The outgoing director of the Defense Health Agency said the biggest challenge facing military medicine in coming years won’t be physician shortages or prescription management or any of the other major issues facing health care in America today.

It’ll be politics.

“The military health system is at an inflection point,” said Vice Adm. Raquel Bono, who after four years in the top military health post will retire next week. “Part of the challenge of any change effort is making sure you have a consistent number of informed and engaged leaders.

“I’m on my sixth acting leader right now … and we’re coming up on another election year.”

Bono is stepping away from her own leadership role amid a dramatic transformation in Defense Department medical operations. Over a three-year period that began last fall, the DHA will assume direct management of all military health facilities, trimming redundancies throughout the services’ current medical sites.

The next steps in the move, mandated by Congress in 2016, include overseeing budgets for dozens of separate locations, shepherding in a new electronic medical records system compatible with the Department of Veterans Affairs, and trimming as many as 17,000 medical billets from the ranks in the name of efficiency.

But Bono, who has served in various medical leadership roles over her 40-year career, said those issues all become more complicated if Pentagon leadership doesn’t stay focused on ensuring the changes are implemented methodically and with patients’ needs in mind.

“Change is always going to be a challenge,” she said in a roundtable with reporters this week. “But there is a real interest (from military families) in us moving forward.

“From the patients’ perspective, at first they won’t see many visible changes. But as our new markets and the (military treatment facilities) begin to evolve, what they’ll see is how they make an appointment in Virginia will be the same way they make an appointment in San Diego.”

But that depends on consistent funding and attention from senior Defense Department and administration officials. Bono acknowledged that in recent years, the turnover within military leadership ranks has complicated that process, requiring a significant amount of remedical explaining as new officials come in.

“It’s an effort in getting them up to speed as quickly as possible, making sure they know what the main issues are, and being able to show the projected outcomes,” she said.

Next year’s election could likely bring more upheaval, regardless which presidential candidate wins. “Our stakeholders are Congress too, and there is going to be changeover there too,” Bono said.

On the potential 17,000 medical billet cuts — among the most controversial military health care changes under consideration — Bono said about a quarter of those positions are currently vacant. The agency will spend the next few months evaluating how to better fill those needs, then evaluate whether the other positions should also be outsourced or otherwise replaced.

She also sees increased collaboration with VA medical facilities as a natural next step in military medicine’s evolution, especially in light of the massive shared electronic health records project the separate agencies are developing.

That could mean more shared medical sites, similar to joint DOD and VA hospitals in Illinois and Alabama. Bono, who plans continuing her health care work as a civilian, said she sees those kinds of partnerships as critical not only within the federal systems, but in the private sector as well.

“The military health system is a microcosm of the larger national health system, and the challenges we have … they’re not unique to military health,” she said. “So much of what I’ve learned in the military system has great applicability to the larger American health care system. So I’d like to be able to disrupt health care in my next job too. I think there are opportunities there.”