Gentlemen, I understand you have all agreed that your full statements will be included in the record, and without objection they will be entered into the record in full, and I would welcome any opening remarks you may have before we get into questions.

Dr. Mayer, would you lead off.

STATEMENT OF DR. WILLIAM MAYER, ASSISTANT SECRETARY OF DEFENSE (HEALTH AFFAIRS), DEPARTMENT OF DEFENSE Dr. MAYER. Thank you, Mr. Chairman, Senator Wilson.

I was particularly interested in both of your opening statements because they are right on the button. It is a great temptation for me to emphasize the positive things that you mentioned, Senator Wilson. It is true we have started a major change in the CHAMPUS program. We have started a worldwide computer system that should carry us well into the next century.

You are absolutely right when you say that the problem is not with the individual people. Actually, we have never had such a superb collection of personnel among our physicians and nurses, dentists and corpsmen.

The truth is that we are faced with a system that was designed before there were profound demographic changes in the quality of the Armed Forces. The system really has evolved over time from a period in history when the bulk of the Armed Forces was young, unmarried, male.

Today we have very large numbers of married older persons among our enlisted people, we have much larger numbers and we are much more reliant upon our female members than in the past. And the system simply was not designed to accommodate the needs of this changing patient population. It is an anachronism and it cannot be changed overnight.

But I believe that the changes that are needed are well under way. There are some dangers right now that are more serious than anything we have faced in the past. It is true that we have made tremendous progress in acquiring deployable medical systems overseas.

From essentially zero base 4 years ago, we now have in hand or on order, about 60 percent, or a little better, of all the deployable medical equipment that the services feel they would need, at least in the early phases of a general war. That is an incredible achievement, considering that the gear had to be standardized, agreed upon among all the services, and the procurement of that kind of equipment in sets takes 2 to 3 years.

So up at 60 percent is an extremely worthwhile achievement.

Senator GLENN. It is, Dr. Mayer, but let me interrupt. That means we are 40 percent short if we start combat.

Dr. MAYER. Absolutely. And our goal is to achieve 100 percent by 1994. I think we will be over 90 percent by 1992. Considering that goal was set 4 years ago, that is remarkable.

Of course, we dare not have war before then.

We have started a number of very aggressive initiatives to correct the disastrous shortfalls, in the Reserve components, in particular, upon which we rely for 70 percent of our medical strength. They have yet to bear significant fruit, but I believe that they show real indications of doing so.

Again, whether they will meet our original target of being somewhere in the 90-percent range of required people by 1992, I cannot pretend to know, I rather doubt it.

The dangers that we face right now are in the legally mandated officer personnel cuts. We are an officer-rich part of the service and totally dependent upon our commissioned officers. The disasters that will arise if we have the 1 percent, 2 percent, 2-percent cuts in the officer corps will put this anachronistic system even further behind in its ability to meet the demands of the new kind of Armed Forces.

A second danger has always existed, and that has to do with ceilings. The actual determinations of what portion of the legally allowed strength of the Armed Forces could be in the medical serv

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ices, as far as I can tell, were not taken as a result of careful studies and careful conscious processes.

They have kind of evolved. Now, in all fairness and loyalty to the military departments, overall strength of the medical departments has increased over three times as fast as the increase in the total strength. That is, we have increased the medical services personnel by about 12 percent since 1981.

Furthermore, the medical services have enjoyed a slightly greater growth in funding than the rest of the Department of Defense. And I think all of this signifies again what Senator Wilson said: There is a consciousness now on the part of the war-fighters or on the part of the leaders in the Pentagon that the medical support of their fighting forces is an absolutely critical part of the deterrent and of the credibility of the deterrent.

What nobody has yet come to grips with is that the technology changes in medicine, the increasing demand for care, legitimate care, have way outstripped even those substantial increases.

So we are determined-and I can speak without any fear of contradiction—the four of us at this table are determined to continue to improve the peacetime health care system, but, at the same time, not to falter in any step toward trying to achieve an acceptable level of medical readiness.

That is all I wanted to say to begin, sirs, I would be very happy after the other statements to answer your questions.

[The prepared statement of Dr. Mayer follows:)

STATEMENT

OF

WILLIAM MAYER, M.D.

ASSISTANT SECRETARY OF DEFENSE (HEALTH AFFAIRS)

MR. CHAIRMAN AND MEMBERS OF THE SUBCOMMITTEE:

It is a pleasure to appear today to discuss the Military

Health Services System and our efforts, along with those of this

Subcommittee, to effect gceatly needed reforms to this massive

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fulfill our primary inission of medical readiness, our reform

efforts are directed towards obtaining an appropriate mix of

resources

including staffing, equipment, and facilities

upon

which we would rely if this country were engaged in a conflict.

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5,000 dentists, 14,000 nurses, and 104,000 enlisted personnel

a

total of close to 150,000 personnel.

Even with this sizeable

network of facilities and staff, the direct care system cannot

provide more than about seventy percent of all the medical care

needed by our beneficiaries.

Care that is not available in the

direct care system is sought by our beneficiaries in the civilian

health care sector and partially paid for by the civilian Health

and Medical Program of the Uniformed Services (CHAMPUS).

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