A MARTÍNEZ, HOST:
For the past decade, the Department of Defense has been trying to cut the costs of medical care for its millions of troops and retirees and their families. NPR's Quil Lawrence reports officials inside and outside the Pentagon now say the cuts have gone too far and they're hurting military health and readiness.
QUIL LAWRENCE, BYLINE: War is the mother of invention, and the 20 years of U.S. deployments in Iraq and Afghanistan produced a lot of medical advances, including people - battle-tested doctors and nurses.
TODD RASMUSSEN: My name is Todd Rasmussen. I'm a vascular surgeon, professor of surgery at the Mayo Clinic in Rochester, Minn.
LAWRENCE: The Air Force put Rasmussen through med school. For that, he owed them several years of service, and then he figured he'd go into private practice. He started a few weeks before September 11.
RASMUSSEN: We were only about 8 miles from the Pentagon. You could sort of see smoke from the Pentagon. And I think from my perspective, I thought, boy, my military career as a surgeon would - it's going to be vastly different than what I expected.
LAWRENCE: Rasmussen switched to trauma surgery as casualty numbers lifted to the highest rates since Vietnam. At first, the way patients arrived so quickly from the war zone amazed him.
RASMUSSEN: They'd been severely injured, you know, 5 or 6,000 miles away just three or four days earlier.
LAWRENCE: The wonder wore off, though, because patients weren't getting care soon enough. They arrived with contaminated wounds too late to treat.
RASMUSSEN: It's hard to admit we could have done better, but I think maybe the only thing worse is not admitting it.
LAWRENCE: And the military did do better, getting surgery done inside what's known as the golden hour after injury. At first, they improvised tent hospitals where patients arrived with tourniquets made from cargo straps. As the war ground on, newly designed tourniquets became standard gear. Units of whole blood seemed to work miracles. By 2005, about when he had planned to be going into private practice back home, Rasmussen deployed to Iraq and saw the innovations in real time.
RASMUSSEN: I remember one U.S. service member who came to us from the front lines in Fallujah, and he had been operated on by a small group of surgeons near the front line. So I think the assumption was that we would need to amputate.
LAWRENCE: The doctors near the front line had used a temporary shunt in a new way. Basically, they stuck a plastic tube into the thigh to keep the blood flowing around the wound and save the foot.
RASMUSSEN: Then we said, wait a minute, we can actually fix this because of what the surgeons have done in their creativity and skills, sort of put the amputation saw away.
LAWRENCE: Rasmussen deployed six times between 2005 and 2012. On the last one, in Afghanistan, he operated in a fully equipped hospital with new concrete floors and access to MRI and CT scans. Then the wars wound down, and Rasmussen noticed a drastic change.
RASMUSSEN: There were efforts to outsource beneficiary care from the military treatment facilities to civilian institutions, which emptied out and hollowed out storied military medical centers like Walter Reed.
LAWRENCE: That outsourcing was planned. In the past decade, the Pentagon tried to tame its massive health care costs by pushing medical care, especially for family members, into the private sector. The result was a sort of spiral. Military hospitals lost the numbers of patients they needed to keep doctors in practice. Because of that and also the pandemic, many clinicians left the military, and the cuts kept going, says Rasmussen.
RASMUSSEN: Then lastly, even, you know, what I would, in my own words, call, like, crazy ideas, you know, that were floated to close the Uniformed Services University, right? I mean, why do we need a military medical academy?
LAWRENCE: The Uniform Services University is the military's medical school.
ART KELLERMANN: OK. I'm Dr. Art Kellermann. For seven years, I was the dean of the Uniformed Services University of the Health Sciences.
LAWRENCE: Art Kellermann was a leading voice against downsizing the system, especially the university, which he says preserves and supports all the military medical advances from the past 20 years and many of the doctors who made them.
KELLERMANN: They achieved the highest rate of survival for battlefield wounds in the history of warfare. They were able to save people that would have died in any prior conflict.
LAWRENCE: That, as much as a helmet or flak jacket, gave U.S. troops confidence, Kellermann says, to rush into a firefight, knowing they would probably survive. U.S. allies joined the fight, knowing that an American medivac would fly to the rescue within 30 minutes if they got blown up - and that they'd not just survive but live well, Kellermann says.
KELLERMANN: They dramatically improved their ability to rehabilitate wounded warriors after being injured and many of them were able to return to duty, and others were able to return home to be with their families and to function for the rest of their careers. Some of them today are members of Congress.
LAWRENCE: Kellermann says America needs that same ready medical force for any future conflict. And the Pentagon now seems to agree. A Defense Department internal memo obtained by NPR found that outsourcing didn't actually save money but did hurt readiness. The memo directs the Pentagon to reverse course to bring more medical care back to its hospitals on base and increase medical staff. But the next war may be very different. In Iraq and Afghanistan, the golden hour was possible because the U.S. had air superiority. The enemy had no planes or helicopters.
SEAN MURPHY: Sooner or later somewhere, we're not going to have air superiority. And I don't care if we think we are. We should plan for not having it.
LAWRENCE: Dr. Sean Murphy served 44 years, retiring as Air Force deputy surgeon general. He's thinking about Ukraine, two conventional armies squared off with massive casualties being evacuated by ground, or even more extreme, a possible conflict with China around Taiwan.
MURPHY: What we've realized when we start looking at a theater like the Pacific and the distances and a peer-to-peer fight, there is no way we're going to get to the golden hour.
LAWRENCE: The solution, says Murphy, is to make every soldier and sailor a medic. To do that, he says, the Pentagon needs urgently to build back its ready medical force. Dr. Todd Rasmussen agrees.
RASMUSSEN: The most important fighting system or weapon system we have is the human system. It's not a plane or a ship or a tank.
LAWRENCE: Rasmussen says he saw that again and again when he served.
RASMUSSEN: That's the most lethal and most important fighting system we have on the battlefield. And that human system is only optimized and cared for if there is a robust and expert military health system, and I think degrading that risks our national security.
LAWRENCE: Rasmussen retired after 28 years, and he is finally a civilian vascular surgeon at the Mayo Clinic. He still mentors military doctors, though, and the ones who do join give him great hope.
Quil Lawrence, NPR News.
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