BULLY BOY PRESS & CEDRIC'S BIG MIX -- THE KOOL-AID TABLE
THE PROOF IS IN THE PEW! A NEW REPORT BY PEW DOCUMENTS WHAT THE COUNTRY ALREADY KNEW, THE MEDIA IS KOO-KOO FOR BARRY, GAA-GAA FOR BAMBI AND HORNY AND DRUGGED OUT AND SITTING ON DEATH ROW AS CIRCULARTION CONTINUES TO PLUMMET.
WHEN REACHED FOR COMMENT, BARACK SHOWED NO INTEREST IN THE PRESS BUT DID WONDER, "WHAT DOES THIS MEAN FOR ME?" BEFORE WE COULD REPLY, CARL HULSE OF THE NEW YORK TIMES HOLLERED "GOT IT!" AND RUSHED OFF TO DO A FIVE PART SERIES ENTITLED "DON'T LET THEM HARSH YOUR MELLOW, BARACK'S STILL THE ONE!"
FROM THE TCI WIRE:
Baghdad was rocked by bombings today. Two (Los Angeles Times, Reuters and Albawaba) or three (BBC, UPI, McClatchy, Xinhua, Washington Post) car bombings exploded in Baghdad's Sadr City. CNN reports the death toll from the Sadr City bombings (they say three) is "at least 45 people" with sixty-eight more injued. Xinhua explains, "The incident occurred in the afternoon when three booby-trapped cars parked at different popular marketplaces in Sadr City neighborhood in eastern Baghdad, detonated simultaneously, the source said." BBC notes, "The BBC's Jim Muir in Baghdad says the attacks are the kind of provocation, blame on militant Sunni Islamists, which triggered and fuelled a deadly spiral of sectarian violence in 2006 and 2007." Liz Sly and Saif Hameed (Los Angeles Times) report, "Survivors of the carnage turned their wrath on the security forces, hurling bottles and bricks at the police and army troops until the soldiers fired in the air to disperse the crowd." Ernesto Londono (Washington Post) provides this context, "The attack was the deadliest in Sadr City since the Iraqi army wrested control of the impoverished Shiite district from militias last May." He also notes Iraqi police claim "the defused three other car bombs shortly after the blasts." Corinne Reilly (McClatchy Newspapers) observes, "The attacks are the latest sign that security gains here are beginning to reverse. Large-scale bombings targeting civilians have been on the rise since March." Reilly points out that over 200 people have died in Baghdad this month thus far and the last time McClatchy shows that happening was March of last year.
In other violence, Sahar Issa and Hussein Kadhim (McClatchy Newspapers) report a Baghdad car bombing left five people injured and two Baghdad car bombings which claimed 2 lives and left eight injured (this is in addition to the Sadr City bombings which they also note), a New Mosul roadside bombing which wounded two, a grenade attack in Kirkuk on US forces which resulted in two Iraqi civilians being shot and four more wounded. CNN cites US Maj Derrick Cheng stating that the US military had been "working with local police to provide micro-grants" when the attack took place and Cheng states 2 "attackers" were dead with two more injured as well, according to Cheng, one US soldier wounded. Reuters adds that Diyala Province roadside bombings claimed the lives of 3 Iraqi soldiers (two also left injured) and 2 Mosul roadside bombings (this is in addition to the New Mosul one) resulted in the death of 1 police officer and five Iraqi civilians being injured. Going with CNN's 45 dead in Sadr City, that would mean at least 53 reported deaths in Iraq today. Caroline Alexander (Bloomberg News) notes 41 is the death toll in Sadr City according to the political party website of Iraqi President Jalal Talabani. Alsumaria quotes US Brig Gen David Quantock stating that the increase in violence is not due to the release of Iraqi prisoners from US prisons in Iraq.
According to US Major Cheng, one US soldier was wounded today. We'll use that to jump over to a US Congressional hearing this morning. "Today, the Military Personnel Subcommittee will hold a hearing on the organization of the office of the Assistant Secretary of Defense for Health Affairs," stated Subcommittee Chair Susan Davis calling the hearing to order. Of Health Affairs/TRICARE Management Activity, she noted "we are clearly dealing witha different model than the rest of the Department. We do not know if that is good-different, bad-different, or just different. It is therefore important for us to examine this structure so that we may understand exactly how the organization operates and how that impacts care for our men and women in uniform and isn't really that the bottom line here that we're seeking?" (Click here for US House Rep Susan Davis' opening statement, non-PDF format -- but not that I'm quoting her remarks and they're not word for word the prepared statement.) Joe Wilson is the Ranking Member on the Committee and his opening remarks included noting, "General George Washington and the Continental Congress understood the necessity of good medical care during the fight for our independence. After suffering a sizeable number of casulities from disease, the Continental Congress established the medical department of the Army in July 1775. Washington then appointed the first Director General and Chief Physician of the Hospital of the Army." That was Dr. Benjamin Church -- a poor choice who was replaced by Dr. John Morgan. Church was a poor choice? He was a spy for the British. Wilson didn't go into that or name Church, I'm just tossing it in as historical trivia and wouldn't have known it if the office of a Dem House Rep hadn't told me after the hearing (when I asked about the trivia). Other triva included that it is "Surgeons General" and not "Surgeon Generals" when you are dealing with the plural. US House Rep Vic Snyder asked and established that.
Appearing before the subcommittee were the following: Acting Under Secretary of Defense, Personnel and Readiness Gail H. McGinn (DoD, -- PDF formart warning -- here for her opening statement), Acting Assistant Secretary of Defense Health Affairs (DOD -- PDF format warning, here), Lt Gen Eric Schoomaker (Army Surgeon General, PDF format warning, here), Vice Admiral Adam Robinson (Navy Surgeon General, PDF format warning, here), Lt Gen James G. Roudebush (Air Force Surgeon General, PDF format warning, here) and Maj Gen Elder Granger (DoD's Deputy Director TRICARE Management Activity, PDF format warning, here). It was Granger's last appearance before the committee who is retiring. From the opening statements, we'll note one section that is of interest and is not in the prepared remarks.
Lt Gen Eric Schoomaker: In a nutshell, the MHS [Military Health System] exist to support war fighters on the battlefield, the Direct Care System exist to deliver military readiness, Private Sector Care supports and fills the gaps in the Direct Care System. If form is to follow function then the MHS should be optimally organized to suport the Direct Care System. I don't believe this is always the case. For example in the budgeting process, Private Sector Care forecasts are considered must pay while Direct Care System estimates are considered "unfunded requirements." The Department's priority has been to fund the Private Sector Care at 100% of projected requirements while many of our Direct Care System needs are not addressed until year end when overforecasted PSC funding becomes available for distribution to the Direct Care System. Since Private Sector Care is often over-programmed , they return money to the MHS and they're seen as "cost containing." Our Direct Care System health care bills are always after the fact and are seen as "cost overruns." This resourcing construct appears to prioritize Private Sector Care over the Direct Care System.
Most veered from their prepared remarks (Robinson brought up San Antonio, for example) but Schoomaker's veer went to the issues raised in the hearing.
To cut down on the "gobbledeegook," US House Rep Vic Snyder gave the witnesses examples so they could speak in specifics.
US House Rep Vic Snyder: The first example is a special-needs kid which I think some of us have talked about before. General Schoomaker, you talked about supporting our war fighters overseas and I think nothing creates more heart ache for our folks overseas than if they have a special-needs kid and the kid is not getting the kind of care that they think they need while they're at a military facility some place. So let's take a kid with either insulin-dependant diabetes or autism or something that requires a fairly intensive amount of help. The second example might be that I think a lot of us have run into over the last several years would be a somebody in the reserve component who is mobolized for active duty for a period of 18 months or so, so there family then goes into the military health care system but may be geographically living in a place, not near a base, not near providers who are used to dealing with TRICARE. So what I would like each of you to do -- and just tell me if I'm off base. It may be the tensions that we were talking about, which you all were discussing, have nothing to do with those examples but how does what you're talking about relate specifically to our men and women and the care that they give and if these are a couple of examples where it may -- it may give you an opportunity to describe how the tension may relate to the actual care that men and women and their families get?
Lt Gen Eric Schoomaker: Well candidly, sir, from my perspective, both of the cases -- and I'll be interested in hearing what my colleagues have to say -- both of those cases I think are not necessarily confounded by the tensions that we're creating here. In fact, I think that both of them in many cases are a tribute to the far-sightedness and the vision of setting up a TRICARE system as we did 15 years or so ago. In the case of special-needs kids, we have an extraordinary generous benefit which is fairly uniformly applied and, in fact, I think it's resulted in -- in the military health care system being one of the elements of a family's decision with a special-needs child to stay in uniform. So I would have to say that doesn't necessarily -- I don't see my role in executing these programs as being interfered with in any way, shape or form in taking care of special-needs kids. I would have to say the same about the mobilized reserve component -- National Guard and Reserves -- many of whom come from places in this country where we don't have a robust Direct Care System: central Idaho, parts of Montanna, Wyoming. We don't have large, robust medical centers and health services systems. And so having an effective Purchase Care System and a Managed Care Support Contractor that is reaching out and providing care to those families is, I think, that again reflects the far sightedness of a well executed TRICARE program. I'm not taking away from any of that part of it.
Vice Admiral Adam Robinson: I would come at this a little differently. I don't completely disagree with General Schoomaker but I think that the autism and the insulin-dependent diabetic do come into play in this regard. Often -- first of all, the private sector care, the network care and the direct care can both play here. Let's take 29 Palms, I'll just take a Marine Corps base in southern California, very remote location. I'm not going to be able to get network care there. It's going to have to be direct care. It's going to have to be uniform care. Now when I say "I can't get it," there are people that will go there but that's very difficult so I have places in this country that are very difficult to, in fact, get network care. That means I need it in uniform [care]. However, very often there's also been -- and I don't want to get caught in the mire of the gobbledeegook -- but there's also thoughts that very often we on the direct care side and uniform should be be there for very specialized war fighting activities that make us incredibly essential for the battle and for the things that the military system in fact, was built to do. But, in fact, in 2009 we have taken on added responsibilities which include garrison and family care. So my question then is I need pediatric endocrinologists as much as I need trauma surgeons but it may be difficult sometimes to, in fact, get there because of how we have, in fact, looked at what we think we should get from the war fighting versus the non-war fighting situations. Now I'm not suggestiong to you that anyone's denying the Navy or the other services pediatric endocrinologists. I'm just simply saying that there is a tension that does exist because of some thoughts and some assumptions made as to how we really should in fact divy up our uniform versus our network. I'd like to add just one other thing. I'm not going to comment on the reserve component. I think that General Schoomaker's answer is -- would be mine also. I'd only like to say, overseas with our EDIS -- exception developmental instructional programs and also our exceptional family member programs this is also the case because overseas we're not able to, in fact, engage in that war care so if I don't have it -- if I can't either contract it to bring it or if I don't have it in uniform, it's much more difficult to get. And those are just challenges that I must look at. I'm not suggesting that anyone's keeping me from getting there but these are the challenges from an SG's perspective that I must look at.
Lt Gen James G. Roudebush: Congressman, I think you raise a point that really brings out the essence of what we're talking about this morning. There is a role and relationship and it's not "either/or" it's "and." For us in uniform there are in fact places where we are going to need to have in uniform speciality capabilities for family members because family care is mission impact. When our men and women are in harm's way, if they're not confident their families are fully cared for, they will not be focused on what's in front of them and that has mission impact. So family care plays directly into the mission. For us, TRICARE gives us that wrap-around in those circumstances where we may not have the capability readily available for our reserves in areas where we don't have a facility availabe for example. Or for special-needs youngsters, we may not have that readily available within the uniform service. TRICARE gives us that wrap-around capability. And, quite frankly, when you get to speciality care for our youngsters that is rather expensive to make and sustain in uniform. And the more cost-effective solution and clinically effective solution in many circumstances is in fact a contract for that capability and that care through the private sector TRICARE. So it's not "either/or," it's "and" and finding the right balance, each of us within our roles, to get that mission accomplished. So I think you do raise an intersection that's critically important for us to get right.
Subcommittee Chair Susan Davis: Thank you, I'm going to move on. Ms. Tsongas?
US House Rep Niki Tsongas: Thank you. I'm enjoying this testimony and I have to say much of this as a new member as a relatively new member, much of it is new to me. I have to say, many years ago as a child of the Air Force, I needed a very delicate eye surgery and I was in an Air Force hospital in Langley Air Base and then subsequently at Tachikawa Air Base. I received remarkable care and, again, I was with Congressman Wilson in Balad where we did see the remarkable work that you're doing. But obviously we're in a time and an era when health care is far more complicated and far more expensive and it's clear that you're wrestling with both on multiple layers. My question, slightly different though, is we have representatives of the different services and you obviously have different cultures, some times very different needs as a result of the roles you play, and I'm just curious as how this plays itself out given the different tensions that you all have described? Is it another layer to it or is it really not particularly significant?
Lt Gen Eric Schoomaker: Well I'll speak for the Army. I think, ma'am, it's very significant and I think it's why we -- not for parochialism or not because we're looking to build duplication or triplication within -- within the defense health system -- why we insist on executing our programs in each one of our services. Each one of the services -- for very good reasons -- has important differences in how it fights war, in how its military health care uniform members support the deployed force. And that's not to say that there aren't commonalities in some large metropolitan areas, like in the national capitol region or San Antonio, we can't find shared platforms where we can retain common skills, where we can share the opportunities in the greater Washington area where we have 36 or 37 different health care facilities across the three services from Pennsylvania down to Quantico and as far west as Fort Belvoir. We have plenty of opportunities to share those platforms for caring for about a half-million beneficiaries. But when it comes down to ships at sea and brigades in battle, some of the remote sites that General Roudebush and I in the Army have to service, the service cultures are very much a part of this and it's why we, Surgeons General and commanders of our medical forces, want to have a very firm grasp on the execution of these programs.
Vice Admiral Adam Robinson: Each service has a concept of care. I think that as the long war has continued in both Iraq and Afghanistan our concepts of care have actually become much closer together. They've merged. From the Navy's perspective, I'm not speaking now for the Army or Air Force but I don't think they're much different, patient and family-centric care is our concept. It's what we think is important in order to make sure that we can meet the mission. Both the operational -- that is the war mission -- as well as the family and the garrison care mission because we can't separate them out any longer. Since people on the battlefield, men and women can now e-mail and text message family members during an intense encounter, it is no longer the case that I can, in fact not take care of families as I'm also taking care of men and women on the battlefield. We've moved into another era of communication, of technology and of the insistence by the people that -- our beneficiaries that we in fact care for them in a very organized and meaningful way and that's what I think all three services do but we all do it differently -- leverging those things that our service chiefs and the equities of Army, Navy, Air Force and Marine Corps must have in order to meet their missions and at the same time making sure that we leave no patient, no family and no member behind.
US House Rep Niki Tsongas: And not to interrupt but do health affairs and TRICARE management acknowledge this in your relationship or is yet one more -- one of those things that is a source of tension?
Vice Admiral Adam Robinson: I think that Health Affairs does acknowledge that. I think that they do in fact understand the differences in the services and how to meet them. I also think that very often the concept of what is important from a patient perspective can sometimes get clouded or get shaded in relationship to the business perspective of efficiencies and effectiveness. Now that's the world that we live in so I'm not complaining to you about that because everyone has to look at costs and has to look at the bottom line that we're trying to get done. The key here in medicine is that patients usally when they're coming to you and they need something to save their lives, they need something that they think is going to be absolutely essential to their well being are not interested in hearing the business rules involved in doing that. My job is to, in fact, take that into account and to balance that out with the needs of the patient.
Subcommittee Chair Susan Davis: General, do you want to comment?
Lt Gen: James G. Roudebush: Just very quickly. At times folks will talk about culture and say, 'Well culture is interesting." I would suggest to you that culture is a signficant part of what we do. We have an all volunteer force. Every soldier joins the Army because he or she is attracted to the mission and the culture. Likewise every sailor and Marine and Air man joins that service because they are attracted to the culture and the mission. Their families are wrapped in that culture. We care for our servicemen within that culture and within that mission ethos. So culture is a big part and, particularly when these men and women are injured or ill, that culture wraps around them and supports them, helps them through that recovery, rehabilitation. And so while some of the -- many of the clinical activities are certainly the same in the Army, Navy and Air Force that wrap around, that family, that team that's caring for them is an important part of the construct and I think that can't be lost in the discussion.
FYI, April is Autism Awareness Month. Ruth has covered that here, here and here this month. For more information, the Autism Society of America is one resource.
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