Background

The Department of Defense (DOD) administers health entitlements (under Title 10, Chapter 55 of the U.S. Code) through the Military Health System (MHS). The MHS offers health benefits and services to approximately 9.5 million beneficiaries composed of servicemembers, military retirees, and dependents. Beneficiaries may access health care in DOD-operated hospitals and clinics (known as military treatment facilities or MTFs), or through civilian health care providers participating in the TRICARE program. Statutes require the Defense Health Agency (DHA) to be "responsible for the administration" of each MTF (10 U.S.C. §1073c) and to maintain MTFs for the purposes of supporting "medical readiness of the armed forces and the readiness of medical personnel" (10 U.S.C. §1073d).

The Defense Health Agency (DHA) exercises authority, direction, and control of the MTFs and determines the scope of services, population served, and staffing requirements for each facility. For FY2024, DOD reported having a projected total of

45 medical centers and hospitals, 572 ambulatory care clinics, and 115 dental facilities in the United States and in overseas locations; and
129,853 MHS personnel (56% military personnel and 44% civil service personnel).

DHA typically staffs an MTF with a mix of military, civil service, and contract personnel. In certain instances, staffing availability can affect access to MTF care and whether or not an MTF can increase or decrease its capabilities, patient capacity, and military medical training and readiness programs.

During deliberations on a National Defense Authorization Act (NDAA) for FY2025, Congress expressed interest in MTF staffing. Table 1 lists proposed and enacted MTF staffing-related provisions included in the House-passed (H.R. 8070), Senate Armed Services Committee (SASC)-reported (S. 4638), S.Amdt. 3290, and enacted (P.L. 118-159) versions of the FY2025 NDAA.

Table 1. FY2025 NDAA Legislative Proposals

House-passed H.R. 8070 (118^th Congress)	Senate Armed Services Committee-reported S. 4638 and S.Amdt. 3290 (118^th Congress)	Enacted P.L. 118-159 Servicemember Quality of Life Improvement and National Defense Authorization Act for FY2025
Civilian Health Care Personnel
Section 1833 would have amended 10 U.S.C. §1599c(b) to extend, to December 31, 2030, Secretary of Defense authority to use enhanced appointment and compensation mechanisms, under Title 38, Chapter 74, of the U.S. Code, for certain health care personnel that provide care to wounded or injured servicemembers, and support military medical readiness requirements.	Section 1103 is a similar provision to the House provision.	Section 712 adopted the House provision.
Section 1835 would have provided MTF or other DOD health care facility hiring managers with an authority to waive any Office of Personnel Management (OPM) work experience requirements for General Schedule nursing or practical nurse positions when applicants meet certain criteria and have at least a bachelor's degree in nursing. The provision would have also required hiring managers to certify to the OPM Director that such applicants met all other established qualification standards.	Section 5741 (proposed in S.Amdt. 3290) is a similar provision to the House provision that would allow MTF or other DOD health care facility hiring managers to waive any OPM work experience requirements for General Schedule nursing or practical nurse positions when applicants meet certain criteria and have at least an associate's degree in nursing.	Section 716 adopted the House provision.
Section 1836 would have directed DOD to establish a three-year pilot program, at no more than three MTFs, to appoint licensed civilian health care professionals using hiring and compensation authorities under 10 U.S.C. §1599c.	No similar provision.	Not adopted. The conferees stated that DOD "authority to exercise authorities available to the Department of Veterans Affairs under chapter 74 of title 38, United States Code, for purposes of the recruitment, employment, and retention of civilian health care professionals, is extended elsewhere in this Act" (i.e., see Section 712 of P.L. 118-159).
Military Health Care Personnel
Section 1831 would have amended 10 U.S.C. §523(b) to exempt certain licensed mental health providers (i.e., clinical psychologists, licensed clinical social workers, mental health nurse practitioners, or psychiatric physician assistants) from authorized strength limitations for military officers in the grade of O-4 (Major or Lieutenant Commander), O-5 (Lieutenant Colonel or Commander), and O6 (Colonel or Captain).	No similar provision.	Section 403 adopted the House provision with an amendment that temporarily exempts certain licensed mental health providers from authorized end strength limitations between FY2025 and FY2027. The provision also requires the Secretary of Defense to submit a report to the House and Senate armed services committees containing legislative recommendations for eliminating permanent exclusions to authorized end strength limitations.
Section 1837 would have required the secretaries of the military departments to conduct an annual survey and provide an annual report to Congress on why health care providers under their jurisdiction chose to stay or leave active duty service. The survey requirement would have expired on September 30, 2030.	No similar provision.	Section 718 adopted the House provision.
No similar provision.	Section 503 would have authorized the secretaries of the military departments to recommend additional nurse corps officers for promotion to the grade of major or lieutenant commander if "necessary to maintain or improve medical readiness." This authority would have expired on December 31, 2030.	Section 504 adopted the Senate provision with a clarifying amendment.
Section 612 would have amended statutes under Title 10 and Title 37 of the U.S. Code to provide a one-year extension of certain military bonus and special pay authorities, including the special bonus and incentive pay authorities for health professions officers.	Section 611 is identical to the House provision.	Section 611 adopted the identical provisions.
No similar provision.	Section 613 would have amended 10 U.S.C. §2128(a) to increase the maximum accession bonus amount, under the Health Professions Scholarship Program and Financial Assistance Program, from $20,000 to $100,000.	Section 612 adopted the Senate provision.

Source: CRS analysis of legislation on Congress.gov.

Discussion

In 1775, the Continental Congress authorized and appropriated funds "for the establishment of an hospital for an Army consisting of 20,000 men." Since then, MTF staffing levels and challenges to recruiting and retaining military and civilian health care personnel have been the subject of congressional oversight and debate.

DOD's medical workforce has decreased since at least FY2011 (see Figure 1). Several factors may have contributed to this trend, including

changes in the size and composition of the active and reserve components,
conclusion of U.S. military combat operations in Iraq and Afghanistan,
effects of the Coronavirus 2019 pandemic,
shortages in the U.S. health care workforce, and
market competition for health care workers.

Figure 1

. DOD Active Duty Military and Civilian Medical End Strength, FY2011-FY2025

Figure is interactive in HTML report version.

Source: CRS analysis of military and civilian medical end-strength published in Defense Health Program budget and justification estimates for FY2013 through FY2026.

Notes: End Strength refers to the actual number of personnel on the last day of the fiscal year (i.e., September 30). Reserve component personnel are not reflected in these numbers.

Some observers described these workforce reductions and MTF staffing issues as reportedly contributing to challenges in beneficiary access to care. For example, in 2023, the DOD Inspector General issued a management advisory summarizing "concerns with access to care and staffing shortages" in MTFs received through the DOD Hotline and the military services' inspectors general. DOD and other observers also reported on staffing shortages and access to care issues at several MTFs, including Walter Reed National Military Medical Center, Naval Hospital Bremerton, and the 18th Medical Group at Kadena Air Force Base. The Government Accountability Office additionally found that DHA "didn't have the staff to meet its estimated needs" for its previous regional office management construct (i.e., DHA Markets) and "still doesn't know how many staff it needs" for its current construct (i.e., Defense Health Networks) that directly oversees the MTFs.

DOD Efforts to Stabilize the MHS

DOD has announced plans to "stabilize" the MHS and address, in part, certain MTF staffing shortages. In a December 2023 memorandum to senior DOD leaders, the then-Deputy Security of Defense directed a series of actions to "reattract beneficiaries" to MTF care in order to "support the National Defense Strategy, increase clinical readiness, mitigate risks to [military requirements], and reduce long-term cost growth in private sector care." The memorandum also directed the department to, among other actions,

Complete a comprehensive review of medical personnel requirements "regardless of funding source" (e.g., Defense Health Program-funded and service-funded positions) by June 30, 2024.
Establish medical personnel requirements at each MTF that support reattracting at least 7% of "available care from the private sector back to MTF on average" by December 31, 2026.
Redistribute DHA-assigned military medical personnel across the MHS that "optimizes clinical readiness and care opportunities" no later than July 1, 2024.
Implement "enhanced appointment and compensation authority" stipulated in 10 U.S.C. §1599c and Title 38, Chapter 74, U.S. Code, to recruit and retain certain civilian health care providers.

DOD states that the FY2025 MHS budget request reflects investments to stabilize MTFs while fully funding "anticipated [private sector care] requirements to reduce risk to other DOD programs" and limiting growth "to inflation assumptions only."

Considerations for Congress

The following lines of inquiry may support congressional oversight on MTF staffing.

What are the overall workforce requirements to support military medical capabilities and to deliver health care in MTFs?
What is the composition of DOD's medical workforce (e.g., military vs. civilian vs. contract) that is needed to staff MTFs and provide care within the DOD access to care standards?
The FY2026 DOD budget request includes an increase in total military end strength. To what extent would this request increase or decrease the military medical workforce?
What criteria does the Secretary of Defense use to consider special compensation authorities to "recruit and retain experienced civilian health care professionals in critically needed health care occupations?"
In March 2025, DOD established the "Workforce Acceleration and Recapitalization Initiative," which opened the Deferred Resignation Program and offered voluntary early retirement to eligible civilian employees. DOD states that the initiative is to result in a "reduction in the number of civilian full-time equivalent positions, and increased resources in the areas where we need them the most." What effects, if any, would this initiative have on DOD's civilian medical workforce?