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Each of the military services has been moving to reduce their number of uniformed health care clinicians. But Congress isn’t thrilled with the idea, and it’s thrown up a roadblock in the final agreement on this year’s Defense authorization bill.

The overall bill is still awaiting a Senate vote before it moves to the president’s desk. But one of its provisions would at least temporarily bar DoD from following through with the reductions it proposed in its fiscal year 2020 budget. So far, the services have identified nearly 18,000 medical billets they want to reallocate to warfighting functions and replace with civilian medical providers.

With some exceptions, the 2020 National Defense Authorization Act would prohibit those moves until the secretaries of all three military departments conducts a full analysis of the medical manpower they’d need under all of the scenarios laid out in the National Defense Strategy, and the Secretary of Defense sends Congress a full report.

Rep. Trent Kelly (R-Miss.), the ranking member on the House Armed Services military personnel subcommittee, said there is a bipartisan sense that DoD is making major personnel decisions without enough data.

“That’s a lot of billets that are going away, and you talk about near peer and future threats, let me tell you: civilians don’t go downrange,” he said at a hearing last week. “It takes guys and girls in uniform to get our soldiers to the right level of care in that magic hour. And if they’re not there, we have soldiers, sailors, airmen and Marines that die. So we need to make sure that scrutinize each and every one of these medical professionals.”

The bill does allow the services to reduce some of their military medical manpower through attrition — but only for billets that have been left unfilled since October 2018, and only if the department can certify that doing away with a particular position won’t affect the care service members and other DoD beneficiaries receive.

DoD had planned to begin eliminating the billets this fiscal year, starting with unfilled positions. Each service has already identified thousands of uniformed jobs that it believes go above and beyond what it needs to meet wartime medical demands.

“Every year we go through a process to identify what our operational medical requirement is, and that process is called the critical operational readiness requirement,” said Lt. Gen. Dorothy Hogg, the Air Force surgeon general. “That process identifies what I need in uniform to do my operational mission. And last year’s review indicated that I had a little over 4,000 medics that were over my uniformed requirement.”

But the picture is complicated by another major change happening in the military health system right now: the transition of military treatment facilities from the control of the military services to the Defense Health Agency. DHA began officially administering about half of the MTFs as of Oct. 1 of this year, and military health officials acknowledge they still haven’t completed an analysis of the medical manpower they will need to support DHA’s “multi-service” markets.

Rep. Jackie Speier (D-Calif.), the chairwoman of the personnel subcommittee, said it’s “baffling” that the military would start shedding military medical manpower before that report is finished and Congress has had a chance to weigh in.

“DoD seems intent on gutting our military health system and calling it an efficiency,” she said. “The system is costing less and has saved billions of dollars, but there remains urgent coverage needs that should be addressed by reinvesting any savings in the military healthcare system, not continuing to squeeze every last penny out of the system in order to fund other priorities.”

Thomas McCaffery, the assistant secretary of Defense for health affairs, said the military health system is conducting an efficiency review as part of the Defense-wide review Secretary Mark Esper ordered this fall, but that effort is separate from the military medical manpower reduction DoD proposed in its budget.

In the case of the medical billet reallocation, the department says it expects that the medical work being done by the uniformed workforce would be largely replaced by a combination of government civilian medical employees and private-sector providers under the TRICARE system.

But McCaffery said full implementation of those changes is a multi-year effort, and would need to be incorporated into the next round of TRICARE contracts.

“[The contracts are] critical to support the change in the system,” he said “If we’re going to be consolidating all of our MTFs under the same roof that manages the TRICARE program, we need to make sure we are requiring more from our contractors, both to make sure we get the readiness-related caseload we need in our system to keep our own providers current, and to make sure that we have the adequate networks to support our families and our beneficiaries. When we realign services in certain areas in terms of what MTFs are providing, we need to make sure that we have that partnership with those contractors to make sure that that capability doesn’t go away. You may not get something from a uniformed provider, but we still have to make sure you get it from a provider. So I think those are some key things that we are looking at as to what we need to do to support the reform going forward.”

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