Preparing for the Future of Combat Casualty Care

Opportunities to Refine the Military Health System's Alignment with the National Defense Strategy

by Brent Thomas

This Article

RAND Health Quarterly, 2022; 9(3):18


The Military Health System (MHS), through its global network of facilities and providers, meets the health care needs of more than 9 million service members and their dependents during peacetime. It is also responsible for treating casualties during combat operations and in the aftermath of disasters and humanitarian crises. The 2018 National Defense Strategy emphasizes a need to prepare for future combat operations that could be distinctly different from those of the past few decades. The evolving security environment is characterized by precision missile strike capabilities and a risk that adversaries will target critical military infrastructure. These types of attacks could significantly degrade U.S. combat capabilities and significantly increase casualties. There is a range of opportunities for the MHS to align its capabilities to address potential future threats. But to implement effective mitigation strategies, it requires an understanding of the numbers and types of casualties it can expect in a future combat operation, the capability and capacity to treat and evacuate casualties, the network of storage facilities and transportation assets to ensure access to medical supplies, the capacity and capabilities of the U.S. health care system overall, and gaps in the medical supply industrial base. A thorough analysis of these sources of risk highlights how the MHS can build a more agile and resilient medical support capability so that it can continue to provide the best care possible to the warfighter both at home and in combat.

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The National Defense Strategy (NDS), published by the Office of the Secretary of Defense roughly every four years, outlines the direction that the U.S. Department of Defense (DoD) will take to prepare for the global security environment in which it will operate (U.S. Department of Defense, 2018). The NDS, itself, is informed by the executive branch's national security plans and concerns, which are captured in a separate document known as the U.S. National Security Strategy. As such, the NDS informs investments to modernize the force, adapt the U.S. global force posture, and amendments to military policy and strategy to keep them aligned with future challenges.

The Growing Risk of High-Intensity Conflict

The 2018 NDS notes that such potential adversaries as China, Russia, Iran, and North Korea have been investing in long-range, precision missile systems. In response, DoD senior leaders have shifted their thinking about requirements for future combat to ensure the resilience and, ultimately, success of U.S. forces in high-intensity conflict environments. One key element of that planning falls to the Military Health System (MHS), which must ensure that combat casualty care can surmount challenges to medical support that may arise in this future battlespace.

Improving Efficiencies in the Military Health System

In recent years, Congress has directed the MHS to realign some of the responsibilities among its entities. The intent of the realignment was to improve the overall efficiency of day-to-day health care operations across the system. These reforms have been transformative for the MHS, and they have required significant institutional time and energy. For example, transitioning governance of military treatment facilities (MTFs) to the Defense Health Agency (DHA) has entailed not only a restructuring of management functions but also the development of a new electronic health record system, a reassessment of MTF infrastructure requirements, and an evaluation of reposturing options that could move medical staffing billets out of the MHS and into operational military forces.1

Additionally, Congress has directed that DHA's responsibilities include “coordinating with the military departments to ensure that the staffing at the military medical treatment facilities supports readiness requirements” for military operations (Pub. L. 116-92, 2019, Section 712, Support by Military Health System of Medical Requirements of Combatant Commands, para. (b)(1)). With its intense focus on transitioning day-to-day health care operations to DHA, the MHS could benefit from a fresh external examination of what these “readiness requirements” might entail. Namely, it could prove informative to examine readiness through the question of what the MHS might need to be ready for in providing medical support in future military operations.

Aligning MHS Operations with Evolving Threats

This study presents an analysis of the potential ramifications of this confluence of an evolving threat environment and the ongoing reforms to MHS operations. It highlights specific challenges and effects on requirements for combat casualty care. Given that the structure and governance of the MHS has changed under recent NDAAs to focus on identifying efficiencies, the study underscores the risks of underpreparing for potentially vastly increased numbers of casualties than U.S. forces have seen in recent contingencies. The findings raise important questions about the degree to which future operational requirements would stress existing military medical capabilities.

The objective of this study was to identify where MHS capabilities might benefit from closer alignment with the threats that U.S. forces could face in future conflicts. The findings are intended to help clinicians, medical logisticians, and the industrial base for medical supplies prepare for the challenges of supporting future combat operations, and this study suggests a range of mitigation strategies that the MHS could pursue to help close capability gaps in these areas. However, this study is merely a first step in addressing these issues. A more-detailed study is warranted to quantify gaps and to recommend priorities for implementing mitigation options to support an agile force, resilient logistics, robust sustainment, enhanced MHS mission sets, and increased support to the warfighter both at home and in combat.

Developing a clear vision to prepare the medical community for future conflicts can be a daunting prospect. Planning for combat medical support sits at a difficult nexus. It involves integrating a diverse set of stakeholder equities, drawing on military intelligence estimates to evaluate adversary threats, interacting with medical providers to establish a list of required clinical capabilities, and drawing insights from medical logisticians to gain a broader view of where medical practitioners will require sustainment and support. Developing a common plan that integrates insights from each stakeholder group will be essential to success in combat.

Research Approach

To help the MHS identify opportunities to better prepare for the challenges highlighted by the NDS, this study draws on open-source literature exploring how future conflict environments might differ from those of recent decades. It also identifies possible stress points in the network of care that could inhibit the treatment of combat casualties or complicate patient movement from the point of injury to a nearby field hospital and onward to hospitals in the United States (for those requiring more-comprehensive medical care). The analysis was structured around seven research questions:

  • How has DoD's picture of global threats evolved over the past decade?
  • How might weapons on the future battlefield drive different compositions of casualty streams, in terms of both casualty numbers and the distribution of injuries?
  • Are expeditionary MTFs prepared to receive those casualties and offer care at a level that wounded service members have received in recent decades?
  • Given the changing global threat picture that the NDS outlines, are the services able to rapidly establish an expeditionary network of care to receive combat casualties?
  • Is the current MHS posture of medical logistics and sustainment optimized for the likely requirements of a future fight?
  • Does the NDS mission of homeland defense introduce additional stressors that the MHS should consider?
  • Could the stressors of a future fight ripple into the industrial base that supports the MHS in caring for combat casualties?

Although this is not an exhaustive set of relevant questions, the answers highlight a range of opportunities for the MHS to mitigate risk and close potential capability gaps. This survey of challenges is intended to provide an overview candidate problem sets and areas where further analysis could inform future investment in research and development, training, materiel solutions, and other capabilities to improve medical outcomes in future combat operations.

It is important to note that this study does not explicitly address the implications for the MHS in the event of chemical, biological, radiological, or nuclear (CBRN) attacks on a future battlefield. One reason is that the intelligence assessments for these attack modes are rarely discussed in the open literature. That said, it is reasonable to assume CBRN weapon employment would drive a requirement for medical resources far larger than what would be expected in the wake of a conventional attack.

For example, a CBRN attack could accompany a conventional missile strike, so the baseline patient load could include casualties seeking treatment for trauma injuries. But a medical facility receiving CBRN casualties should be prepared to decontaminate patients before they are admitted for treatment. Similarly, if a biological vector is suspected, a mechanism for isolating the infected should be employed to ensure that the spread of the biological agent is restricted. By imposing these additional requirements, a medical facility's patient treatment rate would be expected to decline at a time when there is elevated demand for facility space, caregiver time, and medical supplies.

The following recommendations for the MHS are extracted from themes in the literature and the analytic results presented in this study.


Prepare Combat Casualty Care for a Rapidly Evolving Set of Global Threats

Rather than organizing, training, and equipping the medical force for a fight that resembles recent military operations in Iraq and Afghanistan, the MHS should consider how evolving threat conditions might change the requirements for medical support in a future fight. For example, adversaries are heavily investing in advanced missile systems, a combat capability that stands to generate more (and more-severe) casualties than U.S. forces have encountered in a century.

Forecast Likely Requirements for Care on the Future Battlefield

The MHS evolved agile, efficient networks of deployed medical personnel, facilities, and supply chains capable of quickly stabilizing, treating, and evacuating wounded service members from the Iraq and Afghanistan theaters. It saw tremendous success in treating patients injured in the line of duty and limiting loss of life. However, that posture of medical support has evolved on the predicates of relatively light patient loads and air superiority for U.S. forces to safely evacuate patients to higher echelons of care as needed. As projected in the 2018 NDS, in future large-scale combat operations, these assumptions might no longer consistently apply.

Adversary weapon systems, such as ballistic and cruise missiles, could yield large numbers of blast casualties. Weaponeering analysis suggests that the types of injuries to be expected in these blast events will be similar to those encountered in recent conflicts, but their numbers could be significantly greater. In tandem, by targeting the infrastructure that supports military mobility, an adversary can readily degrade U.S freedom of movement. In future combat operations, large streams of trauma patients and degraded evacuation availability could tax or overwhelm the capability, capacity, and throughput of deployed military medical care.

Enhance Treatment Options at and Near the Point of Injury

In preparing for future combat operations with constraints on the capability of available medical personnel to offer high-quality care to the wounded, the capacity of field hospitals to treat and hold large numbers of combat casualties, and the ability to expedite patient throughput at expeditionary MTFs, the MHS has several mitigations to choose from, and it will most likely want to adopt portfolios of mitigations to address potential gaps in all three areas (capability, capacity, and throughput). For example, better training for first responders (the injured service member, who could administer self-help first aid, and nearby service members) could improve medical capability; augmenting modular MTFs, especially by expanding critical care wards, can help increase patient holding capacity where it is most needed; and pairing resilient resupply mechanisms with triage strategies specific to mass trauma events can accelerate patient throughput.

Evaluate the Benefits of an Expanded Posture of Prepositioned Medical Assets

Given that the 2018 NDS speaks to the potential for a rapid onset of hostilities in the future combat environment, it is important to ensure that critical medical assets are close at hand, and that the U.S. military's network of expeditionary MTFs is in place before the first wave of combat casualties requires treatment.

Cold War–era planners recognized this possibility as well, and a robust network of prepositioned materiel was established in Europe to ensure that needed capability could be set up in the field quickly. Given that robust prepositioning postures have languished in the intervening years, medical planners will likely need to consider a range of options to invigorate the U.S. military's global medical warehousing network. In pursuing this mitigation approach, the MHS has to address several questions, including what to store, where to warehouse it, how to maintain it, and how to move it to likely points of end use. Additional assessments will be key to determining the cost-effectiveness of sustaining the network, how to track effectiveness and speed; and which assets will be available and how they will be transported to their intended points of end use.

Consider Options to Improve the Resilience of Medical Logistics and Sustainment Capabilities

Medical logistics plays an important role in ensuring access to medical support. The special handling and maintenance requirements of many types of stored medical materiel mean there is a need for periodic inspection, repair, and replacement. The MHS has a range of manpower options to support these operations, but it must carefully balance the cost-saving potential of civilian and contract labor against requirements to deploy military personnel in these roles who are able provide broader support for contingency operations.

Where there are gaps in asset maintenance and sustainment support, the MHS could benefit from expanded agreements with partner nations. Moreover, all medical logistics support is predicated on reliable and enduring situational awareness of what assets are where, at what levels, and in what condition. To sustain that awareness in a contested environment during combat, the MHS might need to consider ways to enhance the resilience of key data systems and communication links.

Prepare for Homeland Support and Homeland Defense Missions

The 2018 NDS emphasizes not only the growing potential for conflict overseas but also the heightened need for military support closer to home. Thus, the MHS should consider how adversary threats may drive the need for medical support in the Arctic, for example, and the ramifications for the care of trauma patients in that environment. Because large numbers of casualties could return to CONUS, the MHS would benefit from a clearer map of the rights and authorities involved in managing the flow of patients both within the MHS network and to civilian care facilities.

Build Resilience into the Industrial Base for Medical Supplies

In delivering medical support to large numbers of combat casualties, the MHS may see effects that ripple farther upstream in the medical supply chains, where surge demand could outstrip the capacity of the medical supply industrial base. In their day-to-day support to the MHS, manufacturers can generally meet contracted demands for medical supplies. However, given how the industrial base has achieved significant cost-effectiveness through advances in production efficiencies, access to some supplies could be far more constrained under the surge-demand conditions of a large-scale contingency. This may prove especially true for low-cost goods, such as saline and generic pharmaceuticals, for which supply chains can be long and the industrial base may lack meaningful surge production capacity.

The MHS should consider options to diversify its partnerships with the industrial base—possibly in concert with interagency partners—and invest in enhanced manufacturing practices to more quickly meet surge-demand signals. It could also help international partners enhance their quality-control processes to better align with U.S. Food and Drug Administration practices and regulations. In so doing, the MHS can help mitigate the risk of supply shortages while promoting flexibility in industrial supply chain operations.


Individual mitigations can have significant value in improving casualty care quality and access. However, no single solution appears to be a “silver bullet” that will broadly improve the performance of expeditionary medical care in the conflict scenarios posited by the 2018 NDS. Consequently, it is important for the MHS to develop portfolios of options and to assess each portfolio with respect to its overall cost and performance. For example, which mitigation portfolios would be most cost-effective in improving return-to-duty rates? Do they combine materiel and training solutions, such as investing in a broader network of medical WRM storage sites and expanding training for first responders? Or do they involve a shift in current policy, with increased investment in partner-nation medical support capabilities and enhancements to the industrial base for medical supplies? Clear answers to these questions were not immediately apparent from a review of recent literature. Consequently, as the MHS evaluates these considerations, it will be better positioned to inform decisionmakers and stakeholders of key cost points and where forecasted capabilities will offer maximum benefit.

The NDS has shone a light on an array of considerations for the MHS and projects a future threat environment that is starkly different from the U.S. military's experiences in recent contingencies. This has significantly changed the operational view for front-line combat units and the capabilities they need to prepare to employ against a future adversary. To sustain the warfighter's combat capability, combat service support functions, such as medical, are facing an equally daunting paradigm shift. Careful reflection on the challenges outlined in the 2018 NDS reveals a range of opportunities to improve the capability of the MHS in a future fight. With the objective of building a more agile force, the MHS has numerous options to bring resilient logistics and robust sustainment to its enhanced posture and to optimize its support for the warfighter both at home and in combat.


Military Health System, "MHS Transformation," other, webpage, undated. As of December 9, 2020:

Public Law 116–92, other, National Defense Authorization Act for Fiscal Year 2020, December 20, 2019.

U.S. Code, Title 10, Section 1073c, other, Administration of Defense Health Agency and Military Medical Treatment Facilities.

U.S. Department of Defense, other, Summary of the 2018 National Defense Strategy of the United States of America: Sharpening the American Military's Competitive Edge, Washington, D.C., 2018.


  • 1 These changes were enacted through the National Defense Authorization Acts (NDAAs) for fiscal years 2017 and 2019. For more on the shift to DHA in managing the care of service members, their dependents, and military retirees across the network of MTFs, see Military Health System, undated, and U.S. Code, Title 10, Section 1073c.

This research was sponsored by the Office of the Secretary of Defense and conducted within the Forces and Resources Policy Center of the RAND National Security Research Division (NSRD).

RAND Health Quarterly is produced by the RAND Corporation. ISSN 2162-8254.