Advance Questions for Dr. Sue Bailey
Nominee for Assistant Secretary of Defense (Health Affairs)
Senate Armed Services Committee
March 11, 1998
More than a decade has passed since the enactment of the Goldwater-Nichols Department of Defense Reorganization Act of 1986 and the Special Operations reforms.
Question. Do you support full implementation of these defense reforms?
Answer: I support the full implementation of the defense reforms contained in the Goldwater-Nichols Department of Defense Reorganization Act of 1986 and the Special Operations reforms.
Question. What is your view of the extent to which these defense reforms have been implemented?
Answer: I believe the defense reforms have been implemented consistent with the expressed intent of Congress.
Question. What do you consider to be the most important aspects of these defense reforms?
Answer: This comprehensive legislation has resulted in several accomplishments which I consider important including strengthening civilian authority over the Department of Defense, characterizing the authority and responsibilities of the combatant commanders, developing a robust mechanism for strategy development and contingency planning, and providing the means for more cost effective utilization of defense resources. I believe all of these developments have impacted positively on the DoD and Health Affairs missions.
The goals of the Congress in enacting these defense reforms, as reflected in section 3 of the Goldwater-Nichols Department of Defense Reorganization Act, can be summarized as strengthening civilian control; improving military advice; placing clear responsibility on the combatant commanders for the accomplishment of their missions; ensuring the authority of the combatant commanders is commensurate with their responsibility; increasing attention to the formulation of strategy and to contingency planning; providing for more efficient use of defense resources; and enhancing the effectiveness of military operations and improving the management and administration of the Department of Defense.
Question. Do you agree with these goals?
Answer: I fully support the goals of the Goldwater-Nichols Department of Defense Reorganization Act and will, if I am confirmed, work diligently toward continuing their successful implementation.
Recently, there have been articles, which indicate an interest within the Department of Defense in modifying Goldwater-Nichols in light of the changing environment and possible revisions to the national strategy.
Question. Do you anticipate that legislative proposals to amend Goldwater-Nichols may be appropriate? If so, what areas do you believe it might be appropriate to address in these proposals?
Answer: I have not participated in any discussions to this effect and at this time offer no suggestions for legislative change.
Question. In carrying out your duties, what would be your relationship with:
Under Secretary for Personnel and Readiness –
Answer: If I am confirmed, I will report to the Under Secretary of Defense for Personnel and Readiness . I expect to work closely with the Under Secretary of Defense for Personnel and Readiness and the other Assistant Secretaries of the P&R organization. There are many cross cutting issues that involve a close working relationship including the Under Secretary’s role in benefit definition, force structure and force management. I expect to work closely with the Under Secretary for Personnel and Readiness to achieve the goals of force protection during deployment, to find the best strategy for keeping faith with our retirees who are over 65 and to implement an effective wellness program.
Answer: If confirmed, I will work with the Comptroller, to ensure that, consistent with the Administration’s program, the Defense Health Program is adequately funded to carry out its mission of providing quality peacetime and wartime health care to all beneficiaries. As a performance based organization, I will be expected to ensure that the systems and policies in place effectively manage this $15.6 billion program.
Under Secretary for Acquisition and Technology
Answer: As the Department moves to the next generation of managed care support contracts that are currently under development, it is critical that we have the acquisition reform principles advocated by Vice President Gore’s Reinventing Government activities. These goals include an open solicitation process; performance based requirements, continued uniformity of health care benefits, and the use of best commercial practices. If confirmed, I anticipate working closely with the Under Secretary for Acquisition and Technology as we move forward in these arenas. In addition, it is imperative that I maintain a close working relationship with Defense Research and Engineering on all research related to Persian Gulf Illnesses, combat casualty care, and infectious diseases. I also expect to work closely with that office on the breast cancer research initiatives.
Under Secretary for Policy:
Answer: World-wide deployment commitments have created responsibilities and opportunities for world-wide medical support and cooperative relationships with our allies. Environmental assessments, force surveillance, and force health protection are areas of keen interest and initiative throughout the Department. I plan to work closely with the Under Secretary for Policy on all matters in which medical issues are a part of national security policy.
The Assistant Secretaries of Defense;
Answer: If confirmed, I expect to develop and maintain a close working relationship with all of the Assistant Secretaries. Within the Personnel and Readiness community it is essential that I work in close coordination with the Assistant Secretaries for Force Management Policy and Reserve Affairs on a host of cross-cutting issues such as: quality of life; readiness, physical standards for accession; family policy issues, reserve dental program, and health promotion, among many others.
The DoD General Counsel;
Answer: If confirmed, I plan to actively involve the General Counsel and seek advice on significant policy and program implementation issues. The Associate Deputy General Counsel (Health Affairs) will attend my regular staff meetings to provide me counsel at the working level. All significant policy issues will be coordinated closely with the General Counsel through the Deputy General Counsel for Personnel and Health Policy.
The Assistant Secretaries for Manpower and Personnel in the Military Departments;
Answer. If confirmed, I expect to have an increased interaction with the Assistant Secretaries for Manpower & Reserve Affairs in the Military Departments. While historically the ASD(HA) has had a close working relationship with the Surgeons General, I believe it is imperative to bring the Assistant Secretaries into both strategic planning and policy development discussions.
The Surgeons General;
Answer. If confirmed, I expect to continue the close professional working relationship I developed with the Surgeons General and their senior staffs when I served as Deputy Assistant Secretary. I will hold regular bi-monthly meetings with the Surgeons General and will keep them intimately involved in policy and execution issues.
The Joint Chiefs of Staff;
Answer. If confirmed, my relationship with the Joint Chiefs of Staff will be one of involvement, cooperation, and coordination. The Joint Staff is currently represented on both the Military Health System Advisory Committee, and the Military Health System Executive Committee. As such, they have input into all Health Affairs policy and major issues. In addition, any instructions I would have for the Unified Combatant Commands will be communicated through the Chairman of the Joint Chiefs of Staff, any communications to the Commanders of the Unified Combatant Commands will be coordinated through the Chairman of the Joint Chiefs of Staff.
The TRICARE Lead Agents;
Answer. While the TRICARE Lead Agents will maintain a close working relationship with the Executive Director of the TRICARE Management Activity to address and work on operational issues affecting the TRICARE Program, the Assistant Secretary of Defense (Health Affairs) will be actively involved as a full partner in addressing policy issues that affect the TRICARE Program and the delivery of health care to our beneficiaries.
The TRICARE Support Contractors;
Answer. As with the Lead Agents, the TRICARE Support Contractors will maintain close working relationships with the staff at the TRICARE Management Activity and the Lead Agent offices to ensure effective management of the program. The Assistant Secretary of Defense (Health Affairs) will maintain an open relationship and be an active partner with the Contractors, along with other key personnel, to work through and resolve the implementation and operational challenges associated with the TRICARE Program.
The Designated Providers’ Chief Executive Officers (i.e., Uniformed Services Treatment Facility CEOs);
Answer. If I am confirmed, I will seek to assure a positive relationship between the TRICARE Management Activity and OASD(HA) on behalf of DoD and the CEOs of the Designated Providers.
Section 138b of Title l0, United States Code, assigns the duties of the Assistant Secretaries of Defense as those duties and functions prescribed by the Secretary of Defense.
Question. Assuming you are confirmed, what duties do you expect Secretary Cohen or Secretary de Leon will prescribe for you?
Answer: The duties currently prescribed in the Charter for the position of the Assistant Secretary of Defense for Health Affairs are to serve as principal staff assistant and advisor to the Under Secretary of Defense for Personnel and Readiness (USD(P&R) and the Secretary and Deputy Secretary of Defense for all DoD health policies, programs, and activities and to execute the Departments medical mission. If confirmed, I would expect the Secretary of Defense and USD(P&R) to requirement me to meet the mandate of the Health Affairs Charter and the requirements as their senior medical advisor.
Question. What background and experience do you possess that you believe qualifies you to perform these duties and those outlined in the law and applicable DoD directives?
Answer. I have nearly 25 years experience to help me perform these duties. I received a segment of my training in the ensign 1915 program receiving medical training on active duty at Bethesda Naval Hospital, Bethesda, Maryland, and Philadelphia Naval Hospital, Philadelphia, Pennsylvania. As a former Naval Reserve Medical Officer I continued first hand experience with the uniqueness of military medicine. As Deputy Assistant Secretary of Defense for Clinical Services, I developed policy to strengthen the Department's quality management and mental health programs and developed a program to provide medical care involving deployment and post deployment issues. I was on the ground at Guantanamo Bay and in Haiti and worked with the CINCLANT Surgeon on on-site medical issues. In addition, I have had a long-standing interest and involvement in national health care policy. I have a deep personal commitment to bringing high quality health care to our people at the most reasonable cost.
Question. Do you believe that there any additional steps that you need to take to enhance your expertise to perform these duties?
Answer: I believe I am well prepared for this position given my experience in health care. However, if confirmed, I would plan to schedule personal visits to the field to gather first hand information from our leaders, our active duty troops, their families and retirees to help me better understand how their health care needs are being addressed, both in terms of deployment support and peacetime healthcare needs. I will also schedule early sessions with the Joint Staff and others to assure my up-to-date understanding of current operational activities and their health policy aspects.
TRICARE has been a managed care program in the making in the Department of Defense for a decade. The journey has not been an easy one and now the Department has arrived at a crossroads in the development of TRICARE as it prepares to implement TRICARE 3.0.
Question. If confirmed, what is your commitment to the TRICARE program?
Answer. I am a staunch supporter of the TRICARE program for our beneficiaries. TRICARE represents a profound and fundamental change in the way we provide health care services to our military personnel and their families, although the transition period has been unsettling at times for our beneficiaries. The TRICARE Program is an effective model for a regional integrated health care delivery system which enables the Department to provide improved access to high quality care for more of our beneficiaries in a more cost–effective manner. Working hard to support TRICARE will make it successful, and the Department will continue to meet our commitment to serve and care for those beneficiaries who choose to receive their care in the military system.
Question. If confirmed, what will be your short-term and long-term goals for TRICARE?
Answer: If confirmed, my short-term goal will be to bring stability to the program. TRICARE has been in a constant state of improvement. While this has been to the benefit of our beneficiaries, it has also, I understand, at times, strained the system and has led to a sense of confusion on the part of our beneficiaries. Given recent improvements, I believe we need to encourage and refocus our energy on educating our beneficiaries and providers.
My long-term goal for TRICARE would be to ensure that it continues to provide the highest quality cost-effective health care for our beneficiaries. I will be vigilant in monitoring and providing oversight to the program.
Question. How will you as Assistant Secretary of Defense for Health Affairs capture the essence of the partnering arrangement between the government and the TRICARE Support Contractors, which is necessary for the successful delivery of health care within the TRICARE Program?
Answer. In virtually every region where TRICARE has been implemented, there have been challenges with issues involving access to care, claims processing, pharmacy services, and telephone access difficulties. DoD would not have been able to successfully overcome these difficulties and take a proactive approach to the implementation of new changes to the program without teamwork and partnering from all parties involved with the TRICARE Program. Partnering efforts are underway with all Managed Care Support Contractors.
As Members and staff of the Committee visit installations and military units around the world, it has become apparent that TRICARE is not very well understood by the majority of the service members. As a result, service members may be making poor decisions with regard to the participation of their families within TRICARE. It appears that more effort and attention at the policy level may be focused on addressing the retiree population.
Question. In your view, is the Department focusing a disproportionate effort on addressing how to provide care to retirees?
Answer. I believe that providing access to quality health care for our military retirees and their families is an important priority facing the Department of Defense. Addressing this priority, however, will not impair the Department’s efforts to provide health care to active duty members and their dependents.
Question. In your opinion, what is the role of the operational chain of command in ensuring that service members thoroughly understand the options within TRICARE available to their families?
Answer. I believe the operational chain of command has a responsibility to ensure active duty members are fully informed about the options available to them and their family members under the TRICARE program. I believe it will be, if I am confirmed, my responsibility to ensure that those in the chain of command have the information they need to discuss the TRICARE Program effectively with their troops.
Question: If confirmed, how would you ensure the operational chain of command fulfills that role?
Answer. If confirmed, this is an issue that I intend to raise with the senior leaders as I make visits to our installations. I also plan to solicit ideas from our constituency groups and beneficiaries. I will encourage senior leaders to fulfill this important role through frequent communication with them. I will make it a point, in every interaction I have with officers and enlisted members of the chain of command to see how we can improve the content and the flow of information about the TRICARE program.
Commitment to Military Retirees
Question. In your opinion, what, if any, is the commitment on behalf of the Department of Defense and the military departments to provide health care through the Military Health Care System to those who have retired from the uniformed services?
Answer: I believe we owe an enormous debt of gratitude to these retirees and their families and we must do all we can to provide for their health care needs during their retirement years. I am deeply committed to finding workable alternatives for ensuring that our military retirees and their families enjoy comprehensive health care delivery. I am confident that the Department of Defense and the military departments share this sense of commitment to our retirees.
Question. Is the commitment different for the uniformed services retirees who are Medicare eligible? If so, how?
Answer: I recognize our commitment to Medicare-eligible uniformed service retirees. As you know, under current law, when our retired beneficiaries reach 65 years of age they become eligible for Medicare instead of CHAMPUS and are eligible for care in military facilities on a space-available basis. Because under current law these retirees are not eligible for care under CHAMPUS, they cannot participate fully in the TRICARE program.
I believe that Medicare reimbursement to DoD is key to alleviating the access-to-military care problem facing our Medicare-eligible population. The TRICARE Senior demonstration project authorized by the Balanced Budget Act of 1997 is an important first step in offering comprehensive health care for military retirees over 65 years of age. This demonstration project will enable the MHS to test cost-effective alternatives for delivering accessible and quality care to Medicare-eligible military retirees.
The Department now has three contractor assisted dental programs – the Family Member Dental Plan, the dental plan for the Selected Reserves and the retiree dental plan.
Question. In your opinion, are there other dental programs which are necessary or desirable or do these three programs cover the total beneficiary population?
Answer. I believe these three dental programs make dental care available and affordable for the majority of our beneficiary population. I am advised that in the review of the initial authorizing language, it was determined that there were categories of beneficiaries who appeared to have been inadvertently excluded -- for example, spouses of members who died while on active duty. Health Affairs then proposed language to enable these people to participate in the program, and it was adopted by the Committee and the Congress last year.
Question. Are there inequities among these programs which should be addressed? If so, what are they?
Answer. As noted in my previous response, it is believed that the inequities which existed in the initial language authorizing these dental programs have now been resolved with the adoption of provisions in subsequent authorization bills.
Question. In your opinion, is the benefit package within the retiree dental program adequate to serve the aging population it is designed to serve?
Answer. The retiree dental program benefit package offers a basic benefit. Specialty care has not been addressed.
Major Challenges and Problems
Question. In your view, what are the major challenges confronting the Office of the Assistant Secretary of Defense for Health Affairs?
Answer. I believe the major challenges are:
Question. Assuming you are confirmed, what plans do you have for addressing these challenges?
Answer. If confirmed, I intend to focus heavily on force health protection issues to ensure our active duty troops are medically prepared to accomplish their missions anywhere, anytime. In November 1997 President Clinton directed the Departments of Defense and Veterans Affairs to create a new Force Health Protection Program. Under this program every service member will have a comprehensive, life long medical record of all illnesses, the care and immunizations received, and exposure to hazards. Development and implementation of this comprehensive Force Health Protection Program is one of the major challenges facing the Department. I have been on the ground overseas in the past dealing with these sorts of issues and would continue to be available to do so in the future.
I also plan to work closely with all segments of the Department to continuously improve quality and to develop a comprehensive health promotion plan. A top priority will be full implementation of the TRICARE program, with an emphasis on simplification and beneficiary education.
Question. What do you consider to be the most serious problems in the management of health affairs in the Department of Defense?
Answer. Careful consideration of the separations of policy and execution functions and associated roles and missions is a serious management challenge. The creation of the TRICARE Management Activity assists in the management challenge of strategically directing the Defense Health Program resources to meet the commitments and needs of the beneficiaries of the various military departments.
Question. What management action and timetables would you establish to address these problems?
Answer. If confirmed, within the first 30 days after taking office, I would plan to hold a series of meetings with senior staff to review with them their roles and responsibilities and my expectations for their performance. I will also consider the advisability of a strategic retreat with the OSD and TMA leadership and the Surgeons General to further clarify and refine expectations and responsibilities.
In order to exercise its legislative and oversight responsibilities, it is important that this Committee and other appropriate committees of the Congress are able to receive testimony, briefings, and other communications of information.
Question. Do you agree, if confirmed for this high position, to appear before this Committee and other appropriate committees of the Congress?
Question. Do you agree, when asked, to give your personal views, even if those views differ from the Administration in power?
Answer. If confirmed, I will look forward to the opportunity to work with the Committee on the many issues facing the Department in the health care arena. With that in mind, I would do my best to answer the Committee’s questions.
Question. Do you agree, if confirmed, to appear before this Committee, or designated members of this Committee, and provide information, subject to appropriate and necessary security protection, with respect to your responsibilities as the Assistant Secretary of Defense for Health Affairs?
Question. Do you agree to ensure that testimony, briefings, and other communications of information are provided to this Committee and its staff and other appropriate committees?