The Defense Department has the makings of a plan to address its issues with access to health care. It starts with recognizing that DoD has cut staffing at its own hospitals and clinics too deeply, and that the department needs to clearly understand its health care requirements so that it can “right-size” its medical offerings. But it could be a couple of years before the changes have a meaningful impact.

DoD’s capacity to care for patients in its own military treatment facilities (MTFs) has fallen significantly over the past 20 years. Out of a population of about nine million eligible TRICARE beneficiaries, only about 2.8 million are enrolled in DoD’s direct care system as of this year, according to a Federal News Network review of budget documents. That’s down from 3.2 million in 2014, and 6.1 million in 2004; the rest get their care from private providers, or what DoD calls the “purchased care” system.

“For many years, we’ve been cutting the direct health care system — that’s been the main target,” Dr. Lester Martinez-Lopez, the assistant secretary of Defense for health affairs and a former senior Army medical commander, said during an event hosted by the Association of the U.S. Army this week. “When I left the Army in 2005, most of the care we delivered was in our military treatment facilities. Now 60% of the care is in the [private] network.”

He said that shift has raised significant readiness concerns when it comes to DoD’s medical workforce.

“You need patients to keep your proficiency on the clinical side, and we’ve been moving the patients and military medical personnel out [of the direct care system],” he said. “So when people say they have access issues, it’s because our numbers are really down on the on the provider side. It’s not surprising that we’re having those issues, and what we need to do now is reevaluate how we’re going to go about right-sizing the system.”

‘Stabilizing’ the DoD health care system

The actions DoD is taking now are a response to a memo Deputy Defense Secretary Kathleen Hicks issued late last year, ordering the department to “stabilize” the military’s health care system.

DoD followed up with a directive in June, giving the director of the Defense Health Agency and military medical leaders explicit responsibilities for determining their medical personnel requirements: the numbers of staff they need at each MTF, both to maintain military medical readiness, and to adequately care for patients.

Martinez-Lopez said that sort of data has been lacking, but DoD should have a better understanding of its needs in about a year.

“Right now, we have no defined requirements for [full-service] medical care, or for force generation in the Military Health System,” he said. “So we’re in the midst of just doing the overall study to sort out how many requirements are there. We’re also doing a baseline: What do we have in hand? There will be a delta, and then in a year or so, the leadership of the department will know the risks we’re taking. And then the chairman of the Joint Chiefs of Staff and the secretary of Defense will make a decision about how to mitigate the risk.”

Some of the most recent and impactful decisions impacting DoD’s medical staffing happened in 2019. Just as the Defense Health Agency was beginning to take over management of the department’s MTFs, officials announced plans to reduce uniformed medical positions by about 12,000 and reallocate those positions to other parts of the military. Congress later imposed limits on that plan, but military medical positions nonetheless declined by about 6,000 between 2019 and 2023.

Leaders said at the time that they planned to make up at least part of the staffing reduction by hiring more civilians and contractors, but that never happened. Budget documents show the military health system’s civilian workforce also fell by nearly 12% between 2019 and 2023, though DoD’s budget for next year also showed an expected uptick in civilian staffing this year.

Martinez-Lopez said now is the time to start hiring.

More civilians and military clinicians at MTFs

“We lost a lot of civilians between COVID and not being competitive,” he said. “First, we need to cut the time to hire civilians — it’s 179 days, and that’s impossible. We need to bring it down to something that is manageable. But on top of that, we have to be competitive. We need to move into the same competitive space that the VA and the rest of the federal system is in, and the Congress gave us authority to just do that under Title 38. I at least want to be as competitive as the VA and the other federal health systems.”

But there’s no hiring surge on the immediate horizon. Martinez-Lopez said many of the changes DoD is studying right now won’t take effect until 2026. Indeed, DoD’s 2025 budget calls for almost no growth in the civilian medical workforce, although it does plan for an increase of about 1,400 military medical billets. And most of those uniformed personnel will spend most of their time providing care in MTFs.

“The primary place of duty for military health care providers is going to be the MTF from here on out, like it used to be,” he said. “If you need to be operational in Poland, or need to be in a ship in the Atlantic, so be it. But otherwise, you’re going to be taking care of our beneficiaries in the MTFs. And we get a two-fer out of that: We keep up the trust with our beneficiaries, but also we keep up our readiness by keeping our clinical skills. We’re not going to try to do this at all the MTFs all at once — we’re going to start with critical MTFs first, to re-attract patients. As we succeed into that, we’ll keep expanding. It’s a huge elephant, so we have to do it one bite at a time.”

But even before the requirements analysis is finished, DoD knows it won’t be able to hire enough staff to meet all of its needs — at least the way care is being delivered today. The hope is to bridge at least part of that gap with technology.

“Patients don’t call us because they want to make an appointment. They call because they have a problem that they want fixed, and we want to provide the fix,” he said. “How do we provide the fix? Most patients don’t care. So we can provide care through technology, we can provide it through face-to-face, we can provide it through telemedicine. We’re going to give the patient the option, and make it attractive so they can come back, and we will all be in a better place.”

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