The Defense Department is doing an about-face on a major component of reforms it launched seven years ago to reduce medical care costs, abandoning a plan to push family members and military retirees to private-sector care.

In a memo sent last month to senior Pentagon leaders, Deputy Defense Secretary Kathleen Hicks outlined an effort to "re-attract" beneficiaries to military hospitals and clinics -- at least 7% of those now receiving medical care through Tricare^[1], the DoD's private health program, by Dec. 31, 2026.

Hicks said certain elements of the DoD's health system overhaul, which was mandated by Congress in 2017, have left military treatment facilities, or MTFs, "chronically understaffed" and unable to deliver timely care to all patients.

Read Next: Some Military Patients Left Without Heat for a Week at Texas Base During Blast of Frigid Weather^[2]

The goal for the new plan would be to review current staffing and potentially shift providers among facilities, or add new personnel as needed in order to provide improved access to care and bring back patients, according to the memo, provided Monday to Military.com by request.

In the memo, Hicks said the circumstances at military hospitals have not only affected beneficiaries, they have hindered providers, depriving them of opportunities to maintain their skills.

"Realignment of medical personnel, coupled with a challenging health care economy and ambitious private-sector care capacity assumptions, led to chronically understaffed [military treatment facilities] and [dental treatment facilities, or DTFs] that at times cannot deliver timely care to beneficiaries or ensure sufficient workload to maintain and sustain clinical skills," Hicks wrote.

The fiscal 2017 National Defense Authorization Act gave the Defense Department leeway in reorganizing the military health system^[3] to address rising costs and ensure the readiness of military health care providers to support combat operations and training.

As part of the reforms, management of the military services' 51 hospitals and 424 health and dental clinics shifted to the Defense Health Agency, which also was responsible for overseeing the massive plan to realign staffing at and consolidation of military health facilities while transferring an estimated 200,000 non-military beneficiaries^[4] to the Tricare network for private care.

Under the plan, the services were to cut roughly 12,800 military health billets, while the DHA would close or realign 50 facilities, including 38 that would serve military personnel only.

The DoD hoped that the consolidation and restructuring, which would require non-active-duty families to pay^[5] a larger portion of their health care costs, would curtail the military health system's now $54 billion budget.

Senior health officials said the reforms would be conducted so that patients still were able to access care within standards and, in some cases, have even better access.

But this did not prove to be the case.

In 2019, lawmakers began complaining that their military constituents were unable to get medical care in the private sector^[6] as a result of oversaturated markets and shrinking Tricare networks.

In 2022, evidence began emerging that staffing cuts at military health facilities and inflated estimates of the number of available physicians in civilian networks were affecting patient care in North Carolina, New York, the Pacific Northwest, California and Japan.

In some cases, patients drove an hour each way to receive quality care^[7].

"We are really concerned about access to care overall, those within the direct care system and the purchase care system," said Eileen Huck, senior deputy director for government relations at the National Military Family Association, referring to the military and Tricare health systems, respectively, in an interview Tuesday. "We've been concerned about the erosion of the purchase care network, the lack of providers and specialties in some locations."

Hicks said the key to bringing patients back to military treatment facilities is building and staffing a dependable, high-quality workforce at these hospitals and clinics.

Under the plan:

• DoD must identify its military medical requirements -- including casualty care, combatant command and military department needs -- by July 2024.
• The under secretary of defense for personnel and readiness is to complete a comprehensive review of all medical manpower and staffing.
• The Defense Health Agency and the military services are to identify the capacity of each military treatment facility and the needs for military staff and civilian manpower by July 2024.
• DHA must be able to bring back at least 7% of beneficiaries to military treatment facilities on average by Dec. 31, 2026.
• The services and DHA must come up with a plan to realign staffing and prioritize assignments to ensure that facilities can take care of patients and support operational needs.

"Re-attracting and caring for more beneficiaries in MTFs and DTFs means that DoD needs to increase capacity and improve access," Hicks wrote. "To do so safely, MTFs and DTS must be staffed to provide quality patient care as well as career development, education and training opportunities for medical and dental personnel."

The effort to draw patients back to military treatment facilities echoes a major initiative launched a decade ago by Dr. Jonathan Woodson^[8], then the assistant secretary of defense for health affairs, to attract patients to military treatment facilities in the waning years of the Iraq and Afghanistan wars.

For more than a decade, deployments^[9] of medical staff to combat zones made it difficult for many non-uniformed beneficiaries to get appointments at base hospitals and clinics, forcing them to seek care in their communities.

Citing data that showed direct care at military facilities cost about one-third less than Tricare purchased care, Woodson set a goal to ensure that base hospital usage reached 70% capacity.

At the time, some were running at just 33% capacity.

Woodson now serves as president of the Uniformed Services University of the Health Sciences, the Defense Department's medical school and research university, which, while not mentioned in the memo, would likely contribute to the new efforts given that the school is responsible for educating a portion of the U.S. military's physicians.

Karen Ruedisueli, director of government relations for health affairs at the Military Officers Association of America, remembered that effort and said MOAA is not opposed to the new emphasis on military-provided care -- if the DoD can ensure that the system has the capacity to take new patients.

"It's our concern that ... these folks are going to have trouble getting an appointment," Ruedisueli said. "We think there are a lot of question marks about what this looks like for military families."

She added that MOAA is advocating for beneficiaries to have a system for reporting problems, including access issues, with their health care to the DoD and have more flexibility in changing health plans.

Currently, beneficiaries can change plans only during open season or in a major qualifying life event, such as a marriage, divorce, birth of a child or move on military orders.

Ruedisueli said military families deserve more flexibility to choose plans, something that may be required if the Defense Health Agency wants to bring beneficiaries who use Tricare Select^[10] -- a flexible fee-based plan that lets beneficiaries choose their own doctors but does not let them use military treatment facilities -- back into those hospitals.

"The messaging has been for so long ... 'We're moving people out to the network,' which was all about readiness, and now, it's bringing people back in to support readiness, so there has been some whiplash for us," Ruedisueli said. "At the end of the day, there's still so many details we don't know."

Hicks said the department will move ahead with its plans to ensure that the U.S. military is medically ready to fight a war and all beneficiaries have access to care.

"Our service members, their families, other beneficiaries and all those cared for by military medicine will be better served when we rebuild MTF capacity," Hicks wrote.

Related: Denied Care, Deaths in Japan Result from Lack of Emergency Medical Services for American Personnel^[11]

JERUSALEM — Two American-flagged ships carrying cargo for the U.S. Defense and State departments came under attack by Yemen's Houthi rebels on Wednesday, officials said, with the U.S. Navy intercepting some of the incoming fire.

The attacks on the container ships Maersk Detroit and Maersk Chesapeake further raise the stakes of the group's ongoing attacks on shipping through the vital Bab el-Mandeb Strait. The U.S. and the United Kingdom have launched multiple rounds of airstrikes seeking to stop the attacks.

Meanwhile, Qatar^[1], one of the world's top exporters of liquified natural gas, warned that its deliveries were affected by ongoing Houthi attacks over Israel's war on Hamas^[2] in the Gaza Strip.

Danish shipper Maersk, in a statement to The Associated Press, identified two of its vessels affected by the attacks as the U.S.-flagged container ships Maersk Detroit and Maersk Chesapeake. It said the U.S. Navy was accompanying its ships at the time.

“While en route, both ships reported seeing explosions close by and the U.S. Navy accompaniment also intercepted multiple projectiles,” Maersk said. “The crew, ship, and cargo are safe and unharmed. The U.S. Navy has turned both ships around and is escorting them back to the Gulf of Aden.”

Maersk said both vessels carried cargo belonging to the U.S. Defense and State Departments, as well as other government agencies, meaning they were “afforded the protection of the U.S. Navy for passage through the strait.”

The ships were operated by Maersk Line, a U.S. subsidiary of Maersk that is “suspending transits in the region until further notice,” the company said.

The U.S. military's Central Command in an online statement blamed the Houthis for the attack, saying they fired “three anti-ship ballistic missiles.”

“One missile impacted in the sea,” the statement said. “The two other missiles were successfully engaged and shot down by the USS Gravely,” an Arleigh Burke-class guided missile destroyer.

Central Command did not respond to further questions from the AP.

The Houthis, who have been launching attacks on ships since November over Israel’s war on Hamas in the Gaza Strip, did not immediately acknowledge the incident.

Since November, the rebels have repeatedly targeted ships in the Red Sea, saying they were avenging Israel’s offensive in Gaza against Hamas. But they have frequently targeted vessels with tenuous or no clear links to Israel, imperiling shipping in a key route for global trade.

The U.S. and the U.K. have launched rounds of airstrikes targeting suspected missile storage and launch sites used by the Houthis in their attacks. The rebels now say they’ll target American and British ships as well.

Meanwhile, Qatar announced its shipments of liquified natural gas had been affected by the Houthi attacks. Previous shipments had been delayed previously before heading through the Gulf of Aden and the Red Sea.

Qatar, which has served as a key mediator between Hamas and Israel, has yet to see any of its ships attacked, however. A statement from its state-owned QatarEnergy producer said that its “production continues uninterrupted, and our commitment to ensuring the reliable supply of LNG to our customers remains unwavering.”

“While the ongoing developments in the Red Sea area may impact the scheduling of some deliveries as they take alternative routes, LNG shipments from Qatar are being managed with our valued buyers,” the statement said.

The statement suggests QatarEnergy’s cargos now are traveling around Africa’s Cape of Good Hope, likely adding time to their trips.

Recruiting patterns in the military have increasingly come to reflect the nation's red state-blue state political divide, with recruiting^[1] strong in the South and Midwest but lagging on the coasts, retired Army^[2] Brig. Gen. Michael Meese said at a Rand Corp. event Thursday.

"When you look at it regionally, the North and the West tend to be less positive" on military service "than the South and the Midwest," said Meese, the former head of West Point^[3]'s Department of Social Sciences.

"The implications of that for recruiting are problematic," he said, "because where are you going to fish" to fill out the ranks?

Read Next: Army Has Temporarily Promoted 52,000 Soldiers, But Over 10,000 Still Haven't Completed Required Schooling^[4]

The pattern has been in place for decades and, should it continue, Meese said, he could envision a time 50 years from now when recruits from New York and Oregon would number in the single digits, "and everybody else is gonna be from Georgia and North Carolina" despite the ongoing efforts of the services to attract recruits nationwide.

Meese, president of the American Armed Forces Mutual Aid Association, spoke at a Rand panel discussion on "What Americans Think About Veterans," which amounted to a review of a Rand report in December that examined possible factors in what the Pentagon has called a "crisis" in recruiting.

The report found that Americans still think highly of veterans, but a majority (54%) would recommend against joining the military, particularly in the enlisted ranks. However, nearly two-thirds of those surveyed said they would tell a 17-year-old to join as an officer, either through the Reserve Officers' Training Corps, known as ROTC^[5], or the military academies.

"Although the public still holds the military generally in high esteem compared with other major institutions, that esteem is wavering, influenced by such factors as the end of the war in Afghanistan, the increased polarization of the public, and heightened politicization of the military," the Rand report said.

The Rand report followed several other surveys and studies last year that also showed a decline in the trust and confidence the public gives the military, resulting in another year of missed recruiting goals.

In November, the annual defense survey by the Ronald Reagan Presidential Foundation and Institute found that only a slim majority^[6] (51%) of Americans would recommend that family and friends join the military, while 33% would discourage military service.

The 51% figure was a significant decline from the results of the 2018 Reagan Foundation survey, when 70% said they would recommend joining the military. About half of the respondents to the foundation's survey attributed the decline to "so-called 'woke' practices undermining military effectiveness" and unit cohesion.

In July, a Gallup poll showed that only 60% of the public expressed a "great deal" or "quite a lot" of confidence in the military, the lowest marks in the poll since 1997. "Republicans have been the most likely to express confidence in the military, and they remain so today, but the rate has declined by over 20 percentage points in three years, from 91% to 68%," the poll said.

The military also has to contend with drawing recruits from a stressed-out society, according to the latest "Stress in America" survey conducted by the Harris Poll for the American Psychological Association and released in November.

"The COVID-19 pandemic, global conflicts, racism and racial injustice, inflation, and climate-related disasters are all weighing on the collective consciousness of Americans," the survey said.

Few of the respondents to the survey "reported confidence about the direction our country is going (34%) or said they feel that their government representatives have their best interests in mind (31%)," the APA said.

The growing doubts about military service coupled with other factors -- ranging from low unemployment to the prevalence of youth obesity and the closing of high schools to recruiters during the pandemic -- have all contributed to fewer and fewer young Americans signing up for the military.

In fiscal 2023, only the Marine Corps^[7] and the Space Force^[8] among the five service branches met their recruiting goals^[9]. The Army fell short by about 10,000 of its goal to bring on 65,000 active-duty enlisted soldiers; the Air Force^[10] recruited only 24,100 of the 26,877 it wanted; and the Navy^[11] recruited 30,236 active-duty enlisted sailors, well short of its goal of 37,000.

The shortfall "understates the challenge before us as the services lowered [their] end-strength goals in recent years, in part because of the difficult recruiting environment," Ashish Vazirani, the Pentagon's acting undersecretary for personnel and readiness, told the House Armed Services Military personnel subcommittee last month.

The result is that "the all-volunteer force faces one of its greatest challenges since [its] inception" in 1973 when then-President Richard Nixon ended the draft, Vazirani said, and the demographics argue against a quick turnaround.

He testified that fewer and fewer young Americans have a parent who served in the military, which greatly decreases the propensity to serve. "In 1995, 40% of young people had a parent who served in the military but by 2022, just 12% had a parent who had served," Vazirani said.

"This has led to a disconnect between the military and a large share of society," he said.

In November, Army Secretary Christine Wormuth mused about the possibility of getting past the disconnect with a little help from Tom Cruise. At a Duke University Program in American Grand Strategy session, Wormuth said the Army would "love to find [its] 'Top Gun,'" referring to the boost in recruiting the Navy got from the "Top Gun" movies.

Barring an assist from Hollywood, Wormuth said the Army would focus on modernizing its recruiting methods to include creating a new recruiting MOS, or military occupational specialty, to be called MOS 42T, which will be aimed at talent acquisition.

"We are still relying heavily on call lists and solicitations in places like fast-food restaurants, gyms and shopping malls," she said. "These methods may have worked for us when unemployment was high, but in today's extremely competitive labor market, they have put us at a distinct disadvantage" in contacting and recruiting from Gen Z, the generation born after 1997.

"For us, it is an existential challenge, particularly given the very dangerous security environment that we are facing," Wormuth said. "We need to build back our end strengths so we can continue fulfilling our mission, and the only way we can do that is by recruiting significantly more young Americans to serve in uniform."

Traditionally, recruiting has been good when the economy is struggling and young Americans have difficulty entering the civilian workforce, but reports from the Bureau of Labor Statistics and other government agencies show that inflation is easing, the labor market is strong and unemployment was below 4% for all of 2023.

Wormuth also pushed back on the notion that the Army has gone "woke" in its efforts at diversity and inclusion, which allegedly have taken resources away from training and deployments^[12]. She said the "wokeness" charges stemmed from the hyper-partisan political climate gripping the nation and challenged the critics to come see firsthand how the Army trains.

Duke University political science Professor Peter Feaver, who moderated the discussion with Wormuth, told Military.com last Thursday that charges of wokeness in the military have primarily come from Republicans who have shifted from "adoration of the military to criticism of the military."

"There's no evidence that the military itself is woke" or has been taken over by the political left, Feaver said in a phone interview, but there is evidence that the wokeness charges are having an impact on what the military calls the "influencers" -- the coaches, pastors and respected adults in communities who are sought out for advice by young Americans.

"There are a lot of things in the category of what I call 'more rocks in the rucksack'" for the military in dealing with the recruiting problem, Feaver said, including the effects of the humiliating withdrawal from Afghanistan on how military service is perceived.

In addition, the Defense Department estimates that only 23% of Americans aged 17 to 24 would qualify for military service and the rest would be rejected for being overweight, abusing drugs, or having mental and physical health problems.

"There's nothing the military can do about that," Feaver said.

Veterans groups have noted with concern the reports and surveys on the military's recruiting problems, and the 1.4 million-member Veterans of Foreign Wars took particular exception to charges by some congressional Republicans that the military going woke was discouraging young Americans from joining, said Ryan Gallucci, assistant adjutant general of the VFW and an Army veteran of Iraq.

"We've had these discussions on Capitol Hill" with those alleging that the current administration is presiding over a woke military and delivered the message that "You need to knock that off," Gallucci said.

Related: Big Bonuses, Relaxed Policies, New Slogan: None of It Saved the Military from a Recruiting Crisis in 2023^[13]