Tagged Mental Health

Sharp Increase In Mental Health Illnesses In Young People May Be Linked To Social Media, Cultural Trends

The report also said that lack of sleep could be a contributing factor. Between 2008 and 2017, suicides among young adults in age brackets between 18 and 25 grew by as much as 56 percent, and the rate at which these young people entertained thoughts of suicide rose by up to 68 percent. “It’s an alarming trend,” said Dr. Ramin Mojtabai, a Johns Hopkins University psychiatrist.

Conn. High Court Ruling Clears Way For Sandy Hook Families To Sue Gun Manufacturer Over Wrongful Marketing

In the lawsuit, the Sandy Hook families seized upon the marketing for the AR-15-style Bushmaster used in the 2012 attack, which invoked the violence of combat and used slogans like “Consider your man card reissued.” Lawyers for the families argued that those messages reflected a deliberate effort to appeal to troubled young men like Adam Lanza. The court found that sweeping federal protections for gunmakers did not prevent the families from bringing a lawsuit based on wrongful marketing claims.

Students With Disabilities Call College Admissions Cheating ‘Big Slap In The Face’

For Savannah Treviño-Casias, this week’s news about the college admissions cheating scandal was galling, considering how much red tape the Arizona State University senior went through to get disability accommodations when she took the SAT.

“It felt like such a big slap in the face,” said Treviño-Casias, 23, who was diagnosed in sixth grade with dyscalculia, a disability that makes it more difficult to learn and do math. “I was pretty disgusted. It just makes it harder for people who actually have a diagnosed learning disability to be believed.”

Federal prosecutors have charged 50 people, including actresses Felicity Huffman and Lori Loughlin, in a nationwide bribery and fraud scheme to admit underperforming students to elite colleges. Some of the parents charged, the FBI said, paid to have their children diagnosed with bogus learning disabilities so they could get special accommodations on the SAT and ACT college entrance exams. Such accommodations can include giving students extra time on the tests or allowing them to take their exam in a room alone with a proctor to limit distractions. Prosecutors allege ringleaders in the scandal arranged for proctors in on the scam to correct students’ answers during or after the exam, or had someone else take the test for them.

Now, families and advocates are worried about a backlash that could make it harder for students with legitimate disabilities to get the accommodations they need to succeed.

“There are already too many hoops and hurdles disabled students must navigate in order to vindicate their civil right to higher education,” said Matthew Cortland, a lawyer and disability activist based in Boston. “My fear is that these celebrity fraudsters will incite a crackdown on accommodations. Schools and testing companies will make it even more burdensome for disabled students to get the accommodations that allow them to realize their civil right to access higher education.”

Federal law requires colleges and college testing companies to provide accommodations for students with documented disabilities, including learning disabilities. But in practice, it can be difficult for students — particularly low-income students — to get those accommodations. Students diagnosed in grade school may have to provide updated evaluations documenting their need for special accommodations — testing that can cost thousands of dollars.

Students with legitimate disabilities constantly have to fight the perception that they’re gaming the system, said Lindsay Jones, CEO of the National Center for Learning Disabilities.

Savannah Treviño-Casias, a senior at Arizona State University, worries about the backlash against educational accommodations for students with legitimate learning disabilities. She was diagnosed in sixth grade with dyscalculia, a math learning disability. (Courtesy of Savannah Treviño-Casias)

“Many people in our society assume accommodations give you an advantage. They assume, ‘I, too, would have done better,’ which is a fundamental misunderstanding,” Jones said. “But these individuals are already facing skepticism. The college admissions scandal is incredibly damaging to a population that’s already fighting to prove that they are amazing and can achieve incredible things.”

The FBI did not charge any medical professionals who might have provided a fraudulent diagnosis.

Diane Blair-Sherlock, a real estate attorney in the Chicago suburb of Villa Park, didn’t have any trouble getting entrance exam accommodations for her daughter, who is deaf, although it took three months for the College Board, which administers the SAT, to approve a sign-language interpreter.

Her son, diagnosed with Asperger’s syndrome, a form of autism, was another story. Blair-Sherlock said the College Board turned down her son’s application for accommodations on the SAT despite his having provided documentation of his disability. She finally succeeded after appealing the denial, and her son was granted extra time, breaks and an isolated area in which to take the test. He is now a student at the University of Illinois-Chicago — getting A’s and B’s, she said proudly — and Blair-Sherlock helps other parents facing similar difficulties.

“I’m looking for a level playing field,” Blair-Sherlock said. “You’re playing with kids’ lives here.”

The College Board, which also administers Advanced Placement (AP) tests, has said that requests for accommodations have increased in recent years as more students opt to take the exams, but didn’t respond to questions about specifics from KHN. Such requests rose from 80,000 in 2010-11 to 160,000 in 2015-16, and about 85 percent of requests for accommodation were approved, according to recent news reports.

In 2017, under pressure from disability advocates and amid inquiries from the U.S. Department of Justice, the company said it would streamline applications for accommodations; students who had been granted existing accommodations at their high schools — extra time on tests, for example — would have the same accommodations automatically approved for exams such as the SAT.

When documentation is requested, the College Board requires that a diagnosis be made by “someone with appropriate professional credentials” and that a diagnosis be current. For example, for students with a diagnosis of attention deficit hyperactivity disorder, or ADHD, evaluations should be no more than five years old. The College Board said it combats organized cheating by banning cellphones, analyzing test-taker behaviors and enhancing security measures at test centers, among other actions, though it failed in a number of the cases the FBI investigated.

The ACT organization, which administers the test by the same name, also requires students to have a professionally diagnosed disability and generally to already be getting accommodations in their school classrooms. It may require additional documentation, depending on the type of disability. Students reporting mood or anxiety disorders, for example, would have to provide information on the psychological tests used, as well as a history of medication and treatment. Documentation of a psychiatric disorder must be current within the past year. The ACT declined to comment on whether the number of students granted accommodations has gone up in recent years, citing the ongoing investigation.


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

A Top Oregon Psychiatry Official Acknowledges Gaps In System For Treating, Discharging People Found Criminally Insane

The head of the Oregon Psychiatric Security Review Board Alison Bort, in responding to public scrutiny over the state’s failure to properly oversee inmates who are discharged, said that the board needs to do better. Bort said she hopes a task force can examine four areas: how defendants get into the system, their treatment while under state jurisdiction, the process for early discharges and then dealing with people once they have been freed.

Social Media Activists’ Thought-Policing Is Having A Chilling Effect On Pursuing Cures For Diseases, Researchers Say

Advocates on social media are targeting scientists who release studies that don’t fit into their views on the diseases, going so far as to wishing for the demise of their careers because of a research paper. Scientists say it can dissuade researchers for wanting to do work on certain diseases, setting off a vicious cycle where patients are the ones who suffer. In other public health news: memory, drug side effects, dieting and aging.

Understanding Loneliness In Older Adults — And Tailoring A Solution

For years, Dr. Linda Fried offered older patients who complained of being lonely what seemed to be sensible guidance. “Go out and find something that matters to you,” she would say.

But her well-meant advice didn’t work most of the time. What patients really wanted were close relationships with people they care about, satisfying social roles and a sense that their lives have value. And this wasn’t easy to find.

We need “new societal institutions that bring meaning and purpose” to older adults’ lives, Fried recently told a committee of the National Academies of Sciences investigating loneliness and social isolation among older adults. (Fried is a geriatrician and dean of the Mailman School of Public Health at Columbia University.)

The committee’s deliberations come amid growing interest in the topic. Four surveys (by Cigna, AARP, the Kaiser Family Foundation and the University of Michigan) have examined the extent of loneliness and social isolation in older adults in the past year. And health insurers, health care systems, senior housing operators and social service agencies are launching or expanding initiatives. (Kaiser Health News is an editorially independent program of the Kaiser Family Foundation.)

Notably, Anthem Inc. is planning a national rollout to Medicare Advantage plans of a program addressing loneliness developed by its subsidiary CareMore Health, according to Robin Caruso, CareMore’s chief togetherness officer. UnitedHealthcare is making health navigators available to Medicare Advantage members at risk for social isolation. And Kaiser Permanente is starting a pilot program that will refer lonely or isolated older adults in its Northwest region to community services, with plans to eventually bring it to other regions, according to Lucy Savitz, vice president of health research at Kaiser Permanente Northwest. (KHN is not affiliated with Kaiser Permanente.)

The effectiveness of these programs and others remains to be seen. Few have been rigorously evaluated, and many assume increased social interaction will go a long way toward alleviating older adults’ distress at not having meaningful relationships. But that isn’t necessarily the case.

“Assuaging loneliness is not just about having random human contact; it’s about the quality of that contact and who you’re having contact with,” said Dr. Vyjeyanthi Periyakoil, an associate professor of medicine at Stanford University School of Medicine.

A one-size-fits-all approach won’t work for older adults, she and other experts agreed. Instead, varied approaches that recognize the different degrees, types and root causes of loneliness are needed.

Degrees of loneliness. The headlines are alarming: Between 33 and 43 percent of older Americans are lonely, they proclaim. But those figures combine two groups: people who are sometimes lonely and those who are always lonely.

The distinction matters because people who are sometimes lonely don’t necessarily stay that way; they can move in and out of this state. And the potential health impact of loneliness — a higher risk of heart disease, dementia, immune dysfunction, functional impairment and early death — depends on its severity.

People who are severely lonely are at “high risk,” while those who are moderately lonely are at lower risk, said Julianne Holt-Lunstad, a professor of psychology and neuroscience at Brigham Young University.

The number of people in the highest risk category is relatively small, as it turns out. When AARP asked adults who participated in its survey last year “How often do you feel lonely or isolated from those around you?” 4 percent said “always,” while 27 percent said “sometimes.” In the University of Michigan’s just-published survey on loneliness and social isolation, 8 percent of older adults (ages 50-80) said they often lacked companionship (a proxy for loneliness), while 26 percent said this was sometimes the case.

“If you compare loneliness to a toxin and ask ‘How much exposure is dangerous, at what dose and over what period of time?’ the truth is we don’t really know yet,” Periyakoil said.

Why it matters: Loneliness isn’t always negative, and seniors shouldn’t panic if they sometimes feel this way. Often, loneliness motivates people to find a way to connect with others, strengthening social bonds. More often than not, it’s inspired by circumstances that people adjust to over time, such as the death of a spouse, close family member or friend; a serious illness or injury; or a change in living situation.

Types of loneliness. Loneliness comes in different forms that call for different responses. According to a well-established framework, “emotional loneliness” occurs when someone feels the lack of intimate relationships. “Social loneliness” is the lack of satisfying contact with family members, friends, neighbors or other community members. “Collective loneliness” is the feeling of not being valued by the broader community.

Some experts add another category: “existential loneliness,” or the sense that life lacks meaning or purpose.

Dr. Carla Perissinotto, associate chief for geriatrics clinical programs at the University of California-San Francisco, has been thinking about the different types of loneliness recently because of her 75-year-old mother, Gloria. Widowed in September, then forced to stay home for three months after hip surgery, Gloria became profoundly lonely.

“If I were a clinician and said to my mother, ‘Go to a senior center,’ that wouldn’t get at the core underlying issues: my mother’s grief and her feeling, since she’s not a native to this country, that she’s not welcome here, given the political situation,” Perissinotto said.

What’s helped Gloria is “talking about and giving voice to what she’s experiencing,” Perissinotto continued. Also, friends, former co-workers, family members and some of Perissinotto’s high school buddies have rallied around Gloria. “She feels that she’s a valuable part of her community, and that’s what’s missing for so many people,” Perissinotto said.

“Look at the older people around you who’ve had a major life transition: a death, the diagnosis of a serious illness, a financial setback, a surgery putting them at risk,” she recommended. “Think about what you can offer as a friend or a colleague to help them feel valued.”

Why it matters: Listening to older adults and learning about the type of loneliness they’re experiencing is important before trying to intervene. “We need to understand what’s driving someone’s loneliness situation before suggesting options,” Perissinotto said.

Root causes of loneliness. One of the root causes of loneliness can be the perception that other people have rejected you or don’t care about you. Frequently, people who are lonely convey negativity or push others away because of perceived rejection, which only reinforces their isolation.

In a review of interventions to reduce loneliness, researchers from the University of Chicago note that interventions that address what they call “maladaptive social cognition” — distrust of other people, negativity and the expectation of rejection — are generally more effective than those that teach social skills or promote social interactions. Cognitive behavior therapy, which teaches people to recognize and question their assumptions, is often recommended.

Relationships that have become disappointing are another common cause of loneliness. This could be a spouse who’s become inattentive over time or adult children or friends who live at a distance and are rarely in touch.

“Figuring out how to promote quality relationships for older adults who are lonely is tricky,” Holt-Lunstad said. “While we have decades of research in relationship science that helps characterize quality relationships, there’s not a lot of evidence around effective ways to create those relationships or intervene” when problems surface.

Other contributors to loneliness are easier to address. A few examples: Someone who’s lost a sense of being meaningfully connected to other people because of hearing loss — the most common type of disability among older adults — can be encouraged to use a hearing aid. Someone who can’t drive anymore and has stopped getting out of the house can get assistance with transportation. Or someone who’s lost a sibling or a spouse can be directed to a bereavement program.

“We have to be very strategic about efforts to help people, what it is they need and what we’re trying to accomplish,” Holt-Lunstad said. “We can’t just throw programs at people and hope that something is better than nothing.”

She recommends that older adults take mental stock of the extent to which they feel lonely or socially isolated. Am I feeling left out? To what extent are my relationships supportive? Then, they should consider what underlies any problems. Why don’t I get together with friends? Why have I lost touch with people I once spoke with?

“When you identify these factors, then you can think about the most appropriate strategies to relieve your discomfort and handle any obstacles that are getting in the way,” Holt-Lunstad said.

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

Questions Over Retrieving A Deceased Person’s Sperm Pit Grief-Stricken Families Against Medical Ethicists

Families say the decision to retrieve the sperm of a loved one should be left to them, while doctors and ethicisits worry about the wide-ranging moral complications of starting a life that would otherwise not exist if not for medical technology. In other public health news: eating out while being overweight, medical devices, mental health, parenting, the immune system, infant tongue-ties, exercising, and more.

How Game-Theory Economists Changed The Landscape Of Living-Donor Organ Transplants

Kidney donations from living donors require a close biological match, which can be devastatingly rare to find. But organ exchange chains–where one person’s loved one gives to a patient, whose’ loved one gives to another patient and so on–have been opening up a whole world of possibilities for some families. In other public health news: gun control, depression, diabetes, AIDS, the flu, timeout, rape survivors, meat, pregnancy and more.

Must-Reads Of The Week From Brianna Labuskes

Happy Friday! Headline writers across the world (read: yours truly) breathed a sigh of relief this week when the venture formally known as “the health initiative founded by Amazon, Berkshire Hathaway and JPMorgan Chase” finally picked a name. After more than a year of tight-lipped secrecy, they settled on “Haven.” What do you guys think? I’m just thankful it’s short.

On to what you may have missed this week!

FDA Commissioner Scott Gottlieb sent shock waves through Washington and the industry when he announced he’ll be retiring at the end of the month. Gottlieb was a standout in the anti-regulatory, pro-business Trump administration as one of the most activist commissioners in recent years. Over the past two years, he has launched what could be termed a crusade against teen vaping — his most recent action coming just the day before the announcement, when he called out Walgreens and gas stations for selling tobacco products to minors — and cracked down on “miracle cures” and unregulated stem cell clinics and supplements, among other initiatives. Public health advocates are fretting that with him gone, some of the progress they’ve seen will be chipped away.

The departure is also a blow to the administration in that Gottlieb is a highly liked health official who worked well with Congress, winning over even Democratic lawmakers on Capitol Hill. Behind the scenes, he was known as someone who was “accessible,” would field lawmakers’ questions and was actively working on things that would make Congress happy. “I’ve never seen an administration official, Republican or Democrat, that has worked with the Hill so well on a bipartisan basis,” a senior congressional aide told Stat.

That’s not to say he didn’t have his critics. A decision on approving a powerful opioid late last year, in particular, drew fire from many advocates.

Gottlieb said his decision to leave was based on the fact that he missed spending time with his family, and White House officials confirmed that President Donald Trump did not seek the resignation.

Now the big question is: Who is going to replace him?

Stat: With Gottlieb’s Resignation, the Trump Administration Loses Its Backroom Whisperer on Capitol Hill

Politico: ‘Something Very Rare’: FDA’s Gottlieb Aggressively Tackled Difficult Issues

Stat: The Likely, Possible, and Longshot Contenders to Replace Gottlieb at FDA


As expected, legal challenges to the administration’s changes to the family planning rules came not in a trickle but a flood. California Attorney General Xavier Becerra, in his 47th lawsuit against the administration, said the rules restricting abortion referrals were like something out of 1920 and not 2019. Apart from California’s case, 20 states and D.C. announced they will be filing suits. Then came the announcement that Planned Parenthood Federation of America and the American Medical Association will also challenge the restrictions, deeming the changes a “domestic gag rule” and an overreach from the administration.

The New York Times: California Sues Trump Administration to Block Restrictions to Family Planning Program

The Washington Post: Planned Parenthood, American Medical Association Sue Trump Administration Over Abortion ‘Gag Rule’


Facing increasingly intense outrage over insulin prices, Eli Lilly has decided to offer an authorized generic version of its drug for half the cost. Stories of people dying after they rationed newly pricey insulin have been circulating with ever-increasing frequency, and lawmakers have made it their priority to specifically rout out answers about insulin price hikes. In that context, Eli Lilly’s move here seems more damage control than charitable, but it also puts them in good company with drugmakers who have been hotfooting it to avoid whatever worse would come out of Congress if they don’t make some changes.

Stat: Lilly Will Sell a Half-Price Version of Its Insulin. Will It Appease Critics?


Former Colorado Gov. John Hickenlooper officially threw his hat into the narrowing 2020 field this week. Hickenlooper seems to gravitate more toward the moderate wing of the Democratic Party, saying he supports universal health care in principle but refusing to get behind a “Medicare-for-all” plan. His evolution on gun control (as a governor who oversaw a mass shooting in the state where Columbine occurred) is also worth checking out.

The New York Times: John Hickenlooper on the Issues


There has always been a gap swallowing people who make too much for health law subsidies or Medicaid but not enough to comfortably afford insurance through the exchanges. A new county-by-county analysis looks at just how tough it is for the people who fall into the holes created by the ACA. A particularly striking figure? In almost all of Nebraska, a 60-year-old with a $50,000 income would pay from 30 to 50 percent of that income in premiums for the least expensive ACA health plan.

The Washington Post: ACA Premiums Rising Beyond Reach of Older, Middle-Class Consumers

Meanwhile, the Trump administration is interested in bolstering interstate insurance sales despite there being little appetite for it in the past and experts saying it wouldn’t lower premiums. In fact, the practice is already allowed under the health law, and no one does it because insurers think it’s just not worth it.

The Wall Street Journal: Trump Administration Looks to Jump Start Interstate Health-Insurance Sales


A teenager who got vaccinated against his mother’s wishes was the star witness at a hearing this week sparked in part by the measles outbreak. Ethan Lindenberger, a high school senior, hoisted the blame for his mother’s deeply rooted beliefs squarely on Facebook’s shoulders.

The anti-vaccination movement has long flourished on Facebook, partly because of the site’s search results and “suggested groups” feature. On Thursday, the company announced it has developed a policy to try to curb that culture of misinformation on vaccines, saying it will rank pages and groups that spread that kind of information lower and will keep them out of recommendations or predictions in search.

The Washington Post: Ethan Lindenberger: Facebook’s Anti-Vax Problem Intensified in Congressional Testimony

The New York Times: Facebook Announces Plan to Curb Vaccine Misinformation


After 12 long years, scientists finally announced that a second patient appears to have been cured of HIV. While the news was well-welcomed around the world — “This will inspire people that cure is not a dream,” said Dr. Annemarie Wensing, a virologist — there are some practical obstacles to consider. For example, bone marrow transplants (which is how both patients were cured) are extremely risky, especially since there are drugs that exist that can control HIV fairly well.

The New York Times: H.I.V. Is Reported Cured in a Second Patient, a Milestone in the Global AIDS Epidemic


In a scathing ruling that could have wide-reaching ramifications for the insurance industry, a judge blasted UnitedHealth Group for policies that he says were aimed at effectively discriminating against patients with mental health and substance abuse disorders to save money. The decision is part of a larger debate over parity in relation to coverage for mental health services versus other illnesses like diabetes. Insurance companies have been getting around parity requirements with internal rules, but advocates are viewing the judge’s ruling as a warning shot that those loopholes will no longer be tolerated.

The New York Times: Mental Health Treatment Denied to Customers by Giant Insurer’s Policies, Judge Rules

The FDA this week approved a cousin of party drug “Special K” to help people with severe cases of depression, marking a shift away from traditional antidepressant medications. While many said the news would give hope to desperate patients, others are worried about the potential for abuse.

The New York Times: Fast-Acting Depression Drug, Newly Approved, Could Help Millions


Honorable mention for International Women’s Day: A veritable “tsunami wave of women veterans” over the past several years is forcing the VA to step up in terms of meeting female-specific health care needs. Among basic issues are seeing to it that doctors are trained to deal with gynecological matters and ensuring that VA facilities have child care services available when female veterans come in for appointments.

The Wall Street Journal: As More Military Women Seek Health Care, VA Pursues Improvements


In the miscellaneous file for the week:

• Nearly 600,000 children have dropped off of states’ Medicaid and CHIP rolls over a one-year span. While states rush to assure anyone asking that it’s because the economy is improving, public health experts are alarmed at the disturbing trend.

Stateline: Child Enrollment in Public Health Programs Fell by 600K Last Year

• In a “craning your neck at the car wreck” sort of way, this profile on disgraced pharma bro Martin Shkreli is a wild read. Through the help of a contraband smartphone, Shkreli is, from his prison cell, still pulling the strings at his old company, schmoozing up his prison friends “Krispy” and “D-Block,” and planning his big comeback.

The Wall Street Journal: Martin Shkreli Steers His Old Company From Prison — With Contraband Cellphone

• Last year, doctors burst onto the gun-debate scene through the help of a viral tweet that directed them to “stay in their lane.” But a new analysis provides an interesting look at which lawmakers are getting the most money from physician-related PACs. (Hint: It’s overwhelming ones who are against tighter gun regulations.)

The Wall Street Journal: Doctors’ PACs Favored Candidates Opposing Gun Background Checks

• In slightly terrifying news, research that was halted over concerns it could create deadly flu viruses that could be used by terrorists was just given the green light again —without any explanation as to why. *Gulp*

The New York Times: Studies of Deadly Flu Virus, Once Banned, Are Set to Resume

• Everyone is expecting a big settlement in the sweeping opioid case against Purdue Pharma. But what happens if the opioid maker declares bankruptcy first?

Stat: If Purdue Pharma Declares Bankruptcy, What Happens to the Opioid Cases?

• Luke Perry’s early death from a stroke this week has many middle-aged Americans worried.

The New York Times: Here’s How Strokes Happen When You’re As Young As Luke Perry

• Drug companies and doctors are in a dirty war over fetal transplants. It may seem click-baity at first, but the issue is highly revealing of how the health industry works when it comes to something that could make people lots of money.

The New York Times: Drug Companies and Doctors Battle Over the Future of Fecal Transplants


That’s it from me! Have a great weekend!

Military Doctors In Crosshairs Of A Budget Battle

The U.S. military is devising major reductions in its medical corps, unnerving the system’s advocates who fear the cuts will hobble the armed forces’ ability to adequately care for health problems of military personnel at home and abroad.

The move inside the military coincides with efforts by the Trump administration to privatize care for veterans. The Department of Veterans Affairs last month proposed rules that would allow veterans to use private hospitals and clinics if government primary care facilities are not nearby or if they have to wait too long for an appointment.

Shrinking the medical corps within the armed forces is proving more contentious and complex. In 2017, a Republican-controlled Congress mandated changes in what a Senate Armed Services Committee report described as “an under-performing, disjointed health system” with “bloated medical headquarters staffs” and “inevitable turf wars.” The directive sought a greater emphasis for military doctors on combat-related needs while transferring other care to civilian providers.

Details of reductions have yet to be finalized, a military spokeswoman said. But within the system and among alumni, trepidation has increased since Military.com, an online military and veterans organization, reported in January that the Department of Defense had drafted proposals to convert more than 17,000 medical positions into fighting and support positions — a 13 percent reduction in medical personnel.

“That would be a drastic first cut,” said Dr. David Lane, a retired rear admiral and former director of the Walter Reed National Military Medical Center in Bethesda, Md.

At most risk in the current planning are positions that aren’t considered essential to troops overseas, such as training spots for new doctors and jobs that can be outsourced to private physicians and hospitals — obstetricians and primary care doctors, for example. The reductions may also limit the military’s medical humanitarian assistance and relief for foreign natural disasters and disease outbreaks.

Even in war zones, Lane warned, it would be a mistake to downplay the importance of contributions by doctors who do not specialize in trauma. In the 1991 invasion of Kuwait, for instance, cases of diseases and non-battle injuries rather than combat injuries created the most medical work, he said.

Doctors who train in the military’s highly regarded medical school — who have committed to serve in the armed forces after training— and those who do military residencies comprise much of the staff that serve troops overseas. A major deployment could leave the military flat-footed, said Dr. John Prescott, a former Army physician.

“The majority of folks in the military don’t stay in for their whole career, they stay in for a few years,” Prescott said. “I’m concerned there will be a very small cohort that will be available for deployment in the future.”

The military health system is responsible for more the 1.4 million active-duty and 331,000 reserve personnel, with 54 hospitals and 377 military clinics around the world. Split between the Navy, Army and Air Force, each with its own doctors and hospitals, the service has been targeted for years for overhaul to reduce redundancies and save costs.

The department has already started moving administrative functions under one bureaucracy, called the Defense Health Agency, which is slated to take over the service branch hospitals in 2021.

The budget for the next fiscal year is still being developed and final decisions have not yet been made, a Department of Defense spokeswoman, Lt. Col. Carla Gleason, said in an email. “Any reforms that do result will be driven by the Department’s efforts to ensure our medical personnel are ready to provide battlefield care in support of our forces, and to provide the outstanding medical benefits that Service members, retirees and their families deserve,” she said.

For years, critics of the broad role of the military health services have argued that many medical corps’ services — such as maternity care and pediatrics on bases — could be provided more effectively by civilian doctors and hospitals.

But Lane said there is too much focus on the high-profile trauma cases on the battlefield “that at the end of the day are a small portion” of medical care. “When we’re trying to put things back together that got broken during a war,” he said, “that’s what you need the most of — pediatricians, public health doctors, primary care doctors.”

Some studies commissioned by the department have concluded private hospitals could deliver less costly care, in part because doctors at hospitals take care of more patients. But the Congressional Budget Office said savings were not at all certain and that military hospitals might be less expensive if the government arranged for greater use of them.

Brad Carson and Morgan Plummer, who held senior jobs in the Department of Defense during President Barack Obama’s administration, argued in a 2016 essay that the military isn’t the best training for surgeons because it doesn’t provide them with a sufficient number of cases to develop expertise.

The military health system “has too much infrastructure, the wrong mix of providers, and predominantly serves the needs of beneficiaries who could easily have their health care needs satisfied by civilian providers at far less cost and with equal or better quality,” they wrote.

The government this year is spending $50 billion on the military health system, including Tricare insurance for more than 9 million active-duty service members, veterans, families and survivors, according to Congress’ budget office. That is roughly a tenth of the military budget. The CBO projected costs are on track to increase to $63 billion in 2033.

Defenders of the system reject the idea that non-wartime jobs can be eliminated without it hurting that core mission.

“Military health care providers between deployments maintain their clinical skills by treating service members and millions of beneficiaries,” Dr. Arthur Kellermann, dean of the school of medicine at the Uniformed Services University in Bethesda, wrote in a 2017 Health Affairs article. “Military hospitals provide valuable platforms for teaching the next generation of uniformed health care professionals and standby capacity for combat casualties.”

Prescott, the former Army doctor, said that the military may have trouble turning to civilian doctors in some regions given physician shortages, which he said the military cuts would exacerbate.

“Most hospitals are already pretty full, most health care providers are pretty busy,” said Prescott, now chief academic officer at the Association of American Medical Colleges.

Doctor shortages would increase if the military cut the slots it now has to train doctors, because there wouldn’t be new civilian residencies created to compensate. “Those positions basically disappear,” he said.

Kathryn Beasley, a retired Navy captain who is director of government relations for health affairs at the Military Officers Association of America, said she was also concerned with unforeseen consequences of dramatic cuts.

“Everything’s tied together, there’s a lot of interdependencies in these things,” she said. “You pull a string on one and you might feel it in an area you don’t expect.”