The Military Health System (MHS) is a unique organization with broad responsibility. On one hand, it plays a critical role in the care of injured U.S. service members. On the other hand, it has also been tasked with providing healthcare services to nearly 10 million military personnel and their families
Any organization of this scale will struggle with inefficiency and redundancy. For decades, I have heard some question whether we need an MHS at all. I believe the solid answer is yes due to the system’s unique mission.
However, in this time of government restructuring and downsizing, there lies an opportunity. As the new administration looks to cut waste and unneeded programs from the federal government, now is the time to right-size the MHS and refocus it on its unique mission — providing deployed medical care.
Current landscape of U.S. military healthcare
First, some background: Concurrently with casualty care, the MHS serves all the medical needs of 9.5 million beneficiaries around the world. This includes active duty service members, their families and military retirees. The system’s FY24 budget of $58.7 billion represents 7% of the total Department of Defense (DoD) budget of $842 billion.
Arguably the most unique and important function of the MHS is to care for combat injuries and other unique wartime disease. For that reason, one would believe that most of the system’s spending would be dedicated to this mission. However, the fact is that the majority of the MHS budget goes toward (a) operating the military hospitals known as Medical Treatment Facilities (MTFs) to care for beneficiaries and (b) paying for purchased care in locations without an MTF.
While most MTFs are dedicated to beneficiary care, a number of larger MTFs — such as Walter Reed National Military Medical Center — also serve as casualty receiving hospitals for service members who are critically ill or injured while deployed. In fact, a handful of major MTFs have cared for over 50,000 wounded service members since 2001. This “final mile” of trauma care is a key aspect of the MHS mission, and it includes the acute critical care phase through surgical reconstruction, rehabilitation and restoration of function.
The combat care mission of the MHS is embodied in the Joint Trauma System (JTS), which provides clinical leadership and oversight to the trauma care provided to injured service members. This care extends from initial battlefield treatment, to forward deployed surgical teams, to care during evacuation, and finally to ongoing critical care and rehabilitation at major MTFs.
Although the JTS does not own or command military medics and medical units, it ensures the clinical knowledge and skills readiness of medical personnel, provides best practice guidelines for all roles of care in deployed combat medicine, and advises commanders at all levels regarding the synchronization of operational and clinical decision making.
The JTS was initially established in 2003 at a time when the number of casualties in Iraq and Afghanistan were ramping up and there was a realization that the MHS needed to step up to meet these demands. Since then, the JTS continues to be a critical component of the unique MHS mission and has matured into a permanent organization to continuously stand ready to ensure the best care for our military service members who bravely fight for our freedom around the world.
Why the current plan is not working
We are currently in a relatively quiescent interwar period, but future conflicts with peer opponents such as China, Russia, North Korea, and Iran present the risk of higher numbers of combat casualties for protracted periods of time.
What can the MHS do in between conflicts to sustain the trauma capabilities of the MTFs as well as the skills of medical personnel who must be immediately ready to go?
The usual answer is to leverage the system’s “beneficiary care” mission to maintain trauma readiness. Unfortunately, there are several issues with this idea.
First, the active duty beneficiaries and their families who use MTFs are a generally healthy population. As such, they can provide military medical personnel with nearly no experience in delivering complex medical and surgical care. In fact, the military has allowed a large portion of its older beneficiaries (who often do require complex care) to receive their care through Tricare contracts, meaning purchased civilian healthcare. Still other retirees and veterans receive care through the Department of Veterans Affairs. The end result is the common situation where active duty medical personnel (including physicians and nurses) are assigned to work in MTFs that have very few patients.
Second, most major MTFs do not have a civilian trauma care mission to bolster their trauma readiness. (The one exception is Brooke Army Medical Center in San Antonio, which is the military’s only Level I trauma center.) In some locations, the military MTF is perceived as unneeded by the surrounding community because a sufficient number of civilian trauma centers exist. In other locations, state governments have simply refused to allow local MTFs to be included in the civilian trauma care system. It is true that some jurisdictions have allowed MTFs to participate in the civilian trauma system as extra capacity during extreme circumstances (such as disasters), but this is not enough to sustain these MTFs with a steady flow of patients. In a handful of cases, states have allowed MTFs to send personnel to local civilian trauma centers. While this is helpful for sustaining the skills of the individuals involved, it does little to help non-participating medical personnel or sustain the MTF trauma program itself.
Third, the nationwide shortage of both physicians and nurses means that there are not enough graduating providers to fill the needs of civilian hospitals much less the U.S. military. The Uniformed Services University (USU) School of Medicine and Nursing in Bethesda, Maryland, educates a critical mass of career military medical officers who fill the majority of medical operational positions such as command surgeons. The major MTFs provide the training sites for these future military medical personnel; but, as noted above, many do not have the patient volumes to succeed in this mission. Similarly, the civilian sector cannot support training slots for the numbers and types of specialties required by the DoD to provide battlefield trauma and medical care.
How to refocus and strengthen the MHS
Given the challenges facing military healthcare, I propose that the time is now for the MHS to right-size and refocus on its core mission. To get this right, we must create a coherent strategy based on the unique aspects and critical responsibilities of the MHS.
1. Refocus on the core military mission
The first priority should be to refocus the MHS budget and operations on combat casualty care and deployed medical care. The MHS should be transformed into a functional medical command whose only mission is providing optimal care for deployed military service members around the globe.
This functional command will focus on deployed medicine, including combat casualty care from the point of injury to transport and initial life-saving stabilization. It will serve to sustain and augment the two decades of knowledge and experience developed by the JTS.
2. Invest in core MTFs, divest from the rest
The status quo of taxpayer-funded MTFs that are bereft of patients has not worked for decades. However, we cannot close all the MTFs to cut costs because the MHS would then lose the ability to complete its most critical mission. The solution is to maintain and invest heavily in a core group of major MTFs that support the unique military mission of the MHS and divest from the rest.
We can begin by strategically identifying 6 to 10 major MTFs in the continental U.S. and 4 to 6 others in key locations around the globe. We should then reduce or eliminate purchased civilian care for beneficiaries except for locations not in reasonable proximity to a core MTF. This change will fill the core MTFs with beneficiary patients, which will enhance training for military providers and help maintain MTF capabilities for future conflicts.
3. Reduce redundancy between MTFs and VA hospitals
The third priority is to reduce the redundancy between the Veteran’s Administration (VA) health system and the DoD MHS. In locations where both federal departments operate a hospital, the VA hospital can be combined with the military MTF or eliminated. This will reduce redundancy and costs while still abiding by our promise to care for retirees and veterans who have served valiantly. It will also provide more complex patients to help maintain the skills and the capabilities of the core MTFs.
4. Invest in the military medicine training pipeline
Concurrently, we need to invest in the education and training of medical personnel for the unique military medical mission. USU should be leveraged as the centerpiece of this system, since it has a proven record of educating military medical students who often serve out a 20-year career and who also tend to fill many of the military’s command surgeon positions. The core MTFs can provide essential training during a time when the country is suffering from a shortage of physicians and nurses.
As we all know, it takes years to educate and train military medical personnel, so building this pipeline is not something we can decide at the last minute when a conflict develops. Acting on this now is the only way to ensure we have a continuously flowing pipeline of medical personnel ready for the next conflict.
5. Embrace military-civilian partnerships
Lastly, DoD and civilian healthcare leaders should embrace military-civilian partnerships as a national responsibility and priority. A handful of civilian trauma centers should maintain military hospital staff and beds within their walls. This arrangement will provide personnel and resources to care for injured and ill civilians during normal times, and it can also provide rapid capacity for responding in times of disaster.
The “Mission Zero Act” already describes this arrangement, but the legislation needs to be fully funded and probably further enhanced. We should have 6 to 10 large civilian medical centers committed to hosting active duty and reserve military personnel as their usual place of work for casualty receiving bed capacity and military medical personnel skills maintenance.
Big change needed
Those of us who have served a medical career in the U.S. military implicitly understand what needs to be done to correct the course of the MHS.
Attempts at making incremental changes to the MHS have failed for decades. That’s the status quo. Without big change — and now seems to be the right time for suggesting big change — the MHS will not be ready for future conflicts.
If the new administration decides to address waste reduction in the DoD, it needs to start by assembling a team of military medical subject matter experts who have not been part of maintaining the status quo.
The MHS must remain intact to prevent loss of life and provide rehabilitation and recovery for those injured protecting our freedom, but refocusing the system on its core military mission is critical to ensuring that we are ready for future conflicts
Kyle N. Remick, MD FACS, Colonel, U.S. Army (Ret.) is chief of the Division of Trauma and Acute Care Surgery at Meritus Medical Center, a Level III trauma center in Hagerstown, Maryland. He is also Adjunct Professor of Surgery at the Uniformed Services University School of Medicine in Bethesda, Maryland.