The United States is at increasing risk of mass casualty incidents arising from natural disasters, homeland security threats, and large-scale combat operations, raising significant concern regarding the potential for rapid and overwhelming strain on our existing hospital infrastructures.
But in spite of the significance of this problem, our nation as a whole is actively ignoring one potential solution — fully integrating military treatment facilities into civilian trauma systems.
With very few exceptions, military treatment facilities are excluded from regional trauma systems in the U.S. This exclusion is not merely a missed opportunity — it is a strategic failure with implications for both national defense and public health.
The National Capital Region (NCR) surrounding Washington, D.C., serves as a high-value, high-risk example. Despite the region’s dense concentration of medical resources, hospitals in Maryland, D.C., and Virginia are often functioning at or above capacity, with long ED wait times, minimal bed availability, and little to no surge capabilities. Yet at the same time, Walter Reed National Military Medical Center, a Department of Defense (DoD) medical treatment facility in Bethesda, Maryland, is effectively blocked from treating civilian trauma patients in the region.
Walter Reed is designated as the primary receiving destination for casualties returning from the European, Central, and African theaters during times of war. It also serves as the hospital for the president and other top federal leaders. The facility’s strategic location near Washington and its role as a hub for military medicine make it uniquely positioned to support both military and civilian trauma and emergency/acute care needs.
Despite this, Walter Reed remains an underutilized asset in the region. But given its capability and capacity, Walter Reed could play a central role in the NCR if it were integrated into the regional trauma and emergency preparedness system.
How integration would support public health
Walter Reed’s geographic proximity to key population centers enhances its potential to serve as a vital component in both military and civilian trauma networks.
Geographic information system (GIS) analyses have provided compelling evidence of Walter Reed’s potential public health impact. A recent GIS study found that including Walter Reed as a designated trauma center would substantially improve timely trauma access for thousands of residents, especially within underserved areas of Montgomery and Prince George’s Counties. Specifically, the study demonstrated population coverage increases of 10.5% within the critical 0-5-minute catchment area and up to 12.3% within the 5-10-minute range, timeframes strongly associated with survival in trauma.
Critically, the data reveal that Walter Reed would directly benefit low-income and historically marginalized communities, including Black and Hispanic populations and those living below the poverty line. These groups currently face disproportionate health disparities, and Walter Reed’s integration would help address this systemic inequity. Given that ED wait times in D.C. are the highest in the nation, Walter Reed would provide essential redundancy and resilience in the regional healthcare network.
In addition, recent federal investments to repair and modernize Walter Reed’s facilities further enhance its infrastructure and operational capacity, positioning it to meet the demands of a modern, integrated trauma and emergency care system.
Beyond trauma-specific capabilities, Walter Reed can enhance regional care for other critical emergencies. As a fully staffed tertiary referral center, it houses general, trauma, orthopedic, vascular, neurosurgical, and critical care surgeons, alongside medical/surgical subspecialists capable of managing emergencies and other acute care needs, such as emergency general surgery, acute strokes, and myocardial infarctions.
Including Walter Reed in the regional trauma system would also strengthen the region’s ability to respond to mass casualties. First, the facility is capable of rapidly receiving and treating patients during surges, including mass casualty events and instances when civilian hospitals are on diversion. Second, Walter Reed could provide invaluable leadership in coordinating a mass casualty response.
The absence of a Regional Medical Operations Coordination Center (RMOCC) spanning Maryland, D.C., and Virginia limits the ability to manage large-scale trauma responses across multiple jurisdictions. RMOCCs serve as local or regional hubs that coordinate emergency management, public health, and acute medical care systems to optimize the distribution of resources and patients during crises. Functioning as the “air traffic control” of health and medical response, RMOCCs ensure inclusive coordination among all healthcare partners in affected areas.
In addition, given its capabilities and strategic location — and its extensive experience in patient movement — Walter Reed is uniquely positioned to have a leading role in implementing the National Disaster Medical System (NDMS), a federal system designed to support patient movement and definitive care during large-scale emergencies, and the forthcoming National Trauma and Emergency Preparedness System (NTEPS), which aims to build a unified, coordinated trauma response infrastructure across the nation.
Finally, the exclusion of Walter Reed from the NCR trauma system reflects a more significant national dilemma — the United States currently lacks a fully integrated trauma system. The DoD’s Joint Trauma System (JTS), developed after years of conflict in Iraq and Afghanistan, has proven to be a remarkable model of trauma care excellence, reducing mortality through data-driven performance improvement, clinical practice guidelines, and trauma registry analysis. The JTS is the only system-wide model to consistently deliver high-quality trauma care across all echelons — from the point of injury in combat zones, through transcontinental flights, to definitive care in the United States.
However, this system remains isolated within the military. The 2016 report by the National Academies of Sciences, Engineering, and Medicine, A National Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero Preventable Deaths After Injury, emphasized the urgent need for an integrated national trauma system that includes both military and civilian facilities. The report identified a lack of coordination, fragmentation, and inadequate data sharing between systems as key barriers to improving trauma outcomes. The authors called for a unified effort to ensure “the right patient gets to the right place at the right time,” aiming for the bold goal of zero preventable deaths from trauma within the United States.
Integrating military hospitals (like Walter Reed) into civilian trauma systems is an essential step toward realizing the goal of zero preventable deaths.
How integration would support national defense
Beyond the benefits to civilian patient care, the integration of Walter Reed into the regional trauma system would also support education and long-term readiness for military healthcare providers.
Walter Reed is the academic flagship of the Military Health System and the primary teaching hospital for the Uniformed Services University. It offers a unique curriculum rooted in trauma, operational medicine, and combat readiness. However, due to current regulatory restrictions, care teams at Walter Reed have limited access to civilian trauma cases. This hinders trainees, residents, fellows, nurses, and allied health personnel from maintaining trauma-specific skills.
Expanding Walter Reed’s role in the regional trauma system would offer invaluable real-world trauma exposure to military medical teams, enhancing clinical training for physicians, surgeons, nurses, surgical technologists, perfusionists, and respiratory therapists. Team-based trauma training is essential for military medical readiness and cannot be replicated through external partnerships or “just-in-time” training models that focus only on sending individual providers elsewhere. While partnerships offer value for select personnel, they leave behind the broader team that must function together under combat conditions.
With the drawdown of combat operations following the Global War on Terror (GWOT), Walter Reed and other military treatment facilities (MTFs) have faced increasing difficulty maintaining the volume and complexity of trauma and complex surgical cases necessary to maintain readiness. This challenge has been exacerbated by the “peacetime effect” — a well-documented phenomenon where the cessation of wartime operations leads to a degradation of clinical combat medical skills. The problem is further compounded by a systemic shift of military beneficiaries to the civilian sector for medical care and Walter Reed’s absence from the regional civilian trauma network, effectively sidelining a high-capability facility from providing trauma care to the broader community.
The inclusion of military hospitals in civilian trauma systems has been mandated as a national priority, dating back to the 2017 National Defense Authorization Act (NDAA), which provided the Secretary of Defense with the resources necessary to facilitate military-civilian integration. While the NDAA has consistently supported the broader goal of military-civilian trauma integration at the policy level, this support has not translated into direct, dedicated funding for trauma operations at the MTF level. Military treatment facilities are instead expected to sustain trauma programs through billable patient care, treating trauma as a revenue-generating service line rather than a funded readiness mission. This disconnect between national strategic priorities and local operational realities creates significant challenges for maintaining trauma capabilities essential to the readiness of the Military Health System.
Ultimately, as combat casualty care continues to evolve, as demonstrated most recently in the conflict in Ukraine, the continued absence of Walter Reed from the regional trauma system not only limits civilian access to trauma care but also further erodes military medical readiness, jeopardizing mass casualty preparedness and national security.
Preparing for the next conflict, particularly against a peer adversary, will demand rapid, large-scale trauma care for complex injuries such as burns, blast wounds, inhalation injuries, and immersion injuries, patterns far different from those seen in recent counterinsurgency conflicts. Integrating Walter Reed into the civilian trauma system now is essential to sustain clinical proficiency, reduce ramp-up time at the outbreak of future hostilities, and ultimately prevent avoidable battlefield deaths.
We know it can work
Full trauma system integration at Walter Reed would not only address readiness gaps identified in the NDAA and the NASEM report but also create a stronger, more equitable, and resilient trauma network across the region. We know that the coordination of military and civilian trauma systems is possible because it has already proven successful elsewhere outside the NCR within the United States.
A prime example is the integration of Brooke Army Medical Center (BAMC), the only Level I trauma center in the DoD, into the Southwest Texas regional trauma system, which has allowed military trauma teams to remain actively engaged in high-acuity cases while providing a direct benefit to the local population. BAMC supports a 22-county area and treats thousands of trauma patients annually, about 85% of whom are civilians.
Another example is the integration of Madigan Army Medical Center in Tacoma, Washington, with the Tacoma Trauma Trust and the sharing of trauma care duties between Tacoma General Hospital and St. Joseph Medical Center.
Ultimately, studies have shown that these partnerships improve patient outcomes and enhance the overall efficiency of the local regional trauma systems. So, what stands in the way of more military-civilian trauma partnerships and greater military-civilian system integration? The obstacles are many.
For over a decade, Walter Reed has not been designated as a trauma center within the Maryland trauma system, which is governed by the Maryland Institute for Emergency Medical Services Systems (MIEMSS). In 2017, Walter Reed formally inquired with MIEMSS about the potential for designation as a trauma center within Maryland. MIEMSS responded by citing provisions from the Code of Maryland Regulations that require any hospital applicant not previously designated as a trauma center to demonstrate the ability to generate sufficient patient volume without adversely impacting existing designated trauma centers. Additionally, the state’s regulations mandate the consideration of related factors, such as minimizing duplication of services in close geographic proximity. MIEMSS expressed concern that establishing a new trauma center at Walter Reed, located near existing trauma centers, could negatively affect the ability of those centers to maintain the patient volumes necessary to retain their designation status.
Despite these concerns, Walter Reed’s exclusion from the regional trauma system is not merely a regulatory issue. It is deeply tied to entrenched interests and competitive dynamics within the local healthcare market. Trauma center designation brings not only prestige but also significant financial benefits tied to federal grants and patient volume, making inclusion a highly contested issue. Local hospitals in the region have resisted the integration of Walter Reed into the trauma system, citing concerns about the potential loss of patient volume and associated revenue. While all of these facilities exceed the state’s minimum requirement of 400 trauma admissions annually for Level II designation, competitive pressures continue to pose a barrier to broader regional coordination. This dynamic underscores how institutional self-interest can, at times, hinder efforts to optimize trauma system performance and preparedness.
Moreover, the bureaucratic disconnect between federal and state authorities further complicates the situation. While the 2017 NDAA mandates that military treatment facilities integrate with civilian trauma systems to maintain medical readiness, MIEMSS has emphasized that trauma care regulation is a state-level responsibility. This conflict creates a paradox in which Walter Reed is federally obligated to maintain trauma capability but barred from participating in the very system that ensures the volume and acuity of trauma cases required to sustain that capability.
Not all of the efforts have been unsuccessful. In parallel with its Maryland outreach, Walter Reed has also begun discussions with officials from the District of Columbia regarding the potential for emergency medical services to transport civilian trauma patients to Walter Reed. These early conversations, while slow, have been positive and represent a promising step toward broader regional cooperation.
At the same time, recent changes to Maryland’s trauma payment system, particularly the expansion of the Maryland Trauma Physician Services Fund, provide new funding stability and reimbursement methods that could support broader inclusion efforts.
Local trauma centers continue to experience high divert hours, especially during surge periods and the summer months, highlighting the need for system-level flexibility. Walter Reed stands ready to serve as a regional “pop-off valve,” easing overflow during peak demand while simultaneously advancing military trauma readiness. In this context, all stakeholders may soon find it both financially viable and strategically prudent to re-examine Walter Reed’s formal integration into the regional trauma system.
Ultimately, however, concerns about patient volume, reimbursement, and jurisdictional control continue to limit meaningful progress toward full military-civilian integration.
A call to action
The continued exclusion of military hospitals like Walter Reed from civilian trauma systems is a threat to both public health and national security. Given the importance of maintaining a ready and responsive trauma network, there is a strong argument that all stakeholders should be aligned in supporting military-civilian integration. Moving forward, several key actions are required:
1. Mandate state compliance with military trauma readiness requirements: States must be required to accommodate military treatment facilities like Walter Reed into the civilian trauma system, based on the NDAA. The location and number of surrounding hospitals should not be the reason for exclusion, as demonstrated in the National Capital Region.
2. Establish RMOCCs in areas with military treatment facilities: Regional trauma coordination centers modeled on BAMC’s Southwest Texas Regional Advisory Council (STRAC) should be developed in areas with MTFs. In the NCR, Walter Reed can function as the military lead within the RMOCC. This command center would integrate military and civilian trauma assets across Maryland, D.C., and Virginia and coordinate responses during disasters, mass casualty events, large-scale military conflicts, or system surges.
3. Formalize civilian access pathways: Legal and procedural frameworks should be developed in advance to allow for the treatment of civilian patients for trauma and other emergent cases at MTFs like Walter Reed, under both emergency and routine conditions. This includes coordination with EMS and state licensing bodies.
4. Incorporate VA and NDMS facilities into definitive care planning: Veterans Affairs hospitals and hospitals that participate in the National Disaster Medical System should be included in military definitive care networks to expand the national capacity for trauma, large-scale military conflict, and disaster response. Additionally, VA beneficiaries should have streamlined access to care at DoD MTFs, particularly in regions where military medical capabilities exceed local VA resources, such as the NCR.
A national vulnerability
The continued exclusion of military treatment facilities from civilian trauma systems is not an isolated issue — it is a national vulnerability. Facilities like Walter Reed and other military treatment facilities across the country represent critical, high-capability assets that remain underutilized in daily trauma care, emergency preparedness, and disaster response. To meet the growing threats posed by mass casualty incidents, regional instability, and large-scale combat operations, the United States must fully integrate MTFs into the national trauma framework.
This is not merely a matter of efficiency or clinical optimization but of strategic necessity. As the National Academies have emphasized, achieving zero preventable deaths from trauma requires a unified, interoperable system that draws on the strengths of both military and civilian institutions.
Integrating MTFs into civilian trauma networks will enhance medical readiness, expand surge capacity, and reinforce national resilience in the face of future crises. The time to act is now.