The Warfighter Under the Pendulum
More than a decade of MHS reform has reshaped governance, authority, and budget. The warfighter has lived under all of it.
Friends,
Sergeant Reyes felt the pop in his knee on day three of train-up. His brigade was at Fort Liberty, nine weeks from a rotation. He told the medic. The medic told him to ice it.
He waited a week. The pain held. He went to sick call. Sick call gave him 800-milligram ibuprofen and a referral. The referral routed to the hospital clinic. The first available appointment came thirty-seven days out.
He kept ruck-marching. The unit needed him on the manifest.
When the appointment came, the diagnosis took six minutes. The MRI took another two weeks to schedule. By the time he had a treatment plan, the unit was in its final validation cycle. He deployed at fifty percent.
Reyes is a composite. The system he walked through is real. Its governance, facility authority, and budget architecture have all been reshaped in the last decade. He did not cause those changes. He lived under them.
The Hard Problem
The Military Health System has spent more than a decade trying to solve a problem with too many right answers. Deliver care to about 9.6 million beneficiaries. Preserve operational medical readiness. Control more than $55.8 billion in annual cost. Standardize quality across a global enterprise. Support service-specific missions that have never lined up neatly with any of the above. [3]
Inside that problem, every reform changed three things at once: who held authority, what counted as good, and how care reached the soldier.
The warfighter did not cause the pendulum. The warfighter lived under it.
Before 2013
Before DHA, the system was more service-fragmented. Each service ran its own medical department, hospitals, logistics, and contracts. Duplication was visible at every level. Cost climbed every year. Standards drifted. Service-specific missions pulled in directions that did not always reconcile with enterprise efficiency.
By the early 2010s the pressure was congressional, fiscal, and operational at the same time. Congress wanted accountability for an enterprise past $50 billion. The Pentagon wanted readiness it could measure. Beneficiaries wanted care that did not depend on which gate they drove through. The services wanted medical capability aligned with how they actually fought. Each obligation was legitimate. None lined up cleanly with the others. Reform was inevitable.
The 2013 Stand-Up
The Department of Defense established the Defense Health Agency on October 1, 2013 as a Combat Support Agency. DHA was directed to execute ten joint shared services: TRICARE, pharmacy, health IT, medical logistics, facility management, research and development, education and training, public health, budget and resource management, and contracting. [1] The architecture rested on a March 11, 2013 Deputy Secretary of Defense memorandum implementing MHS governance reform under Section 731 of the FY2013 NDAA. The memorandum also established multi-service market areas where hospitals or clinics from more than one service had overlapping service areas. [1]
The intent was enterprise efficiency. Consolidate where consolidation made sense. Standardize where standardization was achievable. Preserve service-specific responsibility where the mission required it. The early DHA structure tried to hold all three at once.
The 2017 Shift
The 2013 architecture did not settle the question. Four years later Congress went further.
Section 702 of the FY2017 National Defense Authorization Act directed a major MHS transformation, transferring certain authorities and control of military treatment facilities from the military departments to DHA. The implementation report described congressional intent plainly: a single agency responsible for MTF administration would best improve and sustain operational medical force readiness, medical readiness of the Armed Forces, access to care, experience of care, health outcomes, and total MHS management cost. [2]
The component model was the architectural compromise. The DHA Director would administer each MTF through service-led components. The Surgeons General would retain responsibility to recruit, organize, train, and equip medical personnel. [2] Authority for facilities flowed one way. Responsibility for the force flowed the other. The model required both sides to hold the bridge.
Section 702 also moved the center of gravity. From 2013 the question was how much joint shared services would consolidate. From 2017 the question became how much the services retained at the facility level. Different stakes. Different definitions of success.
For a soldier in the line of business, the change came by degrees. The same hospital still treated the same patients. What changed was the chain that approved the staffing model, the appointment templates, the IT investments, and the strategic direction. The result reached the soldier in lead times, in available appointment slots, and in what the MTF was funded to deliver.
The Pendulum
Between FY2012 and FY2022, GAO identified 158 statutory MHS reform requirements written into ten consecutive National Defense Authorization Acts. The Department had completed actions on 115 of them, roughly 73 percent. GAO also found that the Department lacked a systematic process to comprehensively monitor actions taken to address those requirements. [3]
A hundred and fifty-eight reforms in a decade. No systematic way to track what each one was doing or whether it was working.
Sean Donohue, PA-C, MPAS, PMP, in a public comment on a prior MMT issue, described what that produced: a whiplash of leadership. Appointed leaders rotated. Senior civilians in acting positions stayed. The analysis they were working from kept producing the same answers across leadership cycles, even when the stated strategic direction changed.
Each new directive arrived with its own definition of good. One era prioritized standardization across what had been three separate service systems. The next prioritized efficiency through multi-service market areas. The next prioritized network shift to absorb load the direct care system could not. The next prioritized right-sizing and access. The next prioritized direct care stabilization as MTF staffing pressures became visible. The next prioritized re-attraction. The next prioritizes protected combat medicine through the proposed COMP and PSCP appropriation split.
Each shift had a reason. None was wrong on its own terms. The compounding effect was that no single definition of success held long enough to be measured against itself. By the time a clinical initiative was three years into implementation, the strategic direction that authorized it was often two iterations old.
Leaders should have visions. The danger is in how those visions get paid for. Each new vision can be financed by pulling from programs that were already doing the work. When the promised enterprise gain does not arrive, the loss is local: fewer appointments, fewer providers, weaker prevention, more referrals to the network, and a service member who experiences reform as delay.
The Budget Tells the Same Story
The FY2026 Defense Health Program justification said the request prioritized strategic investments in large MTFs as foundational elements of the Direct Care System, with emphasis on access, geographic coverage, service availability, workforce stabilization, technology, standardization, patient safety, and readiness. Private sector care remained more than half of the Operations and Maintenance funding requirement. [4]
The same FY2026 justification stated that the most effective way to take care of people, support the National Defense Strategy, increase clinical readiness, reduce risk, and reduce long-term private sector cost growth was to re-attract beneficiaries to MTFs and maximize medical education and training pipelines. [4]
One year later, the architecture moved again. The FY2027 budget overview proposes replacing the unified Defense Health Program appropriation with two separate appropriations: the Combat and Operational Medicine Program (COMP) and the Private Sector Care Program (PSCP). COMP funds medical training platforms, combat medicine, operational medical capabilities, and readiness-critical clinical platforms. PSCP funds care purchased from the private sector when direct care lacks needed capacity or capability. [5] The FY2027 numbers: $20.3 billion in COMP discretionary funds, $3.1 billion in COMP mandatory FSRM funds, and $22.2 billion for PSCP. [5]
The split is about trust as much as transparency. For years, MTFs and service programs have lived with the risk that money planned for access, staffing, prevention, or readiness could be redirected to cover another pressure point or another vision. Sometimes the new initiative delivered. Sometimes it did not. Either way, the MTF lost capacity first and answered for the access problem later. That is the cycle the split is trying to interrupt.
H2F as a Case Study
The Army describes Holistic Health and Fitness, or H2F, as an investment in soldier readiness and lethality that optimizes physical and non-physical performance, minimizes injuries, improves post-injury rehabilitation, and helps soldiers take charge of their health, fitness, and well-being. [6] H2F places performance and rehabilitation expertise inside the brigade footprint.
A brigade H2F team is multi-disciplinary: strength and conditioning coaches, athletic trainers, physical therapists, dietitians, cognitive performance specialists, occupational therapists, and mental readiness support. The team is collocated with the unit it serves. A soldier with a knee complaint can walk into a familiar facility, see a familiar provider, and start the rehabilitation timeline the same day in many cases.
A retrospective cohort study published in Military Medicine examined H2F at Fort Liberty. The study found that H2F patients were evaluated an average of 33.8 days sooner than soldiers who went through hospital clinics. The mean time from injury to initial evaluation was 68.5 days for H2F patients compared with 102.3 days for hospital clinic patients. The mean time from initial evaluation to discharge was 46.5 days for H2F compared with 67.1 days for hospital clinic patients. [7]
The bounds of that claim are important. One installation. One studied population. A retrospective cohort design with the limitations that design carries. The study is evidence that, in a particular setting, moving performance and rehabilitation closer to the unit changed the access and recovery timeline.
The Same Instinct, Across Services
The Army was not the only service moving prevention and performance closer to the unit.
The Marine Corps Force Fitness Instructor course uses structured functional exercise science to optimize mental and physical performance, reduce injuries, and maximize unit physical readiness. [8] The Marine Corps Embedded Preventive Behavioral Health Capability places civilian behavioral health personnel inside the active-duty Operating Forces and Marine Forces Reserve to inform commanders on prevention strategy, develop MEF-based strategic prevention plans, and liaise with supporting activities. [9] The model puts behavioral health expertise on the commander's staff rather than at the end of a referral chain.
The Navy Nuclear Power Training Command runs an embedded mental health program that provides clinical services, crisis intervention, prevention activities, Expanded Operational Stress Control, Warrior Toughness, Command Resilience Team support, and command consultation inside one of the Navy's most demanding training pipelines. [10] The program shows the same pattern at unit scale: bring the capability to where the operational risk lives.
The Air Force has two visible expressions of the same pattern. Air Combat Command runs True North, embedding mental health practitioners and religious support teams in highest-priority units to deliver in-unit education, counseling, command consultation, and referrals. [11] The Air Force Academy's Integrated Resilience Office runs primary prevention work that integrates suicide prevention, sexual assault prevention, domestic violence prevention, child abuse prevention, and harassment prevention under a single data-driven framework, using an Integrated Primary Prevention Workforce to identify risk and protective factors. [12]
US Special Operations Command was the precedent that proved the model. SOCOM's Preservation of the Force and Family program operates as an integrated human performance capability across physical, psychological, cognitive, social, family, and spiritual domains, using embedded specialists and decentralized execution. [13] POTFF showed the embedded human-performance model earlier, and H2F now brings a related design logic into the conventional Army.
These programs differ by service and mission. They should not be collapsed into one model. What they share is proximity. Services and components keep moving prevention, performance, behavioral health, and resilience support closer to the operational population because the unit is where readiness loss first becomes visible.
What the Pattern Holds
The programs are different by service and by mission. They share four characteristics that the centralized enterprise has struggled to match.
Proximity. The team is collocated with the unit it serves.
Continuity. The same providers see the same population over time.
Commander integration. Unit leadership has visibility into the care, the trends, and the readiness implications.
Funding protection. The program cannot become the bill-payer every time the enterprise changes direction. Proximity and continuity do not survive if the money can be redirected before the outcome matures.
These four together explain why the embedded models keep getting built even as the enterprise architecture changes around them. They survive the pendulum because they do not depend on what the pendulum is pointing at.
Back to Reyes
When Reyes deployed at fifty percent, the system was not absent. It had been reorganized, retitled, reappropriated, restructured, and reauthorized across more than a decade. It was among the most visibly reformed enterprises in the Department. He still waited thirty-seven days.
The pendulum has moved many times. The warfighter has not.
The next move can be different.
How to Break the Cycle
The answer is not another reorganization. The MHS has already lived through DHA's 2013 stand-up, the FY2017 NDAA Section 702 transfer of MTF administration, and a long chain of statutory reform requirements that GAO later found were only partially governed through systematic monitoring. [1, 2, 3] Another swing of the pendulum will not fix what the last decade of swings could not.
The next move has to be more concrete. The administration has to make the direct care system investable again.
That starts with money. The proposed COMP and PSCP split matters because it recognizes that combat and operational medicine cannot keep functioning as a flexible bill-payer for purchased-care pressure or the next leadership vision. The split is intended to restore fiscal discipline and protect combat and operational medicine. [5] That protection only works if the money stays protected in execution.
COMP should have purpose-bound lanes for MTF staffing, access expansion, operational medicine, embedded prevention, readiness-critical specialties, medical training platforms, and medical infrastructure. Any movement of those funds should require written justification, congressional visibility, and an impact statement showing what happens to access, readiness, staffing, or return-to-duty timelines. New enterprise initiatives should not be financed by quietly thinning the same MTFs expected to recover.
The second move is to make re-attraction real. The FY2026 budget justification said re-attracting beneficiaries to MTFs is central to taking care of people, supporting the National Defense Strategy, increasing clinical readiness, mitigating risk, reducing long-term private-sector cost growth, and sustaining medical education and training pipelines. [4] The budget cannot order patients back. They return when the MTF is easier, faster, trusted, and capable.
Re-attraction has to be specialty by specialty and market by market. Start with the care that is high-volume, high-cost, and readiness-relevant: musculoskeletal, physical therapy, behavioral health, imaging, orthopedics, pharmacy, diagnostics, women's health, and chronic disease management. Staff the clinics before assigning recapture targets. Fix appointment templates before blaming patients for leaving. Repair the digital front door before asking beneficiaries to trust the system again.
The third move is to reduce purchased-care burn by stopping avoidable leakage before it leaves the MTF. Purchased care is essential. It should fill gaps when the direct system lacks capacity or capability. When it becomes the default workaround for every direct-care weakness, the Department pays twice: once in network cost, and again in lost MTF workload, weaker clinical readiness platforms, and eroded patient trust.
Every market should know its leakage map. Which referrals left because the MTF did not have capacity? Which left because the specialty did not exist? Which left because the appointment was too far away? Which left because the portal, referral process, or scheduling pathway made the network easier? Those are different problems. They need different fixes.
The fourth move is to protect embedded prevention. H2F, POTFF, Marine FFI, Marine EPBHC, Navy embedded mental health, Air Force True North, and Integrated Resilience differ by service and design. They share one lesson: prevention works best when it is close to the unit, visible to commanders, and tied to mission context. [6, 13, 8, 9, 10, 11, 12] The Fort Liberty H2F study is one example of what changes when care moves closer to the soldier: H2F patients were evaluated an average of 33.8 days sooner than hospital-clinic patients, and their mean time from initial evaluation to discharge was shorter. [7]
These programs should not become bill-payers for the next transformation. If they work, protect them. If they need to scale, scale the design pattern. If they fail, sunset them with evidence. Do not cannibalize unit-proximate prevention to fund enterprise initiatives that may never reach the service member.
The final move is accountability the warfighter can feel. The scorecard should measure the seams: time from injury to evaluation, time to behavioral health support, referral completion, limited-duty days, return-to-duty timelines, MTF recapture by specialty, portal task completion, network leakage, command consultation availability, and patient trust. If a metric does not show whether the service member got care sooner and returned to mission stronger, it is not the metric that breaks the cycle.
The way forward is shared accountability. DHA brings the enterprise spine. The services bring the mission context. MTFs bring the clinical platform. Embedded programs bring prevention close to the unit. Purchased care fills gaps when the direct system cannot. The administration's opportunity is to stop the pendulum by making every part of the system answer to the same question: did the service member get the right care, early enough, in a way that preserved readiness?
Reyes did not. He waited thirty-seven days. The next soldier should not have to.
One fight. One warfighter. One chance to heal before preventable delay becomes readiness loss.
Let's roll.
Mary
Mission Meets Tech
The views expressed in this newsletter are my own and do not represent the official position of any organization. This content is for informational purposes only.
MMT Premium
Today's free issue covers the governance, authority, and budget arc. Premium subscribers received the May 12 Capture Corner: where the pendulum becomes spend. The FY2026 DHP justification's 65 percent purchased-care figure, the December 2023 Hicks 7 percent re-attraction target by December 31 2026, the H2F workforce-and-facility map (129 brigades plus four ARNG states, two USAR commands, 59 Area Support Teams; Serco $247M base period at 15 CONUS locations with HigherEchelon, Hyperion Biotechnology, Resolution Think, and The Geneva Foundation as Team Serco partners; H2FMS data backbone with PEO Soldier procurement), the POTFF single-award IDIQ progression from KBR's $500M in 2018 to the May 2025 USSOCOM forecast at $1.5 billion (with the March 2026 solicitation date slipped — no public SAM.gov notice as of May 12, 2026, and the incumbent contract expiring October 22, 2026 per SOCOM's major acquisition listing, leaving a compressed recompete runway), True North Plus consolidation under AFMEDCOM-aligned execution per PAD 24-04, the 2026 H2F Performance Teams modeled ROI numbers (1,363 adverse events avoided and 37,484 duty days restored annually per brigade; $14.06M mean annual cost avoidance and $24.44M annual total economic value), the MSK wedge that ties access, recapture, network burn, and duty days into one capture surface, and the funding-channel caution that not every embedded readiness buy flows through DHA.
Founding Member rate: $199/year, locked permanently for the first 100 subscribers. Standard rate: $249/year or $29/month.
Premium adds 48-hour early access to deep-dive analysis, monthly Capture Intelligence Sheets with sourced action windows, direct Q&A access (reply to any premium issue), and tool discounts: ProposalPulse $14.99 per assessment, MarketPulse $35 per brief.
Subscribe at missionmeetstech.com/pricing.
Sources
[1] Defense Health Agency, "Our History," dha.mil, https://dha.mil/About-DHA/Our-History.
[2] Department of Defense, "Reform of the Administration of the Defense Health Agency and Military Medical Treatment Facilities," Section 702 Implementation Report, Health.mil, June 30, 2017, https://health.mil/Reference-Center/Reports/2017/06/30/Reform-of-Administration-of-the-Defense-Health-Agency-and-Military-MTFs.
[3] Government Accountability Office, "Defense Health Care: Additional Actions Needed to Improve DOD's Monitoring of MHS Reform Implementation," GAO-23-105710, 2023, https://www.gao.gov/products/gao-23-105710.
[4] Office of the Under Secretary of Defense (Comptroller), "Defense Health Program FY2026 Budget Justification, Volumes I and II," 2025, https://comptroller.war.gov/Portals/45/Documents/defbudget/FY2026/budget_justification/pdfs/09_Defense_Health_Program/00-DHP_Vols_I_and_II_PB26.pdf.
[5] Office of the Under Secretary of Defense (Comptroller), "FY2027 Budget Request Overview Book," 2026, https://comptroller.war.gov/Portals/45/Documents/defbudget/FY2027/FY2027_Budget_Request_Overview_Book.pdf.
[6] U.S. Army, "Holistic Health and Fitness: Soldier Readiness System," army.mil, https://www.army.mil/article/267256/holistic_health_and_fitness_soldier_readiness_system.
[7] Military Medicine, retrospective cohort study comparing H2F and hospital clinic patients at Fort Liberty, https://academic.oup.com/milmed/article/191/3-4/e648/8244219.
[8] U.S. Marine Corps, "Force Fitness Instructor," fitness.marines.mil, https://www.fitness.marines.mil/Force-Fitness-Instructor/.
[9] U.S. Marine Corps, "Embedded Preventive Behavioral Health Capability," MCO 1700.41, https://www.marines.mil/portals/1/MCO%201700.41.pdf.
[10] Naval Sea Systems Command, "Embedded Mental Health, Nuclear Power Training Command," https://www.navsea.navy.mil/Home/NNPTC/Welcome-Aboard/Embedded-Mental-Health/.
[11] Air Combat Command, "True North," https://www.acc.af.mil/Resources/TRUE-NORTH/.
[12] U.S. Air Force Academy, "Integrated Resilience Office," https://www.usafa.edu/cadet-life/cadet-support-services/integrated-resilience-office/.
[13] U.S. Special Operations Command, "Preservation of the Force and Family," https://www.socom.mil/POTFF/Pages/About-POTFF.aspx.
