    [House Hearing, 119 Congress]
    [From the U.S. Government Publishing Office]

                           HIDDEN WOUNDS: EFFECTIVELY
                          SUPPORTING VETERANS WITH TBI
    =======================================================================

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                         COMMITTEE ON VETERANS' AFFAIRS

                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED NINETEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                            THURSDAY, MARCH 5, 2026

                                   __________

                               Serial No. 119-50

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                        Available via http://govinfo.gov
                                   __________

                         U.S. GOVERNMENT PUBLISING OFFICE
    63-371                       WASHINGTON : 2026
    =======================================================================

                         COMMITTEE ON VETERANS' AFFAIRS

                         MIKE BOST, Illinois, Chairman

    AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking
        American Samoa, Vice-Chairwoman      Member
    JACK BERGMAN, Michigan               JULIA BROWNLEY, California
    NANCY MACE, South Carolina           CHRIS PAPPAS, New Hampshire
    MARIANNETTE MILLER-MEEKS, Iowa       SHEILA CHERFILUS-MCCORMICK,
    GREGORY F. MURPHY, North Carolina        Florida
    DERRICK VAN ORDEN, Wisconsin         MORGAN MCGARVEY, Kentucky
    MORGAN LUTTRELL, Texas               DELIA RAMIREZ, Illinois
    JUAN CISCOMANI, Arizona              NIKKI BUDZINSKI, Illinois
    KEITH SELF, Texas                    TIMOTHY M. KENNEDY, New York
    JEN KIGGANS, Virginia                MAXINE DEXTER, Oregon
    ABE HAMADEH, Arizona                 HERB CONAWAY, New Jersey
    KIMBERLYN KING-HINDS, Northern       KELLY MORRISON, Minnesota
        Mariana Islands
    TOM BARRETT, Michigan

                           Jon Clark, Staff Director
                      Matt Reel, Democratic Staff Director

                             SUBCOMMITTEE ON HEALTH

                   MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman

    JACK BERGMAN, Michigan               JULIA BROWNLEY, California,
    GREGORY F. MURPHY, North Carolina        Ranking Member
    DERRICK VAN ORDEN, Wisconsin         SHEILA CHERFILUS-MCCORMICK,
    JEN KIGGANS, Virginia                    Florida
    ABE HAMADEH, Arizona                 MAXINE DEXTER, Oregon
    KIMBERLYN KING-HINDS, Northern       HERB CONAWAY, New Jersey
        Mariana Islands                  KELLY MORRISON, Minnesota

    Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
    hearing records of the Committee on Veterans' Affairs are also
    published in electronic form. The printed hearing record remains the
    official version. Because electronic submissions are used to prepare
    both printed and electronic versions of the hearing record, the process
    of converting between various electronic formats may introduce
    unintentional errors or omissions. Such occurrences are inherent in the
    current publication process and should diminish as the process is
    further refined.
                             C  O  N  T  E  N  T  S

                                  ----------

                            THURSDAY, MARCH 5, 2026

                                                                       Page

                               OPENING STATEMENTS

    The Honorable Mariannette Miller-Meeks, Chairwoman...............     1
    The Honorable Julia Brownley, Ranking Member.....................     3

                                   WITNESSES
                                    Panel I

    Dr. Rachel McArdle, Ph.D., Deputy Executive Director,
      Rehabilitation and Prosthetic Services, U.S. Department of
      Veterans Affairs...............................................     5

            Accompanied by:

        Dr. Joel Scholten, Executive Director, Physical Medicine and
            Rehabilitation, U.S. Department of Veterans Affairs

                                    Panel II

    Mr. Al Johnson, Army Veteran, Flight Surgeon.....................    19

    Mr. Buster Miscusi, Marine Corps Veteran, Graduate of Operation
      Mend...........................................................    21

    Dr. Russell Gore, MD, FAAN, Chief Medical Officer, Avalon Action
      Alliance.......................................................    23

                                    APPENDIX
                        Prepared Statements Of Witnesses

    Dr. Rachel McArdle, Ph.D. Prepared Statement.....................    41
    Mr. Al Johnson Prepared Statement................................    44
    Mr. Buster Miscusi Prepared Statement............................    55
    Dr. Russell Gore, MD, FAAN Prepared Statement....................    58

                           Statements For The Record

    Association of VA Neurology Services (AVANS) Prepared Statement..    67
    Wounded Warrior Project Prepared Statement.......................    69
    Document for the Record Submitted by The Honorable Julia
      Brownley, U.S. House of Representatives, (CA-26)...............    76
    American Academy of Neurology Prepared Statement.................    85
    Document for the Record Submitted by The Honorable Greg Murphy,
      U.S. House of Representatives, (NC-03).........................    88

                           HIDDEN WOUNDS: EFFECTIVELY
                          SUPPORTING VETERANS WITH TBI

                                  ----------

                            THURSDAY, MARCH 5, 2026

                        Subcommittee on Health,
                        Committee on Veterans' Affairs,
                                 U.S. House of Representatives,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 10:15 a.m., in
    room 360, Cannon House Office Building, Hon. Mariannette
    Miller-Meeks [chairwoman of the subcommittee] presiding.
        Present: Representatives Miller-Meeks, Bergman, Murphy,
    King-Hinds, Brownley, Cherfilus-McCormick, Conaway, and Dexter.
        Also present: Representative Stauber.

       OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN

        Ms. Miller-Meeks. The Subcommittee on Health will now come
    to order. Without objection, the chair may declare recess at
    any time.
        Before we begin, please join me in keeping the
    servicemembers deployed to the Middle East and in harm's way in
    our thoughts, as well as the families of the courageous
    servicemembers who recently gave their lives, to keep them in
    our thoughts and our prayers. Two of those individuals are from
    Iowa and deployed with the 103d Sustainment Command out of Des
    Moines.
        I would like to welcome all members and witnesses to
    today's hearing. March is Brain Injury Awareness Month, so this
    is very timely and it is why I am also proud to be leading this
    hearing on how the U.S. Department of Veterans Affairs (VA) can
    continue to lead the way in the care for traumatic brain
    injury, or TBI. In a budget briefing last summer, the VA shared
    that TBI is the top clinical, legislative, and agency priority.
    I look forward to hearing how the VA has prioritized TBI so far
    and what we can expect for the rest of the year.
        I am confident that the VA has all the data, legal
    authority, and funding it needs to effectively treat TBI. Right
    now, I believe the VA's main objective should be to build on
    the quality of data and the quality of care for the veteran.
        Here is what the VA does best: specialized treatment,
    rehabilitation, and research. After enrollment in VA
    healthcare, veterans are assigned to a primary care team. These
    primary care staff are trained on the issues unique to post-
    deployed veterans, and that includes TBI. I am pleased that TBI
    and other issues unique to veterans are part of the primary
    care experience at the VA, not a specialty that requires extra
    steps.
        VA polytrauma centers are a key resource for veterans with
    TBI. At these centers, the VA is not just treating, but leading
    in outpatient and inpatient care for veterans with TBI and, in
    fact, their treatment model will probably become state-of-the-
    art across the United States. The centers in Richmond, Tampa,
    Minneapolis, Palo Alto, and San Antonio are knowledge hubs for
    other facilities treating polytrauma nationwide. This is
    important infrastructure to treat veterans diagnosed with
    complex multi-trauma injuries, including TBI.
        The VA's research enterprise is also unmatched. One
    longitudinal research program, LIMBIC, examines the effects of
    and treatment for service-connected TBI with a focus on long-
    term effects of mild TBI. The LIMBIC goals are, one, to learn
    more about how concussion affects the brain; two, find out
    effects of concussion later in life, such as risk for dementia;
    three, see if some servicemembers and veterans are more likely
    to be affected or have a predilection for; and, four, identify
    the best treatments for concussion.
        VA researchers at this center have documented links between
    combat concussions and dementia, Parkinson's disease, chronic
    pain, opioid use, and suicide risk. They have also developed
    specialized diagnostic tests using questionnaires, physical
    exams, brain imaging, fluid biomarkers, and electrophysiology
    to probe how the brain recovers from injury. With these systems
    in place, as a physician, I believe the VA can evaluate
    veterans with TBI and can enact intervention earlier.
        I have heard many veterans share their positive experiences
    with the VA. Indeed, a report by the VA Office of Inspector
    General (OIG) about TBI treatment at one facility revealed that
    the facility was provided needed care for veterans with TBI.
    Unfortunately, I have also heard from veterans that that has
    not been their experience at the VA. Here is where I have seen
    the VA needs improvement: consistent quality in patient care
    and data.
        In January, the VA OIG released a report about a patient
    who died by suicide after receiving mental healthcare at a VA
    facility. Among the reviewed concerns, the VA OIG found that
    the VA facility did not provide adequate follow up for the
    patient's TBI. This veteran was a middle-aged male with a
    history of mental illness, migraines, chronic pain, and gait
    disturbances with documented falls. In other words, his was the
    classic clinical picture of an individual with TBI. Yet somehow
    the patient did not receive follow ups specific to TBI and his
    mental health only declined until the end.
        Fortunately, the facility in question now requires annual
    training on TBI screening and care consultations. I wish this
    had been the case sooner, but at least it is the case now.
        At another facility, the OIG found that a veteran who had
    screened positive for TBI and died by suicide failed to receive
    adequate care at the VA. Among other issues, faculty staff did
    not submit a consultation for a TBI evaluation following the
    veteran's positive TBI screen, even though a consult is
    required.
        This is not acceptable. These veterans earned TBI care at
    the VA and their service demands better from all of us. Their
    service demands consistency and quality care. They deserve to
    know that the VA has their back. While quality inpatient care
    is the most urgent need, quality and data is also necessary. In
    the past, annual congressional reports have reflected outdated
    information and the number of inpatient beds dedicated to TBI.
    Reports have also omitted key spending information and the
    number of veterans with TBI treated annually.
        Some might say, does it matter? Well, these numbers show
    the VA's capacity to provide care. These numbers should reveal
    the needs of the patient population and how a medical center is
    able to meet those needs. Congress needs this information to
    know what resources to allocate to the VA for TBI care. The VA
    also needs to get these numbers to determine the resources a
    hospital should get.
        I know the VA has the capability to report this kind of
    data. Like I said, VA has all the data it needs. It must
    capture that data consistently and then be able to translate
    that information into clinical practice. Otherwise, wrong data
    takes resources away from areas of need, and I look forward to
    hearing from the VA about how they are going to put this into
    practice.
        Under my leadership, veterans health has always been this
    subcommittee's priority. We must eliminate preventable errors.
    As a practitioner and a 24-year Army veteran, I know excellence
    is possible and it is imperative. The one who bears the cost of
    shortfalls is always, always the veteran.
        This also means positioning the VA to support the veteran
    of contemporary and future warfare. This is where I see
    opportunities for the VA. We may not know the landscape of
    tomorrow's battlefield, but with the right systems and the
    right people in place, the VA can navigate and pivot to
    whatever lies ahead.
        Finally, while we may not discuss it extensively today, I
    want to recognize the veterans who use residential
    rehabilitation for TBI. This population is small, but it is far
    from invisible. I appreciate efforts by the VA's geriatrics and
    Extended Care Program to address the needs of these veterans,
    and I will take the opportunity I can, to ensure that these
    veterans get the care they deserve from the VA.
        Under the leadership of Chairman Bost, President Trump, and
    Secretary Collins, I am confident that the VA's role as a
    premium care provider for veterans with TBI. While the VA is on
    mission, it is the best in the business for veterans with
    chronic and sometimes catastrophic injuries, visible and
    hidden.
        I now yield to Ranking Member Brownley for any opening
    remarks she may have.

          OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

        Ms. Brownley. Thank you, Madam Chair, and thank you for
    your words with regards to our six servicemembers who died
    proudly serving our country. I appreciate it very, very much.
        Traumatic brain injuries are one of the most common
    service-related injuries facing veterans today. Even mild TBIs
    can lead to lifelong complications and challenges for veterans
    who have sustained them. As our understanding of TBIs and their
    risk and our ability to diagnose them, we must ensure that VA
    is equipped to treat and care for veterans with TBIs at all
    points of their recovery journey. I am looking forward to
    hearing more from our VA witnesses about the current approach
    to care and a treatment, as well as future developments the VA
    is working toward.
        TBI is not an illness that goes away with medicine, nor is
    it an injury that heals with bandages. It is a long-term
    chronic condition for which many veterans need ongoing,
    integrated, and well-coordinated care to manage symptoms and
    make strides toward recovery. That is why, as the largest
    integrated healthcare system in the United States, VA is well
    suited to provide the level of care that veterans with TBI
    need.
        Through its Polytrauma System of Care, veterans receive
    specialized, interdisciplinary, customized care for any and all
    injuries and conditions related to their service, including TBI
    and any co-occurring conditions. With its tiered hub-and-spoke
    model, the system is designed to provide care to veterans
    wherever they are and whatever level of care is appropriate for
    them.
        I expect we will hear from some witnesses today that
    legislation like the Veterans TBI Breakthrough Exploration of
    Adaptive Care Opportunities Nationwide (BEACON) Act is
    necessary to fill gaps in VA's care. I do not disagree that
    veterans may need support from several different avenues to
    support their recovery journeys, and I do not discount the role
    that nonprofits and academic affiliates play in facilitating
    and supporting that care. However, I need to draw the line at
    legislation that will take money from existing VA programs and
    redirect it to outside organizations and providers to do
    essentially the very same thing VA is already doing, but with
    fewer guardrails and fewer requirements to ensure quality of
    care.
        The BEACON Act contains several concerning provisions.
    First, the bill would divert funding from both VA general
    mental healthcare programs and the National Center for Post-
    Traumatic Stress Disorder (PTSD) to establish grant programs
    for outside entities. This funding is intended for both the
    provision of mental healthcare and to advance the study and
    treatment of PTSD. Although many veterans with TBI also suffer
    from associated mental health conditions or PTSD, it is simply
    not appropriate to fund outside entities to provide care using
    these sources.
        It is very difficult to understand this funding structure
    as anything other than a drain on the resources that VA can use
    to provide direct care to veterans who need it. One of the
    grant programs even requires VA to contract with a third party
    entity modeled after its own National Center for PTSD to
    administer the grants. If we are serious about expanding TBI
    treatment funding and research for veterans, why are we asking
    a third party entity to copy what VA is already doing instead
    of giving VA the resources it needs to do this itself?
        Second, eligible entities are expected to use the funding
    under these grant programs to conduct clinical trials related
    to TBI. However, the bill does not establish sufficient uses of
    funds or require sufficient scientific rigor to ensure the
    outcomes of the clinical trials are usable. Further, not only
    all of the eligible entities are equipped or have the necessary
    experience to conduct robust clinical trials.
        VA's existing research infrastructure is better suited to
    conduct these trials and already does. There is nothing
    stopping academic institutions and community providers who wish
    to treat veterans from working with VA through its academic
    affiliate network or the Community Care Program.
        Taken together, these concerning provisions of the BEACON
    Act represent an effort to diminish VA's direct care program
    and research enterprise and create no strings attached handouts
    of VA's funding to private companies. Not only is this wasteful
    and duplicative, but it could lead to a further fracturing of
    continuity of care for veterans.
        On that note, I ask unanimous consent to enter into the
    hearing record this article from the American Prospect that
    expands on many of the concerns I have just raised.
        Ms. Miller-Meeks. No objection.
        Ms. Brownley. As our understanding of TBI's diagnosis and
    how to treat it evolves, I am confident that VA's TBI model of
    care will evolve with it. In fact, I believe that many
    colleagues on this committee will continue to provide robust
    oversight and direction to ensure that it does. What VA does
    need is the resources and support to continue to build on its
    existing System of Care. Legislation like the BEACON Act will
    only run counter to those efforts.
        This hearing is an excellent opportunity to hear directly
    from veterans with TBI about their experiences and where VA's
    care can improve. I look forward to hearing from the witnesses
    on Panel 2 about how we can achieve our shared goal of
    improving TBI care at VA. I hope we will all keep in mind that
    the investment we need to make in VA's existing care model to
    achieve that goal.
        With that, Madam Chair, I yield back.
        Ms. Miller-Meeks. Thank you, Ranking Member Brownley.
        I would now like to introduce the first panel. Testifying
    before us on behalf of the VA, we have Ms. Rachel McArdle,
    deputy executive director of Rehabilitation and Prosthetic
    Services at the VA. She is accompanied by Dr. Joel Scholten,
    executive director of Physical Medicine and Rehabilitation
    Services at the VA.
        Dr. McArdle, you are now recognized for 5 minutes to
    present your testimony.

                      STATEMENT OF RACHEL MCARDLE

        Dr. McArdle. Chairwoman Miller-Meeks, Ranking Member
    Brownley, and members of the subcommittee, thank you for the
    opportunity to speak with you today about the Department of
    Veterans Affairs' efforts to support veterans living with
    traumatic brain injury, or TBI. I am joined today by Dr. Joel
    Scholten, executive director of Physical Medicine and
    Rehabilitation. Together, we are honored to share how VA is
    addressing the complex, lifelong needs of veterans with TBI
    through comprehensive care, research, and innovation.
        TBI remains one of the most challenging injuries faced by
    our veteran population. It can occur from a blow to the head,
    rapid acceleration, deacceleration, or blast exposure, and Its
    effects vary widely, from headaches and dizziness to memory
    problems, mood changes, and physical impairments. TBI rarely
    occurs alone. Many veterans experience co-occurring PTSD,
    chronic pain, or sleeping difficulties, which complicate
    diagnosis and treatment. Understanding these overlapping
    conditions, if we are to effectively support veterans at every
    stage of their lives, is essential.
        We also recognize the growing significance of military
    occupational blast exposure, or MOBE, repeated exposure to
    jets, artillery fire, or breaching operations. While these
    exposures may not cause immediate symptoms, they can have
    cumulative effects that resemble TBI and lead to long-term
    challenges with employment, driving, and interpersonal
    relationships. As we better understand the scope of MOBE, VA is
    committed to adapting our care system to meet these evolving
    needs.
        VA has built an integrated nationwide system to ensure
    veterans with TBI receive comprehensive personalized care. At
    the center of the effort is the Polytrauma System of Care,
    which includes 5 Polytrauma Rehabilitation Centers, 23
    Polytrauma Network sites, and numerous polytrauma support
    clinics. Together they support over 110 TBI teams across VA.
        Since 2007, VA has screened 1.8 million veterans, post 9-11
    veterans, for TBI, connecting them with specialists for
    evaluation and treatment. In Fiscal Year 2025 alone, VA treated
    more than 160,000 veterans with TBI-related conditions. Every
    veteran receives an individualized plan addressing physical,
    cognitive, and emotional needs, often integrated with mental
    health services and patient-centered care approaches to support
    recovery and resilience.
        We are expanding access to care through tools like VA's
    Concussion Coach Mobile app as well as telehealth and virtual
    rehabilitation programs that ensure veterans, including those
    in rural or underserved areas, can achieve TBI care when they
    need it.
        VA's commitment extends beyond clinical care. Research and
    innovation remain central to improving long-term outcomes for
    veterans with TBI. VA supports multiple research programs,
    including Long-Term Impact of Military Relevant Brain Injury
    Consortium and the Translational Research Center for TBI and
    Stress Disorders. These efforts advance precision diagnostics,
    identify biomarkers, and develop interventions, including
    understanding the cumulative effects of repeated blast
    exposure.
        The Brain Health Coordinating Center serves as VA's central
    hub for advancing brain health. It integrates data from across
    our medical centers to identify risk factors, track outcomes,
    and support new clinical trials in diagnostics and
    therapeutics. Our academic affiliations and participation in
    TBI model systems ensure VA remains a leader in evidence-based
    rehabilitation and that new research is rapidly translated into
    better care for veterans.
        Despite these advancements, challenges remain. There is
    still no single test capable of distinguishing symptoms caused
    from TBI from those caused by other health conditions and many
    veterans with mild or repeated TBIs continue to experience
    persistent symptoms that are difficult to treat. To address
    this, VA is advancing Total Brain Diagnostics, a precision
    brain health initiative to identify and validate biomarkers
    that improve diagnosis of complex conditions, including TBI.
        Looking ahead, VA will continue to enhance blast exposure
    documentation, expand brain health approaches, strengthen
    telehealth and intensive outpatient rehabilitation programs,
    and deepen relationships with academia, Veterans Service
    Organizations (VSO), nonprofits, and the Department of War.
    Above all, we remain committed to proactive veteran-centered
    care that supports long-term health and prevents functional
    decline.
        In closing, VA is steadfast in our commitment to delivering
    world-class care, advancing research, and supporting veterans
    and families affected by TBI.
        Thank you for your leadership and for your continued
    support. We look forward to your questions.

        [The Prepared Statement Of Rachel McArdle Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you very much.
        As is my typical practice, I will reserve my time until all
    other members have had a chance to ask their questions.
        I now recognize Ranking Member Brownley for 5 minutes for
    any questions she may have.
        Ms. Brownley. Thank you, Madam Chair, and thank you for
    your testimony this morning.
        Dr. McArdle, what are some examples of things VA would be
    able to do within a--pardon me?
        Ms. Miller-Meeks. I wanted to recognize your member.
        Ms. Brownley. Oh, go right ahead.
        Ms. Miller-Meeks. It is already done.
        Ms. Brownley. Oh, okay. I will start from the top. What are
    some examples of things VA would be able to do with an
    additional $60 million in funding to advance the care provided
    to veterans with TBIs?
        Dr. McArdle. Thank you for the question, Ranking Member
    Brownley. It sounds like you may be referring to the pending
    legislation that VA testified on in January. As to how would VA
    spend an additional 60 million, we are grateful for the support
    of this committee. I will take that question back for the
    record in order to conduct a full and appropriate review of our
    programs for you.
        Ms. Brownley. Would you say that VA needs $60 million
    additionally to properly serve our veterans?
        Dr. McArdle. I appreciate the question. My focus today is
    to share with you what we are doing in TBI and I will follow up
    with your office.
        Ms. Brownley. Okay. All right.
        Dr. Scholten, can you expand on VA's integrated approach to
    treat both TBI and co-occurring conditions, including PTSD? How
    does this affect veterans' outcomes, and I want--and this is
    the important part of the question, especially compared to
    individuals who may be navigating care outside of the VA?
        Dr. Scholten. Thank you for that question, Ranking Member
    Brownley. As you point out, TBI and PTSD commonly co-occur in
    veterans. VA research has shown that veterans who participate
    in evidence-based therapies for PTSD also show improved
    cognitive functioning both in regards to their PTSD and/or TBI
    symptoms. This highlights the importance of our approach of
    developing an individualized plan of care for every veteran
    with traumatic brain injury.
        As each veteran has a unique presentation, therefore their
    plan of care should be individually developed. Any efforts we
    can do to better integrate care delivery will likely result in
    greater impact on symptom reduction and treatment reduction.
        I would also like to point out that it is incredibly
    important to engage with a veteran's family and their
    caregiver. Integrated care relies on keeping the veteran
    informed and at the center of the care plan with input and
    assistance from their caregivers and families. That care is
    obviously easier to provide when it is provided within the VA
    healthcare system, as we are focused on providing wraparound
    services for veterans with traumatic brain injury.
        Ms. Brownley. Thank you. Can you describe VA's approach to
    addressing the differences in TBI symptoms and experiences
    between men and women veterans?
        Dr. Scholten. Thank you for the question. Yes, we have a
    very large research program. As was mentioned earlier, VA
    allocates over $50 million to research in Fiscal Year 2025 to
    175 research programs. A specific example that we have learned
    from our VA research includes understanding the unique effects
    that women might experience compared to their male
    counterparts.
        One significant difference is the cumulative trauma
    exposure. We have found that female veterans have a much higher
    trauma burden, disproportionately affected by military sexual
    trauma and intimate partner violence (IPV). Therefore, we need
    to screen for military sexual trauma as well as IPV, and better
    incorporate mental health treatments into the individualized
    care plan.
        In addition, the LIMBIC study, which was mentioned earlier
    in the opening statements, has shown that female veterans with
    a history of at least one TBI present with worse psychological
    health outcomes in the areas of PTSD, depression, TBI symptoms,
    and quality of life, again highlighting the importance of an
    individualized care plan that addresses the unique needs of
    that veteran.
        Ms. Brownley. Thank you for that and I yield back.
        Ms. Miller-Meeks. Thank you, Ranking Member Brownley.
        The chair now recognizes Representative King-Hinds for 5
    minutes for any questions she may have.
        Ms. King-Hinds. Thank you, Chair. Thank you to you, Dr.
    McArdle and Dr. Scholten, for being here and hopefully have a
    conversation about this future of some of these research
    programs that are on the way.
        I had prepared remarks, but I was coming here, this very
    decorated war hero from the Northern Marianas came to mind. He
    is actually a good friend. He is my neighbor and he is
    suffering from TBI, but he is having a challenge connecting the
    TBI to his service. He served in the Iraq War and he was
    exposed to a lot of toxins, which he believes has contributed
    to some of his injuries. The last time I saw him, you know, he
    was sharing that if you were to describe his pain level 1 to
    10, it is a 12. You know, the solution that is given to him is
    just more pain meds. Right?
        I kind of wanted, because we are talking about advancing
    research, I kind of wanted to hear a little bit more from you,
    whether you are considering whether traumatic brain injury
    linked to toxic exposure should be evaluated for presumptive
    service connection. If not, what specific evidentiary threshold
    is preventing that? He has been going through this process and
    every time he files the claim, it seems like he has run out of
    options. I just want to find a way to help him out.
        Dr. Scholten. Thank you for that question and thank you for
    sharing that story. First, I would like to point out that I can
    talk about the clinical presentation of the individual that you
    mentioned. I am unable to comment on the presumptive ratings as
    VA has a process that they work through in studying the
    research evidence to determine those.
        I will say that veterans--VA screens all post 9-11 veterans
    for possible traumatic brain injury. Those individuals with a
    positive screen are referred to a TBI specialist to complete a
    thorough clinical history and physical examination to document
    or come up with a diagnosis. As part of the healthcare system
    and as part of that evaluation, an individual plan of care is
    developed. Hopefully, that individual will also have completed
    the toxic exposure screening that VA offers for every veteran
    and repeats every 5 years.
        We know that each individual veteran has a unique
    presentation. Toxic exposures and other traumas that veterans
    may experience during their military service can affect the
    trajectory of their clinical recovery as well as their symptom
    presentation. Helping to devise a comprehensive evaluation and
    then coming up with a plan that will work for that individual
    veteran is essential.
        Ms. King-Hinds. Okay. Can I just ask a more directed
    question? Is there research currently underway examining
    whether toxic exposures, including burn pits, can contribute to
    a worsening brain injury--to a worse brain injury?
        Dr. Scholten. I cannot--yes, there are certainly a number
    of research projects that are ongoing about long-term effects
    of toxic exposures. We can work with our colleagues back at
    Veterans Health Administration (VHA) to provide you a complete
    list.
        Ms. King-Hinds. Okay. That would be great. Just for my
    personal clarity, at what point in the primary care process is
    a veteran referred to a specific TBI treatment?
        Dr. Scholten. That would occur on the veteran's first
    entrance into VHA for healthcare. The TBI screen would be
    completed and then that would trigger the evaluation or
    referral to a TBI specialist.
        Ms. King-Hinds. Okay. Just one last question. How could we
    better support your efforts to be able to better screen and
    provide the services that our vets need?
        Dr. Scholten. I would say that this hearing is a perfect
    example, raising awareness of TBI and veterans. Also,
    acknowledging that, as was mentioned, March is TBI Awareness
    Month, and we would appreciate your assistance in encouraging
    all veterans to enroll in VHA for healthcare. We know that not
    all veterans do take advantage of that opportunity, but we
    would encourage you to help us spread that message to choose VA
    for healthcare.
        Ms. King-Hinds. Thank you for your time.
        I yield back.
        Ms. Miller-Meeks. Thank you, Representative King-Hinds.
        The chair now recognizes Dr. Conaway for 5 minutes for any
    questions he may have.
        Mr. Conaway. Thank you. Thank you, Chairman Miller-Meeks
    and Ranking Member Brownley, for gathering us here today to
    discuss the treatment of traumatic brain injuries.
        As traumatic brain injuries become more common in the
    veteran population due to more exposure to service-related risk
    factors, like blast injuries, it is crucial that we discuss how
    to advance TBI treatment at the VA. The VA has a long history
    of medical breakthroughs and innovation. VA, in fact, ranks as
    a top research institution and, for the last 20 years, has
    conducted significant research relating to TBIs. Additionally,
    through its Polytrauma System of Care, VA can provide
    integrated care to address TBI as well as co-occurring injuries
    and conditions, including mental health conditions.
        Dr. McArdle, can you explain how the VA's tiered Polytrauma
    System of Care is well suited to address the healthcare needs
    of veterans with TBI, even in areas that do not have a
    Polytrauma Rehabilitation Center in the immediate area?
        Dr. McArdle. Thank you for the question. VA Polytrauma
    System of Care has been in existence for over 20 years and was
    designed to ensure all veterans who are enrolled in VA
    healthcare have access to TBI experts. This System of Care has
    over 110 TBI clinical teams across VHA providing individualized
    care for veterans with TBI. For veterans who are in more rural
    or highly rural areas, we also utilize virtual care to expand
    the availability of services through the lifetime of a veteran
    who is dealing with the chronic symptoms associated with TBI.
    Our primary focus is on making sure veterans get the care they
    need, whether that care is direct care or care provided by the
    community.
        Mr. Conaway. Thank you. Can you elaborate on some of the
    advances? Again, a large research institution with a huge
    patient population and big data that can be brought to bear.
    Can you talk about how the standard of care for diagnosis and
    treating traumatic brain injuries has resulted from the VA's
    own research?
        Dr. McArdle. I will let Dr. Scholten, who oversees the
    polytrauma TBI System of Care and is a practicing TBI
    physician, provide you more information.
        Mr. Conaway. Thank you. Doc.
        Dr. Scholten. Thank you for that question. Again, I would
    like to recognize the incredible research infrastructure that
    VA does possess.
        A number of findings have emerged over the course of the
    last 20 years of the VA's research portfolio. We have
    identified a number of areas to improve veteran access for
    care. One of the things we--in research findings and knowing
    the high prevalence of TBI exposure for veterans returning from
    the post 9-11 conflicts, VA implemented the TBI screen and
    evaluation process to make sure that any veteran who served
    after September 11, 2001, was actually screened for possible
    TBI, and then evaluated by a specialist to ensure that their
    medical record was documented with a specific diagnosis and
    individualized treatment plan.
        We have leveraged emerging findings showing that we do know
    veterans with TBI, compared to their civilian counterparts,
    have a higher comorbidity of mental health conditions. That has
    led our efforts to beef up our mental health integration within
    our TBI and polytrauma teams. We are really trying to, in that
    effort, normalize or destigmatize the fact that mental
    healthcare is required for physical rehabilitation. We have
    also found with the heavy symptom burden, particularly for some
    of our special operators who experience rapid deployments in
    complex combat operations, that they require intensive
    evaluation and treatment.
        VA stood up with a combination of those research findings,
    the Intensive Evaluation and Treatment Programs (IETP) at our
    five Polytrauma Rehab Centers. We have expanded that over the
    past 5 years to ensure--or to improve access to those that
    intensive programming for veterans and servicemembers who need
    it.
        Mr. Conaway. Thank you for that. I will have to run to
    another hearing, but I did want to just raise some issues about
    how certain programs are funded. The BEACON Act, which will be
    discussed by our second panel. Unfortunately, I might not be
    here for all of it. One of the grant programs would award
    eligible grantees $5 million per year to conduct research for
    TBI veterans. The second grant program would require the VA to
    enter into an agreement with a further third party organization
    to administer a grant program to study and implement treatments
    of TBI veterans. The program will be funded by diverting
    existing VA clinical care funds. We know the VA has already
    undertaken clinical trials and research into new TBI
    treatments.
        When considered, I will ask and get to it, and that is the
    diversion of funds within the VA to other programs does concern
    us. Do you have a concern that these diversions would interfere
    with the work that the VA is doing? That is, I would rather see
    you get the additional funds rather than diverting funds from
    other VA programs. Any thoughts on that?
        Dr. McArdle. We appreciate the question, Congressman. We
    will have to take that for the record.
        Mr. Conaway. Thank you.
        Ms. Miller-Meeks. Thank you very much, Dr. Conaway.
        The chair now recognizes Dr. Murphy for 5 minutes for any
    questions he may have.
        Mr. Murphy. Thank you, Madam Chairman. Got a lot to cover
    real quick.
        Dr. Scholten, you said you practice, correct?
        Dr. Scholten. Yes, I do.
        Mr. Murphy. What do you do for TBI and PTSD patients who
    have basically failed your cut and--cookie-cutter approach to
    just TBI? What do you do when people come to the end?
        Dr. Scholten. Well, I personally, in my clinical practice,
    again, as was mentioned earlier, do a thorough history and
    evaluation, come up with a definitive diagnosis, and then
    develop an individualized treatment plan. That plan considers
    what interventions--first it considers which symptoms are most
    problematic for the individual veteran based on their
    functional ability, their ability to work and access the
    community. Then we discuss what interventions have been tried
    and what other opportunities----
        Mr. Murphy. Let me just get to the chase. What therapies do
    you offer these people that basic therapies do not work?
        Dr. Scholten. Well, the therapies that are most commonly
    offered are the standard rehabilitation therapies of physical
    therapy, occupational therapy, and speech therapy. It is
    critical to encourage or to evaluate the impact of mental
    health conditions and then offer appropriate evidence-based
    therapies to help with any diagnoses such as PTSD.
        Mr. Murphy. All right. Let me just get to the chase at an
    end. We get to the point where there is not really much that we
    offer to patients. Sadly enough, this is the part where
    suicide, this is the part where tragedy occurs with family. I
    think this is where personally I think the VA is failing to
    come into the 21st century and understand that there are
    modalities of treatment.
        Are you by any chance familiar with the work of Dr. Shai
    Efrati in Israel with Hyperbaric Oxygen Therapy (HBOT) and
    PTSD, the voluminous work that he has with trauma with PTSD
    using hyperbaric oxygen?
        Dr. Scholten. Yes, I have read some of those articles.
        Mr. Murphy. Your opinion?
        Dr. Scholten. My opinion, along with that of VA and
    Department of War, is after thorough review of evidence on
    hyperbaric oxygen therapy, while there are a number of studies
    that have happened, the guidelines, current clinical
    guidelines, do not find sufficient evidence to offer HBOT for
    use of TBI. We can----
        Mr. Murphy. Are you familiar by any chance of the work of
    Dr. Joseph Maroon at the University of Pittsburgh who does the
    same work?
        Dr. Scholten. I am not familiar with his part.
        Mr. Murphy. All right. Please, if you will, for
    professional education, please familiarize yourself with his
    work.
        I would like to submit for the record a meta analysis done
    in the Frontiers of Neuroscience in October 2023, talking about
    the multiple, multiple studies that show hyperbaric oxygen for
    veterans for PTSD shows an improvement not only in clinical
    data and clinical wellness, but in physiological achievements.
        Ms. Miller-Meeks. No objection.
        Mr. Murphy. You know, the American Academy of Pediatrics,
    in my opinion, was negligent in the fact that they created an
    institution, a generation of children, now adults, who are
    allergic to peanuts, because they refused, through their
    hubris, through their arrogance, to go back and see data was
    wrong. They for 20 years did not go back and do this. Same
    thing with National Institutes of Health (NIH), with the fact
    that we deprived women of getting Premarin and estrogen
    replacement, increase in cardiovascular disease, bone loss, and
    so many of these other things.
        I believe the VA is being absolutely negligent and still
    living in 1950's and 1960's and 1970's science and not looking
    at real data in an era where we are failing our veterans that
    are, in my opinion, conducive--presenting conducive
    environments and allowing our veterans in an environment that
    creates for suicide. We are stuck back in saying that we are
    not right now. The VA may have had data back years ago, but
    look, I want you personally to read this paper. We are being--
    the VA is being negligent and not allowing veterans access to
    this treatment.
        In North Carolina, there is an institution called HBOT for
    Heroes. They have treated over 250 veterans with, in my
    opinion, my clinical objective opinion, because I have scrubbed
    this data because as a surgeon, I am a skeptic first, that they
    have helped a tremendous number of our veterans where nothing
    else worked. I am tired of the cubicle captains at the VA still
    repeating the same rows over and over and over again, saying
    this does not work, when clinical data shows otherwise. You
    guys have a duty to our veterans to stop this massive suicide
    rate when we can intervene.
        With that, I will yield back.
        Ms. Miller-Meeks. Thank you, Dr. Murphy.
        The chair now recognizes Dr. Morrison for 5 minutes for any
    questions she may have.
        Ms. Morrison. Thank you, Madam Chair. Thank you, Ranking
    Member Brownley. Thanks to our witnesses for being here today
    and for the work that you do on behalf of our veterans living
    with traumatic brain injury.
        Dr. Scholten, you understand well that traumatic brain
    injury rarely exists as a single diagnosis. In practice what we
    see are veterans who are navigating a variety of challenges:
    cognitive symptoms, headaches, sleep disruption, chronic pain,
    depression, PTSD, and difficulties with memory, concentration,
    and executive function. A trend we have observed across
    patients is increasing medical complexity.
        Veterans understand from their own lived experience that
    conditions often overlap and reinforce each other and evolve
    over time. Treating one in isolation can fall short of truly
    addressing their needs. That is why the model of care is so
    critical. One of VA's strengths is that it was built to address
    complex service-oriented conditions across a veteran's
    lifetime.
        When we talk about TBI care at VA, we are not just talking
    about a neurology visit or a rehabilitation consult. We are
    talking about a system that integrates rehabilitation medicine,
    neurology, behavioral health, pain management, and social
    support. That integrated approach is especially important when
    we think about the kinds of injuries prevalent in modern
    military service. Many vets are exposed to blast injuries,
    repeated concussive events, and operational stressors.
        The non-VA health systems do not have the expertise to
    anticipate or to understand. Understanding how the various
    exposures interact with mental health and other service-
    oriented--service-connected conditions is essential to
    providing effective care. The VA has built a system
    specifically designed for that challenge. Through the
    Polytrauma System of Care, veterans with complex injuries can
    access specialized rehabilitation centers, network sites, and
    support clinics that work together across disciplines.
        From a clinical standpoint, that kind of coordination is
    rare and incredibly valuable. Those who have spent time
    navigating our health system know exactly how difficult it can
    be for patients to navigate fragmented systems where different
    specialties are all operating in silos. For veterans with TBI,
    fragmentation and a lack of military-informed treatment can
    mean delayed diagnosis, incomplete treatment, or symptoms that
    fall through the cracks entirely.
        Another important part of this conversation is
    identification and long-term management. Over the past two
    decades, VA has screened large numbers of post 9-11 veterans
    for traumatic brain injury and continues to treat a significant
    population of veterans living with TBI-related conditions. Many
    vets experience symptoms that fluctuate or become more apparent
    years after the original injury. This makes continuity of care
    and longitudinal follow up critically important and it also
    highlights why military-informed care is so essential.
    Providers need to understand the exposures veterans experienced
    in training and combat, the cultural context of military
    service, and the ways those factors influence both diagnosis
    and recovery.
        Dr. Scholten, how important is it that traumatic brain
    injury care be integrated with treatment for other common co-
    occurring conditions?
        Dr. Scholten. Thank you for the question. It is incredibly
    important that all of the factors, all the diagnoses, all the
    trauma and the exposures, that that individual veteran brings
    to the table that may affect their traumatic brain injury.
        One thing I did not mention on the earlier question with
    research findings is that TBI is viewed now as a chronic
    condition, thanks in a large part to the ongoing research
    efforts through VA. What that means is that a TBI is not just a
    point in time. Veterans do not just come to a TBI
    rehabilitation clinic and have a silo of care and then move on
    and live the rest of their life. Instead that intensive
    evaluation and skilled treatment is focused on improving the
    veteran's symptoms, improving their functional ability and
    their ability to communicate, or participate in community
    activities.
        Then when that has ended, we help transition veterans
    toward wellness activities because we know very well that long-
    term brain health is affected by a number of factors. In
    mitigating the chronic effects of a traumatic brain injury, it
    is essential to transition into a long-term brain health
    wellness plan or a brain health prescription, which we have
    recently developed and deployed through the VA.
        Ms. Morrison. Thank you for that answer.
        Dr. McArdle, in your testimony you described VA's
    Polytrauma System of Care. What advantages does that model
    provide for veterans with complex injuries compared to more
    fragmented systems of care?
        Dr. McArdle. Thank you for the question. VA's Polytrauma
    System of Care, the way it was established, to provide the
    individualized team-based care in the case management that
    comes with that. We utilize the wraparound care, the primary
    care, the mental healthcare, other specialties to optimize
    their entire care in order to optimize the outcomes that also
    are associated with TBI. The VA is uniquely set up to be able
    to do all of this in a single system.
        Ms. Morrison. Thank you. Really quickly----
        Ms. Miller-Meeks. Thank you.
        Ms. Morrison. Oh, I am past my time.
        Ms. Miller-Meeks. Your time has expired.
        Ms. Morrison. Thank you both for your service to our
    veterans.
        Thank you, Madam Chair. I yield back.
        Ms. Miller-Meeks. Thank you very much.
        I now yield myself 5 minutes for any questions that I might
    have.
        Dr. Scholten, how long does a typical TBI screening take?
        Dr. Scholten. Thank you for the question, Chairwoman. The
    TBI screen takes possibly 30 to 60 seconds to complete.
        Ms. Miller-Meeks. Is this--the TBI screening that is done
    at the VA, is that similar to what you would do at Active Duty?
    Is it similar to what is done in the civilian workplace? As we
    know, TBI can occur from a variety of occurrences, not just
    those that are acquired in the military.
        Dr. Scholten. Yes, our screen that we use in VA is similar
    to the screen used at the Department of War. It is different
    compared to the community because our patient population has
    typically sustained their traumatic event months to years
    previous. In the community, most TBI care is delivered acutely,
    you know, following a concussion or an accident. The screen is
    different.
        Ms. Miller-Meeks. Since I am not on House Armed Services
    Service Committee (HASC), is Active Duty military, Department
    of War, are they now, given the knowledge we have about TBI,
    which was not the same when I was a nurse on a neurosurgical
    floor or even when I was director of Public Health in Iowa? The
    knowledge base has certainly changed. With that is the
    Department of War, are they screening for TBIs for those
    individuals that would be at risk or were in theaters where
    they were put at risk so that they have a seamless referral
    into the VA system?
        Dr. Scholten. I know Department of War has an entire brain
    health program. However, I cannot answer for the that agency.
        Ms. Miller-Meeks. Okay. It gives me another mission to take
    on here. What does the TBI treatment look like for future
    veterans, which was the genesis of this question, as the
    landscape and methods of war are constantly changing?
        Dr. Scholten. Again, that would depend on the individual
    veteran, their presenting characteristics and presenting
    symptoms, as well as their cumulative trauma exposure as well
    as other exposures. The key is really taking that
    individualized history, looking at all the available
    documentation, coming up with a diagnosis, and then, again,
    that individualized treatment plan that is shaped in
    collaboration both with the veteran and their caregiver.
        Ms. Miller-Meeks. What treatment protocol have you found to
    be the most promising in treating the whole neuropsychological
    syndrome of TBI?
        Dr. Scholten. In my experience, and what the scientific
    literature would support, is integrated holistic care that is
    providing wraparound services. Given team-based care where the
    team actually has a chance to meet and discuss along with the
    veteran progress, prioritizing goals. Then the other important
    piece of that is ensuring that mental health experts are
    participating in that plan and supporting the veteran.
        Ms. Miller-Meeks. If a veteran is remotely located from--so
    the polytrauma centers are all at major, I am going to say,
    academic VA medical centers. If a veteran is remote, i.e., in
    Iowa, it could be 2 hours away or 3 hours away or 4 hours away
    if they are in northwest Iowa, would this team approach be done
    virtually?
        Dr. Scholten. Yes, it certainly can. In our Polytrauma
    System of Care, we see a little over 50,000 veterans in our
    TBI-specific clinics every year. Fifty-four percent of those
    veterans in Fiscal Year 2025 had some type of virtual care
    offered to them throughout the year.
        Ms. Miller-Meeks. To follow up on that, considering TBI to
    include mTBI, it may be more widespread given now screening,
    more widespread than previously understood. Does VHA have the
    capacity to treat our current and future veterans with the
    highest impact treatment protocol?
        Dr. Scholten. Thank you for that question. As we mentioned,
    VA has over 110 specialized teams in the Polytrauma System of
    Care that are expert in assessing and--assessing, diagnosing,
    and then treating those veterans. We with those care plans that
    are developed, any care that is not able to be offered to that
    veteran in a timely manner can be utilized through our
    community care partners. Then we will take that information,
    integrate it back into the care plan to ensure a seamless care
    delivery.
        Ms. Miller-Meeks. Thank you for acknowledging that. My time
    is about to expire, but can you estimate the proportion of the
    veteran population that likely has TBI, but has not been
    evaluated by the VA for TBI?
        Dr. Scholten. I do not have a good answer for that. I can
    tell you that in the TBI screening and evaluation process,
    about 20 percent of veterans have a positive screen that then
    are referred on for a comprehensive evaluation.
        Ms. Miller-Meeks. Thank you very much. I yield back my
    time.
        The chair now recognizes General Bergman for 5 minutes for
    any questions he may have.
        Mr. Bergman. Thank you, Madam Chair, and my apologies for
    being late. I was on the floor doing a memorial speech for a
    leader in my district who passed and who also happened to be my
    first cousin. If I sound a little--I do not have an emotional
    bone in my body, so I have been told, but I do have a lot of
    passion.
        The passion is running hot right now, especially as I was
    coming up here finding out that some of my colleagues were
    attacking the BEACON Act. I am, you know, in God's grace and
    forgiveness, I will not talk about either a person's inability
    to comprehend what we are trying to do or a bias to prevent
    good things from happening. That will sort itself out in life.
    We all know who, if you spoke the words, you spoke the words.
    They are recorded.
        I think about 20-plus years ago, when we had four
    polytrauma centers: Palo Alto, Minneapolis, Richmond, Tampa,
    the original four. When I was in uniform, I traveled to all of
    them because some of my Marines were in there for treatment
    during the time. When we think about here we are 20-plus years
    later, still trying, having made some advancements, but not
    nearly enough for the need and what the Veterans Administration
    is trying to do and what the BEACON Act does to help the
    Veterans Administration in a very positive way.
        Anybody who uses the word ``privatize'' obviously has
    either no creative thought, no historical knowledge, or no
    vision of the future when it comes to treatment for veterans or
    the population in general. Because of the factor that if we are
    going to solve--and I do not know if solve is the right word,
    if we are going to diagnose and treat and the future treatments
    going forward for traumatic brain injury, we need to have all
    hands on deck. Anybody who uses the word ``privatize''
    obviously either does not care or has an alternative agenda. As
    my mother would say, shame on them.
        Now, enough of that, because I was always taught to be
    positive. Let me ask you a question. Okay. Thanks to our
    doctors for being here.
        Dr. McArdle, you describe the five Polytrauma
    Rehabilitation Centers and also a broader network, polytrauma
    network sites, support clinics, and over 110 TBI teams. What is
    the real difference in care a veteran gets at a Polytrauma
    Rehabilitation Center versus those other sites?
        Dr. McArdle. Thank you for the question. I am going to
    defer it to Dr. Scholten who oversees the Polytrauma Network.
        Mr. Bergman. Okay.
        Dr. Scholten. The difference in the care provision at some
    of our larger centers is there are more rehabilitation and TBI-
    related assets, more intensive programming. Most of our
    intensive inpatient treatment programs are located at those
    five centers. That allows us to leverage the huge amount of
    expertise in clinical care not only for TBI, but also in
    expertise in other clinical areas to include neurosurgery,
    internal medicine, orthopedic surgery, and mental health to
    provide that intensive and expert level of care. Once if a
    veteran is not from that area and accesses one of those
    Polytrauma Rehab Centers, once they transition back to their
    home area, the System of Care is set up to have--to remain
    connected to that veteran so that they can return to their home
    area, access primary care and other specialties.
        Mr. Bergman. Not to put words in your mouth, this is truly
    developing a network, a broad-based network of care. When you
    think about before the early 1980's, surgery centers did not
    exist. Pretty much if you wanted any type of surgery, no matter
    how minor, you had to go to a hospital, pretty much. Surgery
    centers that now do everything from lower back surgery to
    cataract surgery to all of those different things and have
    brought the care to the community in such a way that the
    patient result is better, the accumulation of knowledge in the
    providers is better. It is a success story. Anybody who opposes
    the BEACON Act in this case is seeking to, whether it is
    intentionally or accidentally, prevent better care for
    veterans.
        With that, I yield back.
        Ms. Miller-Meeks. Thank you, General Bergman.
        The chair now recognizes Representative Cherfilus-McCormick
    for 5 minutes for any questions she may have.
        Ms. Cherfilus-McCormick. Thank you so much, Madam
    Chairwoman. Thank you so much for being here.
        This is like one of the main issues we have been having. In
    My VA, we had several suicides and making sure, our veterans
    can actually get the care they need is so important to us. We
    also have some concerns also when it comes to making sure the
    cultural competency that comes to the--our soldiers and our
    veterans are there and they are being provided. My question for
    you as we are looking at that, do you have any concerns and how
    would you address those concerns to make sure that every
    practitioner can actually be aware and to recognize certain
    things that are specific to our veterans?
        Dr. Scholten. Thank you for that question. Cultural
    competency when it comes to healthcare delivery is critical. We
    know that in VA we have--we feel we have better veteran
    awareness or better awareness of military-specific issues. Our
    System of Care is developed so that it provides these
    wraparound services that can address those military-and
    veteran-specific issues.
        As you know, suicide prevention is one of the--is our
    highest clinical priority within VA. Our Office of Suicide
    Prevention as well as our Office of Research and Development
    has focused their efforts in better understanding suicide risk
    as well as better understanding interventions to decrease--or
    to promote suicide prevention efforts. In our integrated system
    we can enhance as well as deliver that enhanced screening and
    treatment for trying to minimize the suicide risk for our
    veterans.
        Ms. Cherfilus-McCormick. Well, that is also my question.
    When it comes to the screening process, it seems like the
    screening tools that lack reliability and biomarkers, what is
    the VA doing to improve diagnostic accuracy so veterans are not
    misdiagnosed or missed entirely and whereas veterans still are
    falling through the cracks?.
        Dr. Scholten. As we mentioned earlier, VA's Office of
    Research and Development allocated 50 million in direct
    research funding for Fiscal Year 2025 research projects for
    traumatic brain injury. Part of those efforts are aimed at
    developing better biomarkers not only for traumatic brain
    injury, but also other co-occurring mental health diagnoses. As
    we work to better understand and better identify biomarkers not
    only for TBI, but also looking at those associated or
    affiliated risk factors that can enhance suicide risk, we will
    better be able to care for veterans as we take that information
    and turn it back into our healthcare system.
        Ms. Cherfilus-McCormick. My next question is that the
    BEACON Act would establish new grant programs that shift
    funding to non-VA entities for TBI research and treatment. Why
    should Congress divert resources outside the VA instead of
    strengthening the VA's existing research infrastructure? How
    could outsourcing care impact continuity and suicide prevention
    efforts while also taking into context that cultural competency
    for our community care providers?
        Dr. Scholten. Thank you for that question. VA does its best
    to provide that integrated care. However, there are times when
    the expertise does not exist in the VA or cannot be provided in
    a timely manner. It is important then that we do--where it is
    time-sensitive, where we do work with our community partners to
    get veterans in the community care network to get that piece of
    their care provided in the community. We need to integrate
    those results back into their treatment plan.
        Ms. Cherfilus-McCormick. Now, do you believe that there is
    an advantage to having services done at the VA and that there
    is a way we can actually harmonize the two? Because the
    expertise, I guess the concern is that the expertise of the VA
    might be lost when our soldiers go--our veterans go into the
    community. Do you believe there is a way we can harmonize the
    two so we are not losing any expertise?
        Dr. Scholten. As a 28-year employee of the Department of
    Veterans Affairs, as a healthcare provider, I think we are well
    positioned to--very well positioned to provide that wraparound
    care and leverage that military and veteran competency to
    maximize the results.
        Ms. Cherfilus-McCormick. Now, are there any specific steps
    you would like to see Congress take to make sure that exists in
    all situations?
        Dr. Scholten. As I mentioned earlier, we appreciate the
    ability to testify here today on VA's TBI programs. We
    appreciate the fact that this is helping to spread awareness
    about TBI and veteran-specific injuries, especially since March
    is TBI Awareness Month. We appreciate your help in encouraging
    veterans to enroll in VHA for care or to choose VHA for their
    healthcare.
        Ms. Cherfilus-McCormick. Thank you. I yield back.
        Ms. Miller-Meeks. Thank you, Representative Cherfilus-
    McCormick.
        On behalf of the subcommittee, I want to thank you all for
    your testimony and for joining us here today. You are now
    excused and we will wait for a moment as the second panel comes
    to the witness table.
        Welcome to all of our witnesses and thank you for your
    participation today testifying on such an important matter. In
    accordance with committee rule 5(e), I ask unanimous consent
    that Representative Stauber, who is not here yet, from
    Minnesota, be permitted to participate in today's subcommittee
    hearing. Without objection, so ordered.
        On our second panel, we have Mr. Al Johnson, retired U.S.
    Army lieutenant colonel and a flight surgeon, who was present
    when the Iranians attacked Al-Asad Air Base in retaliation to
    neutralizing the Islamic Revolutionary Guard Corp (IRGC)
    terrorist Soleimani; Mr. Buster Miscusi, former U.S. Marine
    Corps sergeant and graduate of Operation Mend; and Dr. Rusty
    Gore, chief medical officer at Avalon Action Alliance. Once
    again, thank you all for your participation in today's hearing.
        Mr. Johnson, you are now recognized for 5 minutes to
    present your testimony.

                        STATEMENT OF AL JOHNSON

        Mr. Johnson. Thank you, Chairwoman Miller-Meeks and
    distinguished members of the subcommittee. Thank you for
    inviting me to testify today. My name is Al Johnson. I am a
    retired lieutenant colonel and physician assistant (PA) who
    served in the Army for over 27 years. I am testifying not on
    behalf of the Department of War, but in my personal capacity. I
    speak both as a military medical provider and as a patient that
    suffered TBI, someone whose life was permanently changed by a
    traumatic brain injury, in fact.
        On January 8, 2020, while deployed to Al-Asad Air Base in
    Iraq, I was injured in one of the largest ballistic missile
    attacks on U.S. forces in the history of war. Iran fired 15
    medium-range ballistic missiles at our base, each weighing
    roughly 1,500 pounds. I was sheltered in an indirect fire
    shelter which was not adequate for ballistic missiles. It was
    more designed for rockets and mortars. I have no memory of the
    first three impacts because I was knocked out at impact number
    three. I came to just as impacts number four, five, and six
    were hitting the base. All of these were in very close
    proximity to my position, with No. 6 being 60 feet away from my
    position. That massive percussion wave knocked me unconscious
    for the second time that day.
        The missiles struck occupied operational areas, resulting
    in damage to critical infrastructure and barracks.
    Environmental testing after the attack detected radioactive
    isotopes, heavy metals, and toxic chemicals at the site.
        As a result of the missile attack, I have been diagnosed
    with a TBI, PTSD, cranial nerve damage causing double vision,
    insomnia, tinnitus, neck pain, everything that you can imagine
    that would come with a blast injury. I struggle emotionally
    with hypervigilance, depression, a sense of distance from the
    people I love and my friends. I am also in a thyroid
    surveillance program due to multiple thyroid nodules that have
    developed since the attack.
        After the attack, and despite our own injuries, myself and
    my two medics immediately began treating other servicemembers,
    many who now live with injuries similar or worse than mine. One
    soldier, specifically Specialist Jason Quitugua, suffered a TBI
    that resulted in headaches, insomnia, PTSD, and severe
    depression. Sadly, he died by suicide on October 7, 2021. The
    injuries he sustained during the attack ultimately cost him his
    life.
        Another was Chief Warrant Officer Thomas Caudill. I
    diagnosed his TBI using the Military Acute Concussion
    Evaluation (MACE) 2 screening tool available to us on the base
    and arranged for his medical evacuation. He was subsequently
    evacuated, had a Computed Tomography (CT) of the brain
    performed which was unremarkable, and returned to duty
    literally the same day back into theater.
        Many soldiers passed the largely self-reporting screening
    and remained in mission-essential roles due to conscientious
    underreporting. They immediately began to assist in cleanup.
    Many other servicemembers now experience chronic medical and
    mental health conditions, including thyroid disease.
        I have coauthored two different peer-reviewed studies on
    the servicemembers who were there. One showed that out of 583
    exposed personnel, over 80 percent reported blast exposure and
    nearly half were still symptomatic a month later. Another
    identified 20 percent more TBI diagnosis a month after the
    attack than what were initially thought. People passed early
    screening because these tools often missed or delayed
    cumulative blast injuries.
        Another soldier, Patrick Benn, was assisting in cleanup,
    ultimately diagnosed with thyrotoxicosis and underwent
    thyroidectomy after being exposed to the toxic chemicals. I am
    aware of multiple similar other cases in that cohort of
    soldiers that were on the base during that attack.
        While improvements have been made since Al-Asad, prevention
    and early detection must be our first line of defense. Modern
    warfare involves repeated blast exposure in toxic environments,
    and our medical system must evolve to address those concerns
    accordingly.
        Early identification is not only a medical issue, it is a
    compensation and access to care issue. Servicemembers injured
    in terrorist attacks depend on documentation to qualify for VA
    care and benefits. Due to recent legal rulings, many injured
    veterans are now unable to recover compensation from other
    sources that they once could. While injuries are missed,
    veterans lose both treatment and the support Congress intended.
    That is the commitment we owe the men and women who are injured
    in service to our country. Thank you for your time and
    continued commitment.

        [The Prepared Statement Of Al Johnson Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Mr. Johnson.
        Mr. Miscusi, you are now recognized for 5 minutes to
    present your testimony.

                      STATEMENT OF BUSTER MISCUSI

        Mr. Miscusi. Chairwoman Miller-Meeks and members of the
    subcommittee, thank you for the opportunity to speak today on
    behalf of veterans living with a traumatic brain injury.
        Each veteran's injury and recovery is unique. They rarely
    follow a straight line. After years of living with this injury
    and walking alongside other veterans who bear a similar burden,
    I have learned that these stories, like history, may not
    repeat, but the patterns tend to rhyme. I am here today because
    my story is one of those patterns and because what helped me
    should not be the exception, but the rule.
        Before my injury, I could tolerate chaos, process
    information quickly, and stay oriented to my environment and to
    the people around me. These skills were critical not just for
    success in the military, but for being a present husband and
    father. They allowed me to have a clear identity, a clear role,
    and a future that made sense.
        After my deployment to Afghanistan in 2012, I was diagnosed
    with PTSD. After a brief sequence of cognitive behavioral
    therapy, I learned enough skills to get back in the fight. In
    2015, I was diagnosed with Crohn's disease and sent to Wounded
    Warrior Battalion for medical retirement. During that process,
    I was also diagnosed with a traumatic brain injury from low
    blast exposure.
        At first, I did not believe the TBI diagnosis. I had never
    been in an Improvised Explosive Device (IED) explosion. I had
    never been knocked unconscious. When I first joined the Marine
    Corps and was training to deploy to Afghanistan, low blast
    exposure was not something we talked about. We were not
    screened for it and we were not taught to look for it. Mortars,
    explosives, and overpressure in training environments were just
    part of the job.
        In the infantry, headaches, confusion, explicit jokes, and
    anger were normal. We joked about bloody noses and ringing
    ears. We laughed off losing our hearing for weeks at a time. We
    assumed our inappropriate jokes and angry outbursts were part
    of the military culture. Back then, there was not anything that
    we thought could not be solved with sufficient nicotine,
    caffeine, and Advil.
        By the time I reached Wounded Warrior Battalion in 2015,
    the understanding of brain injuries had changed. Now clinicians
    were looking for low blast exposure, and they were able to name
    what I had been experiencing all along. Confusion was not a
    personal shortcoming. It was impairments in memory and
    information processing. Explicit jokes and anger were not part
    of the culture. It was a loss of cognitive filtering.
        Going forward, the initial treatment plan helped. I was
    medically retired in 2018 and started college. Then everything
    collapsed again. I began having episodes where half my body
    stopped working. My face sagged, my speech slurred. When these
    occurred, I could not walk, talk, or eat. At first, these
    episodes happened almost daily. The VA ruled out a stroke. One
    doctor told me the engine still has power, but the transmission
    just keeps slipping out of gear. It was a good line and, in a
    way, it helped me understand what was happening. Understanding
    alone was not enough to restore function.
        These episodes were associated with my brain injury and put
    my life on hold. I had to stop driving. I had to leave school.
    My symptoms worsened, and I fell into a deep depression. I
    began to believe I was a burden, that the meaning I had built
    my life around was gone. My wife refused to give up, continuing
    to search for help.
        Eventually, we found University of California Los Angeles
    (UCLA) Operation Mend. Operation Mend treated my injury
    differently. They did not try to make it disappear. They worked
    with me, not on me, to learn skills and find resources to work
    with my limitations. Most importantly, they included my wife as
    an essential partner, recognizing that this injury does not
    affect one person alone. Previously, my wife had been rejected
    by the VA caregiver support program and struggled with burnout
    and caregiver fatigue. Operation Mend was the first time she
    was Included as an integral part of the care team. Recovery,
    like military operations, is a team effort. They understood
    that.
        Operation Mend did not cure my TBI. I still live with
    migraines, stroke-like episodes, ringing ears, cognitive
    overload, and emotional volatility. What they restored was my
    sense of agency. My limitations are no longer evidence of
    failure. They are evidence of survival.
        My story is not unique. Low blast exposure does not require
    an IED, loss of consciousness, or an infantry role. Many
    veterans and families are struggling to find the resources to
    develop the skills to learn to work as a team. Programs like
    Operation Mend, where symptoms are treated as challenges to
    work with rather than obstacles to destroy, and where
    caregivers are honored as integral partners rather than a
    dispensable afterthought, should be the gold standard of care
    across the VA. The capacity to provide this level of care
    already exists within the VA system. What is needed is
    organization, training, and recognition of veterans and
    caregivers as key stakeholders.
        Who is responsible? The ones who know. I know what this
    injury feels like. I know what helped me and my family. Now
    that you understand it as well, the responsibility to act no
    longer rests with veterans alone.
        Thank you.

        [The Prepared Statement Of Buster Miscusi Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you very much, Mr. Miscusi.
        Dr. Gore, you are now recognized for 5 minutes to present
    your testimony.

                       STATEMENT OF RUSSELL GORE

        Dr. Gore. Chairwoman Miller-Meeks, Ranking Member Brownley,
    and members of the committee, thank you for the opportunity to
    testify today. My name is Dr. Russell Gore. I am a veteran. I
    served as an operational flight surgeon in the United States
    Air Force. I am now a neurologist specializing in traumatic
    brain injury.
        Today and over the past 12 years, my work has focused on
    treating veterans and servicemembers with mild to moderate
    traumatic brain injury and the common co-occurring disorders we
    have discussed today. These are complicated, persistent. These
    result in life impairments that are associated with significant
    impairments throughout the lifespan.
        I want to start with a simple truth from the clinic and
    from the trenches. TBI is not a single event with a clear
    recovery timeline. For many veterans, it is a chronic condition
    with symptoms that can be delayed, misunderstood, or
    misattributed. Veterans with TBI struggle with impairments
    affecting function in the community and relationships at home
    and at work. These struggles are often invisible but impactful,
    resulting in isolation and fractured relationships, a
    combination leading to a loss of purpose, a loss of
    productivity, and often despair.
        The VA's 2025 National Suicide Prevention Report states
    that the suicide rate for veterans was 35 per 100,000.
    Critically, the rate for veterans with TBI is much higher. A
    veteran with TBI is more than twice as likely to commit suicide
    than a veteran without TBI. Veterans with TBI are an
    astonishing 5.5 times as likely to commit suicide than the
    average American. TBI and common associated conditions are
    fueling an epidemic of veteran suicide.
        As Dr. McArdle highlighted earlier, we are just starting to
    understand the scope of this TBI problem. The U.S. Department
    of Defense (DOD) reports 500,000 servicemembers have been
    diagnosed with TBI since 2001, but this number represents just
    the tip the of the iceberg. Many veteran--many injuries go
    unreported, and this number does not account for injuries due
    to repetitive exposure to blasts.
        U.S. military tactics are highly kinetic and this is a
    battlefield advantage, but the kinetic nature with which we
    train and fight is injuring our servicemembers over time.
    Estimates suggest that 2 million have experienced a TBI, and
    the most robust clinical data available indicates that over 50
    percent may experience chronic symptoms.
        The VA has made meaningful progress addressing veteran TBI
    with some of the current initiatives also outlined by Dr.
    Scholten and Dr. McArdle earlier. I am privileged to serve on
    the Federal Advisory Committee overseeing VA neurotrauma, so I
    have experienced firsthand the compassion and tireless effort
    of VA clinicians managing this epidemic of TBI. Enhanced
    screening efforts in the Polytrauma System of Care have
    certainly helped many veterans.
        Despite this progress, the VA cares for only two-thirds of
    veterans, and among veterans completing suicide, fewer than 40
    percent were seen in the VA the preceding year. Many veterans
    are not accessing TBI care within the VA. The reality is that
    VA TBI care, and indeed TBI care nationally, is currently
    fragmented. Veterans assessed for TBI often receive a series of
    disconnected referrals without a coordinated plan that treats
    the whole person. Veterans with persistent symptoms need an
    integrated pathway, comprehensive evaluation, individualized
    interdisciplinary rehabilitation, and reliable follow up. I see
    firsthand at the Shepherd Center every day what integrated
    brain injury rehabilitation looks like when it is done well.
        In order to address these challenges, three organizations
    are offering treatment with intensive neurorehabilitation. This
    includes the VA's five polytrauma centers, the Avalon Action
    Alliance, and the Warrior Care Network. These three
    organizations are treating approximately 1,000 veterans with
    mild TBI per year. This is only a small fraction of the
    capacity necessary to treat the veterans who may benefit from
    this care. There is an urgent need to scale capacity. All
    veterans deserve access to evidence-based life-saving care,
    care that helps them return to family roles, school and work,
    care that restores function, care that restores dignity.
        The BEACON Act offers the opportunity to provide funding
    for the research needed to urgently scale life-saving
    treatment. This legislation is designed to evaluate effective
    treatments and leverage civilian and academic TBI expertise
    that is aligned with the VA's mission. The BEACON Act will help
    us to identify what works, scale it, and make it available to
    more veterans. This is not an attempt to privatize care, but to
    complement VA research and clinical capacity by partnering with
    proven programs to reach veterans who otherwise are not being
    served effectively.
        Here is what success looks like from my perspective.
    Approval of the BEACON Act to establish the efficacy of the
    intensive neurorehabilitation treatment model. Expand
    partnerships to increase VA capacity. Scale access to this
    treatment through reimbursement from government and private
    payers. Establish this treatment as the standard of care for
    any American suffering from chronic mild TBI.
        Members of this committee, it is not the responsibility of
    the VA to stop this epidemic. It is our national
    responsibility. The VA should not have to do this alone. With
    smart, coordinated partnerships and targeted investment, we can
    reach more veterans earlier, treat them more effectively, and
    reduce veteran suicide.
        Thank you for the opportunity to testify. I look forward to
    your questions.

        [The Prepared Statement Of Russell Gore Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Dr. Gore. I thank all of our
    witnesses for appearing here today.
        As is my typical practice, I will reserve my time until all
    other members have had a chance to ask their questions.
        I now recognize Ranking Member Brownley for 5 minutes for
    any questions she may have.
        Ms. Brownley. Thank you. Thank you to all the witnesses for
    being here and your testimony as well.
        Mr. Miscusi, in your testimony you say that VA has the
    capacity and the platform to provide the type of care you
    received at Operation Mend. What, from your point of view, is
    holding VA back? Do you think that diverting $60 million from
    existing VA programs as the BEACON Act requires helps or
    hinders VA in implementing intensive outpatient programs like
    the one you have completed? I am grateful that you have had the
    treatment that you need.
        Mr. Miscusi. Thank you, Ranking Member Brownley. I cannot
    answer to how the money could be used, but I cannot answer to
    whether or not why I think that those resources are available.
    I am not engaged with the veteran--with the Veterans Health
    Administration on the level of understanding how things are
    organized. I do engage directly with their practitioners and I
    receive care from them, so I know that they care deeply. That
    is ultimately what is needed, is people who care deeply.
        The thing that is missing is organization, I think. If
    these pieces could be organized together, I think that it could
    be effective. Operation Mend is a model of how that
    organization could occur where the money goes. Ultimately, I
    want it to serve veterans. That is what matters most.
        Thank you.
        Ms. Brownley. Well, and I appreciate that. I think your
    point about in the VA they care is one of the primary reasons
    why veterans, if they have a choice, would prefer to go to the
    VA other than community care outlets. You know, I do not have
    any data to support that on the TBI issue necessarily, but
    generally, that is what veterans tell me every single day is
    they would prefer to be in the VA and under VA care. I
    appreciate that.
        You have--you never attempted to try to get care in the VA
    with regards to your situation?
        Mr. Miscusi. I did receive care and I continue to receive
    care at the VA for the TBI.
        Ms. Brownley. Okay. Okay, very good.
        Dr. Gore, in your testimony, you, also--well, you claim
    that the BEACON Act was written to supplement, not supplant,
    VA's existing clinical care and research. The bill is pretty
    clear to me as written that it would divert $60 million from
    the VA National Center for PTSD and Mental Health Services. I
    am trying to understand how that is not supplanting, but it is
    supplementing.
        Dr. Gore. Thank you for that question. I see this as an
    opportunity for building partnerships, building capacity, and
    for establishing the evidence necessary to shift what we
    consider to be the standard of care for traumatic brain injury.
    This is a national problem. The VA and the work that we are
    doing with veterans is an opportunity to leverage the volume of
    individuals with traumatic brain injury and the resources
    available so that we can demonstrate that the standard of care
    needs to shift.
        All of the downstream opportunities for folks to receive
    care and access to care are dependent on establishing a
    standard of care. The current standard of care for traumatic
    brain injury in this country, in particular mild to moderate
    injury, is to do nothing. That is scary. Folks in this room,
    your friends, your loved ones are affected by this every single
    day. They get no care when they have these injuries and are
    released from the Emergency Room (ER).
        All of us are doing an amazing job just because we care and
    we are providing intervention. We need to establish a standard
    of care which is going to improve both VA care and care
    external to the VA.
        Ms. Brownley. What does that look like?
        Dr. Gore. What that looks like for me is that veterans have
    an option to seek care in a place that they choose. In my
    experience, veterans are frustrated with the VA care that they
    receive. They receive multiple referrals from very well meaning
    providers, and those referrals are at different locations
    throughout their community. They are poorly coordinated. It is
    very difficult to execute on those plans.
        This intensive program brings all of those resources under
    one roof and provides care, over 100 visits for care, over a 3-
    to 4-week period. It has been shown to work. The VA has
    actually modeled their IETP program after programs like mine at
    the Shepherd Center. We started doing this in 2006. What we
    have seen is that this seems to work.
        The problem is the VA is treating fewer than 100 veterans
    per year in the IETP program. I heard 50,000 veterans a year
    are being treated in the VA for TBI. Just my basic math, 80
    percent are mild and 50 percent of those have chronic needs.
    That is 20,000 a year that should have access to this care. It
    is less than 100 because most of the folks receiving that care
    are actually Active Duty servicemembers and mostly special
    operators.
        I see providing access to this life-saving care as my
    personal priority and I hope that you will appreciate that.
        Ms. Brownley. Thank you. I yield back.
        Ms. Miller-Meeks. Thank you very much.
        The chair now recognizes Representative King-Hinds for 5
    minutes for any questions she may have.
        Ms. King-Hinds. I want to start off by saying thank you to
    Mr. Miscusi and Mr. Johnson for your testimony today. I think
    when folks talk about traumatic brain injury, they do not
    really have a full idea of the lived experience. I want to be
    able to give you the opportunity to, one, share your thoughts
    as to if you had just one ask that Congress could do to make
    your life better. As somebody who has TBI, share that thought
    and, you know, give us a day in the life of what it looks like
    to live with this type of injury.
        I will start with you, Mr. Johnson, and then we can go to
    Mr. Miscusi after.
        Mr. Johnson. Thank you for your question and your comments,
    Representative King-Hinds. The comments you made earlier about
    the toxic exposure interest me more than you can imagine
    because that is our cohort.
        Personally, my experience in dealing with my traumatic
    brain injury is I have been working in emergency medicine for--
    you know, in some capacity for 37 years. About 18 of that or 15
    of that was as a sole provider in a rural community, which is a
    lot like tailgate medicine that you find on the battlefield.
    After my traumatic brain injury, however, I had to bench myself
    from being the only provider with two nurses in a rural setting
    because of my difficulties in complex--you know, navigating
    complex medical disease pathways and things like that. That is
    how it has affected me personally. I cannot do what I love to
    do anymore.
        If I had my one ask to Congress, and, believe me, it has
    taken me 6 years of dead end attempts to finally get in front
    of an audience that can maybe help the folks that were on Al-
    Asad that day. The toxic exposure has created a unique
    opportunity along with a traumatic brain injury cohort. You
    have got 147, 150 soldiers that were in one place at one time
    that all experienced the same exposure, blast exposure and
    toxic environment exposure. You talk about a control for a
    research program, you cannot ask for anything better than that.
        The care that they need, here is the problem. When you have
    a 22-year-old, now separated soldier from the service because
    they were medically retired, that goes to their primary or
    their VA Community-Based Outpatient Clinic (CBOC) and says,
    hey, I think I was exposed, I am not really sure what I was
    exposed to, what do I need to do about it? A lot of times it is
    nothing. These individuals should be getting baseline screening
    for cancers. They should be getting thyroid ultrasounds,
    advanced brain imaging as needed, including Magnetic Resonance
    (MR) venograms, too. I have had a couple of patients, me
    personally, in the ER that have had traumatic brain injuries. I
    end up doing an MRV, which I know none of my partners would do,
    and sure enough, venous sinus thrombosis, which are causing
    their symptoms. I know the research on that is like 4 percent
    of traumatic brain injuries have that, but it could be higher.
    We just do not search for it enough I do not think.
        Baseline screening, like Prostate-Specific Antigen (PSA),
    colonoscopies earlier than age 40, those--cancer screening
    process, in addition to the traumatic brain injury and mental
    health, finding this--finding not just the treatment for their
    symptoms, but the root cause that can change their life to
    reverse the symptoms of their brain injury, whether it is HBOT,
    as Dr. Murphy said, we need to expand on that. This cohort
    specifically needs to be in a medical surveillance program that
    encompasses their entire care from traumatic brain injury to
    toxic exposure because I believe, as you do, that they are
    connected.
        Ms. King-Hinds. I have 30 seconds and you have the rest.
        Mr. Johnson. Sorry.
        Ms. King-Hinds. My time--it is okay.
        Mr. Miscusi. Thank you for the question. I would say if I
    had an ask for you today, from my evaluation, it seems like the
    question is what is the barrier? Is it money or is it
    institution? Are there institutional barriers within the VA
    that prevents them from making the programmatic changes that
    are needed to treat veterans and families with TBI? If there is
    an institutional barrier, well, then the BEACON Act solves
    that. If there is not, well then. I would ask you to evaluate
    what--so the question that--the thing that I would ask is how
    do you get--which program gets the care to the veterans fastest
    as they need it?
        Then as far as a day in the life, I would say that I have
    five medical devices that have to shock some different part of
    my brain or my neck or something like that throughout the day
    so that I do not have those migraines and those episodes
    anymore. I would say that it is ongoing care throughout the
    day. Thanks.
        Ms. King-Hinds. Thank you for that.
        I am out of time. I yield back.
        Ms. Miller-Meeks. Thank you.
        The chair now recognizes Representative Cherfilus-McCormick
    for 5 minutes for any questions she may have.
        Ms. Cherfilus-McCormick. Thank you so much. Thank you so
    much for your testimony.
        Thank you, Mr. Johnson, for your recommendation because I
    think that is something that has been missed is looking at the
    root cause and testing for cancer. Thank you for bringing that.
        Thank you also, Mr. Miscusi, for your statements because I
    think we have the same concern. What is the problem? Is it
    institutional? Who can get the services to our veterans faster?
        That brings me to Dr. Gore. Thank you for your testimony,
    also. The concern really is if we are shifting money to outside
    organizations, you mentioned that 100, you said--I think you
    said 100 people are serviced with TBI within the VA. Is that
    what you said in your testimony earlier?
        Dr. Gore. Yes, ma'am, within the intensive--the IETP
    program, that is the equivalent of what our programs are doing.
        Ms. Cherfilus-McCormick. The concern is if we shift that
    money, then less than 100 people will be treated within that
    program. The question that I have is, is there any evidence to
    suggest that shifting those dollars would show that more people
    will be treated, that more veterans will have access? Is there
    any evidence for that?
        Dr. Gore. I cannot speak to the shift in funding and how
    that may affect your decision-making and shifts--and decision-
    making from a legislative standpoint, but I can comment that
    absolutely, evidence is required for infrastructure to be in
    place to deliver care and for the finances to be in place to
    receive care.
        Ms. Cherfilus-McCormick. Specifically, my question is, is
    there any evidence that these organizations would provide more
    care and better care to our veterans than if we have kept those
    funds within the VA? We already said the number in the VA is
    100. Do we have any tangible evidence to show that these
    outside organizations can do more and can do it better?
        Dr. Gore. We do. We have evidence that the VA has collected
    that they see strong responses to treatment that is in line
    with evidence from multiple external organizations, including
    the National Intrepid Center of Excellence (NICoE) program in
    the Department of Defense. All of those programs have
    demonstrated that this treatment is effective.
        A comparison between the VA and the civilian sector in this
    regard, I am not sure how really to answer that because what we
    are hoping to achieve is the research necessary to establish
    this as the standard of care. Once that is established as the
    standard of care, and that is what these resources would go
    toward, as well as other innovative treatments for TBI, I would
    suggest it is then the VA's responsibility to make a
    determination as to where to allocate funds so that they are
    taking care of veterans in the most optimal way.
        These funds are not intended to just to treat veterans.
    These funds are intended for us to establish that this should
    be the standard of care and to look at more innovative models
    of treatment.
        Ms. Cherfilus-McCormick. Well, before we shift those funds,
    I think we would want to know, like, with a substantial
    certainty that this would actually benefit our veterans versus,
    you know, shifting--leaving it where they are and actually
    growing it there. If there is any information that you can give
    to us that can help us come to that certainty, that would be
    extremely important.
        My next question is your partner--your program partners
    with several academic and private institutions to deliver
    intensive short care treatment. You mentioned that. Can you
    walk us through the specific training and credentialing
    requirements for clinicians delivering TBI care in your program
    and how those standards compare to the interdisciplinary teams
    and clinical programs' practice guidelines used in the VA?
        Dr. Gore. Within our programs, the credentialing of the
    physicians and rehabilitation specialists is very similar to
    the credentialing that would occur through the VA. To your
    questions, which I appreciated of Dr. Scholten earlier, we
    actually have a robust program that is focused on veteran and
    military competency across all of our providers. This is the
    same for also the Wounded Warrior Program treatment programs.
        A vast majority of the clinicians have a connection to
    either the VA, to military service, whether it is their selves
    individually because they served or whether it may be a family
    member or previous experience practicing in the VA. The
    credentialing and the training process is very similar. We
    share a lot of the same talent within our programs as we see
    within the VA.
        Ms. Cherfilus-McCormick. Do you have any specific programs
    for making sure that they have the cultural competency for
    military service or our veterans? Do you have anything specific
    that you guys are doing to make sure each and every
    practitioner is exposed to it?
        Dr. Gore. We do. That programming actually for our network
    is seeded through my own program at the Shepherd Center in
    Atlanta because we have been doing this for so long and so we
    do have a training program that is geared toward cultural
    competency to make sure that individuals are aware of the
    unique needs of veterans and servicemembers.
        Ms. Cherfilus-McCormick. While I have a few seconds, my
    last question is, do you believe that if it was mandatory for
    all outside organizations to have some kind of training, do you
    think that would be a benefit or do you think it would be a
    burden?
        Dr. Gore. I think when you are looking at opportunities to
    provide care external to the VA, and there are numerous
    examples of this, not just in the TBI space, but also in the
    behavioral health space with programs specific for post-
    traumatic stress, that there is a massive benefit to ensuring
    that individuals are competent in that area. You know, whether
    that should be mandatory is a question maybe that I will leave
    up to you. I do not think that that would be a burden. I think
    that is important.
        Ms. Cherfilus-McCormick. Thank you.
        Ms. Miller-Meeks. The gentlewoman's time has expired. Thank
    you very much.
        The chair now recognizes Dr. Murphy for 5 minutes for any
    questions he may have.
        Mr. Murphy. Thank you, Madam Chair, and thank you all for
    coming today. For those of you guys that are dealing with the
    after effects of serving and sacrificing for my Nation, my
    heart goes out to my prayers with you. I pray that your journey
    and all this improves with each day. If you are having to have
    shocks with vagus nerve stimulators, I am guessing, I am
    assuming that is what it is, did you get that at the VA, may I
    ask?
        Mr. Miscusi. Yes, sir, I did.
        Mr. Murphy. Okay. Expediently done in a quick manner, good
    manner? Were you happy with the process?
        Mr. Miscusi. It took a while to realize that that was the
    resource that was needed. Then once it was prescribed, I
    received it in a timely manner.
        Mr. Murphy. Okay. How helpful is that to you? If you do
    not--I am sorry asking you personal questions.
        Mr. Miscusi. I do not mind at all. It is the difference
    between me having an episode every day and being able to sit
    here and function. Maybe it occurs once a week.
        Mr. Murphy. These are wonderful technological
    breakthroughs. We are on the cusp, especially with Artificial
    Intelligence (AI), of being able finally to, I think, crack the
    brain. It is the great frontier of the human body. We have a
    lot of work to do, but I pray that we can really crack the-on
    this stuff. Thank you for your service.
        You know, I still, after being on this committee for years
    and years, do not understand the rationale of why we have to
    play us versus them as far--and with the veterans being bounced
    back between them, why it is VA versus outside institutions.
    Why can we just not care about the veteran first? Why is there
    this provinciality that we have to be so concerned about our
    own little world rather than what is best?
        You know, Dr. Gore, I would love for you to just talk about
    your experience and whether you--you know, how you deal with
    these folks, what your protocol is, and how you deal with, you
    know, folks who come from the VA that may not have gotten the
    attention that they needed to and at what point do they show up
    on your door?
        Dr. Gore. Thank you. I appreciate that question.
        You know, I would start by saying that the Veterans
    Administration does a fantastic job managing a vast majority of
    the needs of our veterans. When these individuals come to my
    program, they have often cycled through a number of different
    treatment opportunities. There is some fracturing in the
    continuity of care, they are often left seeking care external
    to the VA. I think that that is natural.
        I think if you are suffering and you are not finding the
    solutions that are addressing your suffering, it is normal and
    it is human. Honestly, you know, as a veteran myself, you know,
    we are individuals who want to get things done and we are going
    to find solutions. Folks are hungry to find opportunities and
    solutions to address their suffering.
        When they come to us, I hear the full spectrum of stories.
    I hear about the positive experiences within the VA. I hear
    about the negative experiences. I hear about the negative and
    the positive experiences within the rest of the civilian
    healthcare system.
        Mr. Murphy. Sure.
        Dr. Gore. This issue is not unique to the VA. We have a
    very fractured TBI treatment system within the United States.
    When they come to us, we have an opportunity to really wrap our
    arms around them. What we hear consistently is, I have never
    had someone sit down and spend this much time with me. I have
    never been surrounded by a group of specialists all at the same
    time, all in the same room, all around the same table who are
    explaining to me the different deficits and how they are
    affecting my day-to-day life, and coming up with a plan. This
    is what interdisciplinary care is really all about.
        One of the things I am really proud of is similar to the
    national statistics, only two-thirds of the veterans who come
    to us are connected to the VA. After we complete treatment, in
    their follow up phase after treatment, 90 percent are connected
    to the VA. We want them to utilize those resources smartly and
    we want to get them reconnected. The problem is that this
    treatment needs to be available and it is not currently within
    the VA in any meaningful way.
        Mr. Murphy. Yes. You know, I think it has been the hallmark
    of, excuse me, medicine, at least in the last 20 years, that
    interdisciplinary study--interdisciplinary treatments is the
    way to go. We do it in oncology. We do it in other different
    fields. It is the best way to deal with all this.
        You know, some people think just throwing money at a
    problem is the way to do it, and all you do is end up turning
    bureaucracy. You want a system that is efficient, that works,
    that gives you expected results, may not be able to deliver,
    you know, perfect outcomes every time, but if you are dealing
    with that type of efficient system, that understands that a
    blast is a blast and that you have to treat it from different
    angles, and also, just blasting out money is not the way you
    solve problems, this is the best mode of treatment that we
    can--or the best the best avenue of treatment that we can get
    for any patient, whether in their VA or not. I thank you guys
    for your service.
        Lieutenant Colonel Johnson, it hurt me to hear that you
    feel that 50 percent of our folks consciously underreported.
    That is self--that is putting country before self. That hurts
    to hear. It is not unexpected because that is what our
    soldiers, airmen, Marines, et cetera, do, they put their
    country before for self. That is a lot of--it just hurts to
    hear that, but that is a reality.
        Anyway, thank you all so much for your service. This is
    such a difficult, challenging problem, but thank you for
    working so hard.
        Ms. Miller-Meeks. The gentleman's time has expired.
        The chair now recognizes General Bergman for 5 minutes for
    any questions he may have.
        Mr. Bergman. Thanks, Madam Chair. While I stepped out to
    take another meeting, I understand, you know, the committee
    process goes on, so I am going to just kind of lay out what the
    congressional Record was recorded as a few minutes. This is the
    quote, ``Congresswoman Brownley to Mr. Miscusi, quote, 'Do you
    think that diverting $60 million from existing VA programs as
    the BEACON Act requires helps or hinders VA in implementing
    intensive outpatient programs like the ones you have
    completed,' question mark, end quote?''
        The BEACON Act does not, unless my team is mistaken, does
    not require the VA to divert $60 million. Instead, it allows
    the Department to use existing mental health funding and
    provides appropriators the option to allocate further funding
    specifically for the bill's purposes. I just want to make sure
    that the record stands straight that there is no diverting of
    $60 million here. Okay? I just wanted to inform my colleague
    that--of the mistake in her assumptions.
        Having said that this is not personal. This is about facts.
    The panel's testimony makes clear that even when a TBI is
    labeled mild, the consequences for a veteran can be anything
    but. A significant number of veterans continue to live with
    persistent symptoms that affect daily function and community
    reintegration. That reality underscores why we must continue
    pursuing new treatments and innovative procedures to care for
    the veterans still living with these injuries.
        With that as background, Dr. Gore, could you briefly
    explain the differences between a VA Polytrauma Rehabilitation
    Center and the other VA sites with TBI teams or polytrauma
    clinics?
        Dr. Gore. Yes, thank you for that question. You know, I can
    certainly comment on my experience working with patients who
    have been in these--in the VA clinics, but I do not have
    personal experience working within the polytrauma center or one
    of the satellite community centers.
        My experience talking with patients about this experience,
    their experience within the VA, the IETP programs are modeled
    after what we do. These are intensive programs with wraparound
    services, a therapy team that surround an individual for an
    intensive period of time. It is generally anywhere between 3
    and 6 weeks of intensive treatment. That is only provided at
    the VA polytrauma centers.
        The care that is provided in the general community is
    important screening care, potentially referrals to the
    polytrauma centers. Generally, individuals are given
    rehabilitation referrals that are to different locations around
    the community. The coordination of those referrals is very
    difficult. There is no communication or not a lot of
    communication between the providers providing that care, and
    that care occurs over an extended period of time. It is more
    the traditional model of rehabilitation that we see in this
    country. The fact that----
        Mr. Bergman. I am going to--I know you could talk for a
    long time on this time, please. The point is, I would suggest
    that in any--we all use the term ``stovepipes.'' We know what a
    stovepipe is. You can have two stovepipes sitting next to one
    another, the Veterans Administration being one, a new, you
    know, polytrauma center, TBI teams, whatever, in another. If
    you are not communicating and sharing experiences of lessons
    learned, neither one of you are doing your job.
        As we look at the Veterans Administration to get
    uncomfortable, in other words, get the hell out of your
    stovepipe and look at what you are proposing to do and see if
    you have got second and third order effects of what is working,
    what is not working, so that we expand on the quality of the
    care and the quality of the therapy and the quality of then,
    ultimately, outcomes when it comes to that. Because one thing,
    as we have talked about in all the committees I am on,
    especially Armed Services and Veterans' Affairs, is to break
    down the unnecessary stovepipes that have been allowed to grow
    over time and are beginning to look like weeds in a garden.
    When you got weeds in a garden, you do not get the beautiful
    flowers or the vegetables or whatever it is you are growing.
    Let us knock down the stovepipes.
        With that, I yield back.
        Ms. Miller-Meeks. Thank you, General Bergman.
        The chair now recognizes Representative Stauber for 5
    minutes for any questions he may have.
        Mr. Stauber. Thank you, Madam Chair.
        I want to begin by thanking Chairman Bost and you for
    allowing me to wave on to today's timely hearing. I also want
    to thank each of our witnesses for their service to our Nation,
    for sharing their experiences.
        As the husband of an Iraq War veteran, I personally
    understand the burden our country puts on our military
    families. Behind every servicemember is a family who supports
    them. It is our duty as a Nation to help during and after
    service.
        I want to take a moment to highlight my good friend Al
    Johnson, who is a constituent of mine in northern Minnesota.
    Mr. Johnson served with honor and distinction during his time
    in the Army and the Minnesota National Guard. I know it is his
    expert testimony that the Minnesota National Guard is the best
    in the Nation.
        Mr. Johnson, I want to take--I want to ask you a quick
    question before I talk and not answer my 92-year-old father's
    phone call there. Mr. Johnson, I want to ask you about your
    experiences following the attack on Al-Asad. You note in your
    testimony that there is ample evidence that Iran used dirty
    warheads during this attack, correct?
        Mr. Johnson. Thank you for your question, Congressman
    Stauber. I do not have the credentials to make that official
    call that it was a dirty warhead. I can tell you this, people
    are getting sick after this attack. In addition to when we were
    deployed there, we did not receive dosimeters to wear. After we
    left, they were issued dosimeters. There was some level of
    concern that occurred with the amount of radioactivity that was
    on the base post attack.
        Mr. Stauber. Have Al-Asad veterans been able to easily
    access things like cancer screenings because of their presence
    during and after this attack?
        Mr. Johnson. They have not. This is part of the problem
    where when these people separate, they spread all over the
    world or all over the United States. They become recluse. You
    lose contact with them. They are young. They do not know what
    to ask for because you do not know what you do not know. That
    is some of the gaps in not having a medical cohort surveillance
    program.
        Mr. Stauber. You believe that because we do not have
    something like a medical surveillance program for Al-Asad
    veterans, they are----
        Mr. Johnson. I think they are under-triaged, correct.
        Mr. Stauber. In your testimony, you mentioned the tragic
    loss of SPC Jason Quitugua, who has become another victim in
    the veteran suicide epidemic plaguing our Nation. How many Al-
    Asad veterans like SPC Quitugua are slipping through the cracks
    because we do not have a medical surveillance program in place
    for the Al-Asad veterans?
        Mr. Johnson. I do not know an exact number, but I know of a
    handful that nobody can get a hold of, and I do not know if
    they are suicidal, have addiction problems. That is concerning.
        Mr. Stauber. Would it be your testimony that these veterans
    are not getting the care they need at the moment?
        Mr. Johnson. That is correct.
        Mr. Stauber. Do you believe having a medical surveillance
    program in place would help make sure those veterans get the
    support that they need?
        Mr. Johnson. Yes, sir.
        Mr. Stauber. You also raised an interesting point about
    accountability regarding SPC Quitugua's death. Did SPC Quitugua
    have TBI before the Al-Asad attack?
        Mr. Johnson. Nothing was indicated in his record to say----
        Mr. Stauber. Did SPC Quitugua have PTSD before the Al-Asad
    attack?
        Mr. Johnson. Not that was indicated.
        Mr. Stauber. Is SPC Quitugua dead because the terrorist
    regime in Tehran attacked Al-Assad?
        Mr. Johnson. In my opinion and the opinion of experts that
    mTBI--all agree, yes.
        Mr. Stauber. I just with the remaining time, Mr. Johnson, I
    want to give you the opportunity to highlight anything that you
    think was missed in today's hearing. The floor is yours.
        Mr. Johnson. Well, first and foremost, I want to thank you
    and all of the panel for their commitment to the health and
    welfare of our veterans. We have made great strides in
    improving the lives of our warriors and families. We cannot
    leave the families out of this who deal with the consequences
    of war at home on a daily basis. There is always room for
    improvement.
        Whether it is improving the equipment that protects us on
    the battlefield with the gear that we wear, passing legislation
    that holds terrorist countries accountable for what they do to
    innocent victims of, like in our case, blast injury, or funding
    for continued research to discover how to reduce or eliminate
    symptoms of TBI and PTSD, we rely on you, Congress. You are one
    of the conduits to solve these challenges.
        The challenges of our servicemembers now that are facing in
    the Middle East, and this could not be more timely, this is not
    the last we are going to see about blast injuries and traumatic
    brain injuries continuing from the battlefield. It is just
    going to get worse. As we move into a more linear battlefield,
    these instances of recognizing TBI and appropriate care are
    going to be more prudent.
        Mr. Stauber. Thank you very much, Madam Chair. I yield
    back.
        Ms. Miller-Meeks. Thank you, Representative Stauber.
        I now yield myself 5 minutes to ask any questions I may
    have.
        All three of you are military veterans, correct? Sergeant
    Miscusi, Lieutenant Colonel Johnson, Colonel Gore, Dr. Gore?
    Let me ask you a question. The VA budget is just under, the VA
    healthcare budget, is just under half a trillion dollars. When
    we are talking about the BEACON Act, which is not diverting
    funds from any entity, it is $60 million for the BEACON Act. Do
    you know what percentage of the entire healthcare budget that
    is for the VA? Fifty percent, 10 percent? More like 1 percent
    of the entire VA healthcare budget.
        I have heard--and so I am a 24-year military veteran. You
    all do not know me. I am a doctor. I was a nurse before. Left
    home at 16 to put myself through medical school. Let me ask
    you, all three of you are veterans. Sergeant Miscusi, when you
    went to Operation Mend, did you feel that they were culturally
    incompetent?
        Mr. Miscusi. No, I did not.
        Ms. Miller-Meeks. Lieutenant Colonel Johnson, as a PA or a
    medical flight, when you have received care outside the VA, did
    you feel that they were culturally incompetent?
        Mr. Johnson. No, ma'am.
        Ms. Miller-Meeks. Dr. Gore, having been both a veteran and
    providing services now not at a VA facility, do you feel and do
    the veterans feel that you are culturally incompetent?
        Dr. Gore. I feel culturally competent, ma'am.
        Ms. Miller-Meeks. Yes. Might you as veterans know if you
    are receiving culturally incompetent care? You might well--damn
    well know if you are receiving culturally incompetent care.
        What I hear from veterans every single day, and as a
    veteran, married to a 30-year veteran, the daughter of a
    veteran, six of eight children having served in our military,
    veterans want choice. Veterans want care. They are fully
    capable of determining if they think care is culturally
    competent or if it is competent or if they have access to that
    care.
        It is not really a question so much as it is that we are
    talking about getting care to veterans in a timely fashion to
    which they have access and to which they can determine if it
    meets their needs and if it allows them to be a functional
    human being, father, spouse, community member once again. That
    is why I support the BEACON Act, because to me, what is most
    important as the chair of this committee is that you receive
    the care that you need and that we expand services where we
    think there is unmet and undetected need.
        Mr. Johnson, and I think you have answered this, how common
    is routine exposure to low level blast overpressure from
    breaching mortars? How is this different from regular infantry
    and special operations forces?
        Mr. Johnson. It is more common than we recognize, these
    multiple sub-concussive events that happen daily over and over
    again in our line of work.
        Ms. Miller-Meeks. Thank you. Dr. Gore, do you think that we
    currently are meeting the need that you have perceived through
    the VA system as it currently exists?
        Dr. Gore. I think we could do much better.
        Ms. Miller-Meeks. I think, Sergeant Miscusi, you would
    probably echo that sentiment?
        Mr. Miscusi. Yes, ma'am.
        Ms. Miller-Meeks. Yes. With that, I yield my time.
        I think it is very profound, the testimony that we have
    heard today and the stories told by our guests. They bear
    witness to several things, especially with an ongoing conflict
    in the Middle East. They bear witness to the incredible
    strength and resilience of our American servicemember.
    Apologize for getting emotional on that, as well as the
    achievements of our VA healthcare system, which are incredible
    achievements, but also to the shortcomings of our system. It
    has been illuminating and an insightful hearing.
        It is a moment in time when we are treating our veterans
    from the past two decades of warfare while catching a
    terrifying glimpse of what our future warfighters could face.
    It is imperative that Congress and the VA step up to the
    challenges of ensuring the health and safety of our future and
    our current veterans. Whether it is an institutional problem or
    whether it is a funding problem, both those things need to be
    addressed.
        Representative Brownley, would you like to make any closing
    remarks?
        Ms. Brownley. Thank you, Madam Chair. You know, all I am
    trying to say here is I, you know, certainly recognize and
    support the role that community partners and nonprofits play in
    getting needed care to veterans with TBI. In fact, many are
    already participating in VA's Community Care Network and
    academic affiliation. What I am just arguing for is we should
    be putting more money into the system to improve care to keep
    with the research that is out there to give optimal care to our
    veterans and not have the VA have to make choices between
    funding their existing services and supporting entities outside
    of the VA.
        General, sitting over there, I am happy to work with you on
    this. I have great respect for you. We have served on the
    committee for a long, long time. We have had bills together. I
    would love to sit down and talk with you more about what our
    concerns are, what your concerns are, and see--and I know Ms.
    Elfreth as well. I have spoken with her this morning and would
    love to see if we can come to an agreement between us.
        Mr. Bergman. This is bipartisan.
        Ms. Brownley. Thank you. I yield back.
        Ms. Miller-Meeks. Thank you, Ranking Member Brownley.
        Again, just want to state that both as a physician and as a
    veteran, as a physician who has provided community care, I have
    always felt that my goal was to give excellent care, the
    highest quality of care, and in a culturally competent way,
    even if I was not trained by the VA in what some might consider
    culturally competent care. I appreciate our witnesses who have
    experienced both systems for letting us know where they think
    are the tremendous attributes of the VA as well as where the
    deficiencies are. It is through them that will prepare and
    extend a system that meets the needs of veterans.
        I want to thank you for your participation in today's
    hearings and for the discussions that we have had on this very
    important topic. The complete written statements of today's
    witnesses will be extended--entered into the hearing record.
        I ask unanimous consent that all members have 5 legislative
    days to revise and extend their remarks and include extraneous
    material. Hearing no objection, so ordered.
        I thank the members and the witnesses for their attendance
    and their participation today. This hearing is now adjourned.
        [Whereupon, at 12:14 p.m., the subcommittee was adjourned.]
    =======================================================================

                             A  P  P  E  N  D  I  X

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                        Prepared Statements of Witnesses

                                  ----------

                      Prepared Statement of Rachel McArdle

        Chairwoman Miller-Meeks, Ranking Member Brownley, and Members of
    the Subcommittee: Thank you for the opportunity to testify on the
    Department of Veterans Affairs' (VA) efforts to support Veterans living
    with traumatic brain injury (TBI). Joining me today is Dr. Joel
    Scholten, Executive Director, Physical Medicine and Rehabilitation.
    Together, we will share how VA addresses the complex needs of Veterans
    with TBI through clinical care, research, and collaborations.

    Understanding TBI

        TBI is defined as a disruption of normal brain function caused by
    an external force, such as a blow to the head, rapid acceleration or
    deceleration, or blast exposure.\1\ It can result in symptoms ranging
    from headaches and dizziness to memory problems, mood changes, and
    physical impairments. For Veterans, TBI is often associated with
    military service, particularly in combat environments, but it also
    occurs in training and civilian life.
    ---------------------------------------------------------------------------
        \1\  VA/DoD Clinical Practice Guideline for the Management and
    Rehabilitation of Post-Acute Mild Traumatic Brain Injury. The
    definition is on page 6. Available at: https://
    www.healthquality.va.gov/HEALTHQUALITY/guidelines/Rehab/mtbi/
    VADODmTBICPGFinal508.pdf
    ---------------------------------------------------------------------------
        TBI is considered a ``signature injury'' of recent conflicts, yet
    its impact extends across all eras of service. Importantly, TBI rarely
    occurs in isolation. Many Veterans experience co-occurring conditions
    such as posttraumatic stress disorder (PTSD), chronic pain, and sleep
    disturbances, which complicate diagnosis and treatment. Understanding
    this complexity is essential as we consider how to best support
    Veterans throughout their lives.
        In addition to traumatic events that may cause a TBI, Service
    members may also have exposures labeled as Military Occupational Blast
    Exposure (MOBE). MOBE is caused by repeated exposure to jets on
    aircraft carriers, artillery fire, or blast during breaching
    operations. These exposures can cause symptoms similar to TBI and can
    accumulate over time leading to the development of persistent symptoms.
    MOBE is often overlooked, yet it may contribute to symptoms resulting
    in difficulties with employment, driving, and interpersonal
    relationships. As we recognize the scope of this issue, it will be
    important for VA to adapt how it structures its care systems to meet
    these needs.

    VA's Care Systems

        VA has built a comprehensive care system to address TBI across the
    continuum of care. This includes screening, diagnosis, individualized
    treatment planning, and long-term support. At the heart of VA's
    approach is the Polytrauma System of Care, a nationwide network
    designed to provide specialized rehabilitation for Veterans with
    complex injuries, including TBI. This system includes five Polytrauma
    Rehabilitation Centers that deliver inpatient and outpatient,
    intensive, interdisciplinary care for Veterans with severe injuries.
    These centers work closely with Polytrauma Network Sites and Polytrauma
    Support Clinics to lead over 110 TBI teams across VA. Dedicated case
    managers coordinate services, facilitate transitions between settings,
    and support families throughout recovery.
        VA screens all post-9/11 Veterans for TBI. Since 2007, VA has
    screened more than 1.8 million Veterans and connected Veterans with TBI
    specialists to complete an evaluation and develop a treatment plan. In
    Fiscal Year 2025 alone, VA treated over 160,000 Veterans with TBI-
    related conditions.
        Every Veteran with TBI receives a personalized care plan tailored
    to his or her unique needs. These plans address physical, cognitive,
    and emotional symptoms, and often include therapies for co-occurring
    conditions, such as PTSD and chronic pain. VA emphasizes integrated
    care that combines rehabilitation with mental health services and whole
    health approaches. This comprehensive model helps Veterans manage
    symptoms, build resilience, and maintain gains achieved during
    rehabilitation. While clinical care is essential, VA also recognizes
    that research and innovation are critical to improving outcomes and
    shaping the future of TBI treatment.

    Research and Innovation

        VA is committed to advancing knowledge and improving outcomes for
    Veterans with TBI through research and innovation. Our efforts focus on
    understanding long-term effects, developing precision diagnostics, and
    creating effective treatments. VA engages with leading academic
    institutions and the Department of War through initiatives such as the
    Long-Term Impact of Military-Relevant Brain Consortium, Chronic Effects
    of Neurotrauma Consortium, and the Translational Research Center for
    TBI and Stress Disorders. These programs study chronic effects of TBI,
    identify biomarkers, and develop interventions to improve brain health.
        VA is also actively investigating the impact of repeated MOBE that
    occurs during military operations and training. These exposures may not
    cause immediate symptoms but can lead to cumulative effects over time.
    Research is underway to better document these exposures and understand
    their relationship to long-term health outcomes. In addition, VA has
    developed tools such as the Concussion Coach mobile application to help
    Veterans manage symptoms and access resources. Telehealth and virtual
    rehabilitation programs are expanding access to care, particularly for
    Veterans in rural and underserved areas. These research efforts and
    innovations are not isolated--they are integrated with VA's clinical
    programs and academic affiliations to ensure that discoveries translate
    into better care for Veterans.
        The Brain Health Coordinating Center (BHCC) serves as VA's central
    resource for advancing brain health research and care. The Center
    integrates data from across VA medical facilities to identify risk
    factors, track treatment outcomes, and develop strategies that protect
    cognitive function in Veterans. The BHCC will also coordinate future
    brain and mental health clinical trials in diagnostics and
    therapeutics.
        VA works closely with universities and TBI Model Systems, a
    multicenter longitudinal data base that captures rehabilitation and
    functional outcomes of individuals with TBI, to advance evidence-based
    care and train clinicians.\2\ These relationships allow VA to share
    best practices, conduct multi-site research, and accelerate the
    translation of findings into clinical care. By leveraging these
    connections, VA ensures that Veterans benefit from the latest
    scientific advances and that our workforce remains at the forefront of
    rehabilitation medicine. As we look to the future, these alliances will
    be essential in addressing remaining gaps and improving care for
    Veterans with TBI.
    ---------------------------------------------------------------------------
        \2\ The Traumatic Brain Injury Model Systems (TBIMS) National Data
    base is a prospective, multicenter data base and the largest
    longitudinal traumatic brain injury (TBI) data base in the world,
    funded by National Institute on Disability, Independent Living, and
    Rehabilitation Research (NIDILRR).

    ---------------------------------------------------------------------------
    Opportunities to Put Veterans First

        Despite progress, challenges remain. Currently, there is no single
    test to definitively distinguish symptoms caused by TBI from those
    related to mental health conditions. Veterans with mild or repeated
    TBIs may experience persistent symptoms that are difficult to treat. To
    advance the brain and mental health of Veterans, Total Brain
    Diagnostics is an ongoing precision, mental health research initiative
    to identify, validate, and integrate brain and mental health biomarkers
    among Veterans with specific consideration for depression, anxiety,
    PTSD, bipolar disorder, other mental health conditions, and TBI. The
    goal of this initiative is to assist clinicians in diagnosing complex
    brain and mental health conditions.
        Looking ahead, VA will continue to improve documentation of blast
    and occupational exposures during military service, expand precision
    brain health approaches that tailor treatment to individual needs, and
    strengthen telehealth and intensive outpatient rehabilitation programs.
    We are committed to enhancing integration of mental health and whole
    health concepts into TBI care and deepening relationships with
    academia, Veterans Service Organizations, non-profits, and the
    Department of War to accelerate research and innovation. Finally, we
    aim to develop proactive case management strategies that engage
    Veterans with persistent symptoms and prevent functional decline.
    Through these efforts, we will continue to focus on putting Veterans
    first and advancing comprehensive care to Veterans with TBI.

    Conclusion

        VA remains committed to delivering world-class care, advancing
    research, and supporting Veterans and families affected by TBI. Through
    our Polytrauma System of Care, research collaborations, and innovative
    programs, we strive to improve outcomes and quality of life for those
    who have sustained these injuries. Thank you for your leadership and
    continued support. We look forward to your questions.

                        Prepared Statement of Al Johnson
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                      Prepared Statement of Buster Miscusi

        Chairwoman Miller-Meeks, Ranking Member Brownley and Distinguished
    Members of the Committee, thank you for the opportunity to represent my
    fellow veterans who bear the invisible burden of traumatic brain
    injuries. I hope that my testimony today honors their service and
    experiences. While each of our journeys of injury and recovery are
    unique, rarely follow a straight path, and are unlikely to be repeated,
    they do tend to rhyme.
        In 2001 I was in fourth grade on the Lower East Side of Manhattan
    on 9/11 when the United States was attacked. I remember being a 9-year-
    old kid reading the comics and sports pages on 9/10, and then sitting
    on those same playgrounds on 9/12 discussing international politics and
    the ethics of a military strike with my friends. It was then that my
    goal to serve in the U.S. military first materialized--a goal I would
    realize 9 years later when I enlisted in the Marine Corps infantry. I
    dreamt of a long career fighting in combat against the enemies of the
    United States, getting justice for the 2,977 victims of 9/11 and the
    countless other Americans whose lives were irreversibly changed that
    day.
        Before my first deployment, that dream looked achievable. I was
    good at my job, getting meritoriously promoted twice within my first
    year. I could glance at a map, go on a 5-hour patrol, and know exactly
    where I was. I could expertly navigate the social world I lived in,
    understanding non-verbal communication, sarcasm, irony, and implied
    meaning to foster strong relationships with my unit, my newly wedded
    wife, and my family. I could tolerate change and new experiences,
    finding my way through chaotic environments. My future military
    career--and my life--looked bright.
        When I came home from Afghanistan in 2012 I was diagnosed with
    PTSD. After a 3-week sequence of cognitive behavioral therapy I was
    well enough to get back in the fight.
        Unfortunately, in 2015 I was diagnosed with Crohn's Disease and
    sent to Wounded Warrior Battalion East in Camp Lejuene, North Carolina
    to be medically retired. My dream of a long career in the Marine Corps
    had been shattered. Overnight I was no longer the mortar man, infantry
    squad leader, or martial arts instructor I had been for the past 5
    years. Now I was a patient.
        During the battery of appointments and evaluations for my medical
    board the providers diagnosed me with TBI on top of the Crohn's Disease
    and PTSD. From the outside looking in it looked like the wheels had
    come flying off the moment I slowed down. In reality, it was that by
    slowing down I realized that the wheels had fallen off a long time ago.
    What I was struggling with wasn't new, it had just built up so slowly
    over time that I had adapted little by little and barely noticed how
    far I had fallen.
        During my time in the infantry I had fired thousands of rounds of
    mortars and detonated numerous explosives, but I never thought I had a
    TBI because I hadn't been exposed to an IED blast and I couldn't recall
    ever being knocked unconscious. Back then, the cumulative effects of
    repeated low blast exposures were not widely recognized, screened for,
    or understood within the military or clinical settings.
        Additionally, because the majority of us in the infantry suffered
    from some type of headache, confusion, and anger problems we assumed it
    was normal. The effects of these repeated overpressure blasts were
    shared by all and treated with humor. Whether it was bloody noses,
    blood coming from our ears, or losing my hearing for 2 weeks--even
    while wearing ear protection--nothing was immune from an infantry
    marine's sense of humor. Somewhere there is a photo of me, flanked by a
    marine on either side, with two lit cigarettes dangling out of my ears
    in a poor man's attempt at ear candling after I had lost my hearing for
    2 weeks. Back then, nothing couldn't be solved with a laugh, and a
    headache was no match for a sufficient amount of nicotine, caffeine, a
    change of socks, a drink of water, and some Advil. My headaches and
    vertigo were chalked up to dehydration, confusion was assumed to be
    caused by a character flaw, and inappropriate jokes, whether violent or
    sexual, were accepted as part of the military culture.
        Now at Wounded Warrior Battalion, these experiences were seen as
    symptoms. I initially pushed back against the TBI diagnosis, confused
    since I had never been exposed to an IED. My providers explained that
    PTSD and TBI can share overlapping symptoms and that there were some
    ways that I was thinking and processing information that were uniquely
    related to TBI. The doctors explained that being exposed to repeated
    shock waves from firing weapons and detonating explosions in training
    could cause a TBI just as well as any explosion in combat.
        What I had considered a ``painful headache that made things look
    funny'' was diagnosed as a complex migraine disorder with aura. The
    doctors rightly noticed that the confusion wasn't a character flaw, but
    by challenges with memory recall and information processing.
    Inappropriate jokes were recognized not as an infantry cultural norm
    that I couldn't let go of, but as a problem with my capacity to filter
    my thoughts and notice social and non-verbal cues. I was diagnosed with
    a traumatic brain injury caused by cumulative low-blast injuries. The
    doctors prescribed medications to help with my migraines, sent me to
    speech therapy for the memory challenges, and mental health for the
    problem with my filter. With a diagnosis and a treatment plan I was
    medically retired from the Marine Corps in 2018 and began going to
    college with dreams of becoming an astronomer.
        Unfortunately, recovery is not linear and even if we stick to our
    treatment plan to the letter things can fall apart. A year after being
    medically retired from the Marine Corps I began having episodes where I
    would lose function in one side of my body, my face would sag and
    twitch, and my speech would slur and stutter. During an episode I
    couldn't walk, talk, or eat. My sense of touch deadened and I could no
    longer notice the difference between soft and sharp objects, or how
    hard I was holding something. The doctors at the VA ruled out a stroke
    saying that it felt like ``the engine still has power, the transmission
    just keeps slipping out of gear''.
        While humorous in an infantry sort of way, these episodes were
    occurring nearly daily and would require a full day of rest to recover.
    It was no longer safe for me to drive and I had to leave school, unable
    to maintain the course of study. With my ability to function reduced
    such a significant extent, all of the symptoms that were previously
    managed became worse. The VA doctors did the best they could to manage
    these symptoms with the skills they had. They prescribed medications
    and medical devices, I tried acupuncture, massage, and hypnosis, but
    nothing seemed to help me return to a normal level of function. I began
    to fall into a depression, believing that I was a burden and that the
    meaning I had built my life around--service, responsibility, and
    usefulness--was lost.
        Even in the midst of my despair, my wife held on to hope. Her hope
    inspired me to keep trying, to keep searching for anything that could
    help. I was at the end of my rope when I spoke to a nurse case manager
    from Semper Fi & America's Fund, who asked if I had ever heard of UCLA
    Operation Mend--an intensive outpatient program that partners with
    Wounded Warrior Project to help veterans with PTSD and TBI. I told her
    I hadn't, but that I would be willing to try anything once.
        Operation Mend treated my brain injury differently. They didn't
    treat my injury as a problem to solve by trying to make it go away.
    During their intake they collected an entire picture of everything that
    was happening. Every single symptom that I was experiencing, even if it
    might have been associated with Crohn's Disease and not TBI, was
    considered. They took that information and, rather than trying to
    reduce my symptoms alone, they worked with me to identify the strengths
    I already had and the skills and resources needed to work around my
    limitations. They worked WITH me, not ON me.
        More importantly, they included my wife in the process, working
    with her as well--recognizing that this injury does not affect one
    person alone, but impacts the entire family. It turns out that
    recovery, just like military operations, is a team sport. Operation
    Mend helped restore my belief that, while my brain injury was
    debilitating, painful, and difficult to understand, I could find a way
    to live a meaningful life of service if I learned to lean on my
    strengths and develop the skills and resources needed to support me and
    my family. Returning home with this new approach from Operation Mend I
    was able to get connected with a headache specialist who helped me
    understand that challenges I had been facing that I thought were part
    of Crohn's Disease, feeling like I was getting bitten by red ants,
    getting extremely weepy for no reason (don't play bag pipes around me
    unless you want to see me cry), and randomly getting voraciously hungry
    were all part of my migraine disorder too.
        Operation Mend didn't make the migraines, the symptoms, or the TBI
    go away. I wasn't restored to my old level of functioning. But it did
    restore my sense of agency. Today, I still get migraines. I have a
    constant low-grade headache, my ears ring, and my head spins. I still
    break glass ware and I still get lost and need a GPS to get around. I
    struggle to understand sarcasm, irony, or implied meaning conveyed
    through non-verbal communication. I still cry when I hear bag pipes.
    Chaotic, cluttered, and crowded environments continue to confuse,
    disorient, and frustrate me. But now--thanks to Operation Mend, the VA,
    and my wife--these are challenges I have the skills and resources to
    face. I will likely face them for as long as I am alive, but they are
    no longer a sign of my failure. They are a sign of my survival. A
    survival that, while painful, is marked by humor, brotherhood, and
    purpose. While my future no longer looks the way it did when I first
    joined the Marine Corps, it is still full of hope.
        By leveraging the skills and resources I have been given through
    Wounded Warrior Battalion, Operation Mend, Semper Fi & America's Fund,
    Wounded Warrior Project, and the VA, I now have the opportunity to
    discover new strengths and abilities within myself so that I can serve
    my family and my community with more compassion, patience, and wisdom
    than I was capable of before.
        My story is not unique. The infantry is not the only military
    occupation exposed to environments with a risk of overpressure
    injuries. My struggle to describe my experience in a way that allowed
    me to access the right care is shared by many, especially those with
    brain injuries. Veterans, transitioning service members, and their
    families need to know that low blast exposure injuries can occur
    regardless of occupation, deployment history, or combat experience.
    Training must be developed so veterans, transitioning service members,
    and their families are given the language needed to explain their
    experiences and access appropriate care.
        Programs like Operation Mend--where symptoms are treated as
    challenges to work with and through rather than obstacles to destroy or
    be destroyed by; where veterans are listened to for things they don't
    yet have words for; and where caregivers are honored as integral
    partners in the healing journey rather than a dispensable
    afterthought--should be the gold standard of care and emulated
    nationwide throughout the VA.
        The capacity to provide this level of warrior-family-focused care
    already exists within the VA. The programs simply need to be organized,
    and veterans and caregivers need to be honored as key stakeholders in
    the design and implementation process. Developing these programs
    requires the collaboration of those who know what the problem is, those
    who know how to solve it, and those who have the platform to make it a
    reality. I know what this injury feels like, and I know what helped me.
    The VA knows how to solve it and has the platform to make it a reality.
    Now that this Committee understands it as well, the responsibility to
    act no longer rests with veterans alone.

                       Prepared Statement of Russell Gore
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                           Statements for the Record

                                  ----------

       Prepared Statement of Association of VA Neurology Services (AVANS)

        Chairman, Ranking Member, and Members of the Committee:

        Thank you for the opportunity to discuss the care of Veterans with
    traumatic brain injury (TBI) and the role of the Neurology Centers of
    Excellence within the Veterans Health Administration (VHA). It is an
    honor to represent the clinicians, researchers, and staff who care for
    Veterans living with the enduring consequences of TBI.
        After 35 years of Federal service, I retired from the Department of
    Veterans Affairs (VA) on September 30, 2025. At the time of retirement,
    I was the Executive Director of the national Neurology Clinical
    Programs and had supervisory responsibility for the 4 national networks
    of neurology Centers of Excellence (CoEs) and 3 national neurology
    tele-programs. My statement expresses my own opinions and is endorsed
    by the Board of Directors of AVANS.
        Traumatic brain injury (TBI) remains one of the defining injuries
    of modern military service. While some injuries are immediately
    apparent, many TBIs--particularly mild TBIs and concussions--produce
    symptoms that may persist for months or years and are often invisible
    to others. Symptoms may begin months or even years following injury.
    Veterans with TBI frequently experience chronic headaches, seizures,
    cognitive changes, sleep disturbances, mood and behavioral symptoms,
    and, in some cases, increased long-term neurological risk. These
    effects can interfere with employment, relationships, and overall
    quality of life. For many Veterans, TBI is not a single episode of
    care; it is a chronic neurological condition requiring coordinated,
    longitudinal management.
        The Neurology Centers of Excellence play a central role in meeting
    that need. TBI is neurologically complex and often intertwined with
    other conditions such as post-traumatic stress disorder (PTSD), chronic
    pain, substance use disorders, and orthopedic injuries. Accurate
    diagnosis and effective treatment require subspecialty expertise in
    areas such as epilepsy, headache medicine, and neurodegenerative
    disease. The Centers of Excellence ensure that this expertise is
    available across our national system and that Veterans receive care
    aligned with the best available evidence, regardless of geography.
        For example, chronic headaches are the most common long-term
    sequela of TBI. The network of Headache CoE hubs and sites provide
    integrated, multidisciplinary care for refractory migraine and other
    headache disorders, often achieving significant improvements in
    function and quality of life that years of isolated care, whether in
    VHA or in the community, have failed to provide. The risk of epilepsy
    is increased both in the short-term and long-term following TBI. The
    VHA network of Epilepsy CoEs provide advanced diagnostic services such
    as inpatient video and electroencephalographic monitoring to confirm
    the diagnosis of epilepsy and determine the optimal medical, or in
    refractory cases surgical therapies. Veterans having episodic events
    may be found after diagnostic evaluation to have a functional disorder,
    paroxysmal nonepileptic seizures (PNES). More common in Veterans than
    in the general population, and often coexisting with PTSD, the VHA
    Epilepsy CoEs have pioneered the development and implementation of a
    network of clinicians trained in Neuro-Behavioral Therapy that
    effectively treats this disorder but is generally not available outside
    VHA. The incidence of neurodegenerative disorders such as Parkinson's
    disease and Alzheimer's disease is increased in Veterans with a history
    of TBI. To address the former, the VHA Parkinson's Disease Research,
    Education and Clinical Centers (PADRECCs) provide access to experts in
    Parkinson's Disease and other movement disorders for both diagnosis and
    management of therapies.
        One of the most important contributions of the Neurology Centers of
    Excellence is the standardization of care across VHA. As the largest
    integrated healthcare system in the country, VHA serves Veterans in
    urban tertiary medical centers as well as in rural community clinics.
    Without systemwide coordination, practice patterns can vary. The
    Centers develop and disseminate evidence-based clinical pathways for
    the evaluation and management of post--traumatic headache, seizure
    disorders, cognitive impairment, and other neurological sequelae of
    TBI. They support clinical consultation networks and quality oversight
    processes that reduce unwarranted variation and promote consistent,
    high-quality care. A Veteran in a rural facility should receive the
    same standard of neurological assessment and management as a Veteran
    treated in one of our flagship medical centers. This may be achieved
    through virtual modes such as video telehealth and remote
    interpretation of studies such as electroencephalograms (EEGs), as well
    as through in-person care by interfacility referral. There is a
    national shortage of neurologists, especially in rural areas. The CoE
    networks allow Veterans anywhere to receive the benefits of neurology
    subspecialist care and oversight that is unavailable in rural areas,
    which often lack even general neurologists.
        The Centers also operate in close partnership with VA's Polytrauma
    Rehabilitation System and rehabilitation medicine programs. Moderate
    and severe TBI frequently occurs in the context of polytrauma, and even
    mild TBI is often accompanied by comorbid psychiatric and physical
    conditions. Effective care demands coordination across neurology,
    mental health, physical medicine and rehabilitation, pain management,
    social work, and primary care. The Neurology Centers of Excellence
    strengthen these interdisciplinary connections and help ensure that
    Veterans receive comprehensive rather than fragmented care. This
    multidisciplinary coordinated care is generally unavailable within
    other health care systems, especially in rural or underserved areas of
    the country.
        Access is another critical dimension of VHA care. Many Veterans
    live far from major medical centers. Through tele-neurology services,
    electronic consultation models, and remote interpretation of diagnostic
    studies such as electroencephalograms, the Centers extend subspecialty
    neurological expertise into rural and underserved areas. This model
    reduces travel burdens, shortens time to specialty input, and promotes
    equity in access to care.
        Advanced diagnostic and therapeutic capabilities are also
    concentrated within the Centers of Excellence. Veterans with refractory
    post-traumatic epilepsy, chronic migraine and post--traumatic headache
    syndromes, functional neurological disorders, or complex cognitive
    impairment benefit from referral to clinicians with focused
    subspecialty training. The Centers serve as referral hubs for these
    complex cases while also supporting frontline clinicians managing less
    complicated presentations.
        In addition to direct clinical care, the Neurology Centers of
    Excellence serve as engines of translation from research to practice.
    The VHA's integrated electronic health record and large Veteran
    population uniquely position it to conduct longitudinal research on TBI
    and its long-term neurological consequences. The Centers participate in
    and support VA-funded research efforts, evaluate emerging diagnostic
    tools and biomarkers, and integrate new evidence into clinical
    pathways. This research-to-practice cycle ensures that Veterans benefit
    from advances generated within the very system designed to serve them.
        The Centers also contribute meaningfully to opioid stewardship.
    Chronic post-traumatic headache and pain are common following TBI. In
    the past, these conditions often led to significant opioid exposure.
    Neurology specialists within the Centers promote evidence-based,
    multimodal approaches to headache and pain management that reduce
    reliance on opioids and enhance patient safety. Close collaboration
    with mental health and addiction medicine services further strengthens
    the ability to mitigate risk while addressing suffering.
        Workforce development is another essential function. The Centers
    provide education and training to neurologists, advanced practice
    providers, and primary care clinicians throughout the system. Through
    continuing education programs, case conferences, and clinical decision
    support tools, they build durable capacity across VHA rather than
    concentrating expertise in isolated locations. This investment in
    education ensures that expertise remains embedded within the broader
    system of care.
        The impact of these efforts is seen in earlier identification of
    neurological complications, more precise diagnosis that distinguishes
    TBI-related symptoms from overlapping psychiatric and neurologic
    conditions, improved management of seizures and headaches, reduced
    avoidable emergency utilization, and better functional outcomes.
    Importantly, the Centers support long-term surveillance of Veterans
    with TBI who may face elevated risk for later neurological conditions,
    ensuring that care does not end once the acute injury has stabilized.
        Given the central role of the neurology CoEs to the care of
    Veterans with TBI, as well as other neurological conditions, it is
    concerning that the Centers face several operational challenges.
    Budgets have generally increased in recent years, but often
    unpredictably. The neurology Centers are based within VA Medical
    Centers and their staff are hired locally. Even though CoE operations
    are supported through national specific purpose funds, individual
    medical centers may be reluctant to hire new staff if future funding
    may be cut or fail to provide for annual cost-of--living and other
    increases. Due to the recent focus on downsizing VHA staffing, a number
    of key positions are currently vacant due to clinical and
    administrative staff reassignment, resignation to accept positions
    outside VHA, or opting for early or standard retirement. Key vacancies
    include positions of national significance, such as regional CoE
    Directors and national CoE network administrators, as well as local CoE
    clinicians and other staff. In times of uncertainty concerning the
    stability and desirability of Federal employment, vacancies are proving
    hard to fill, and declinations of VHA job offers are now common. Even
    though full-time CoE hires are permitted under current policy,
    confusion remains regarding the rules and limits pertaining to CoE
    staffing. This can unintentionally place the Centers in competition
    with the host facilities for hiring.
        The neurology Centers must retain large populations of Veterans to
    pursue their clinical, training and research missions. Recent trends to
    outsource Veteran care to the community threaten the ability to deliver
    on these missions. Further, measures that would use VA appropriations
    to fund extramural research related to TBI, such as the proposed BEACON
    Act, if passed, could drain vital resources from ongoing research,
    training and clinical programs, diverting funds to institutions with
    uncertain track records and limited experience working with the Veteran
    population.
        A final concern, one not limited to the neurology CoEs but relevant
    to clinical care throughout VHA at the present time, is the changes in
    the workplace environment and culture in which VHA employees provide
    care. The VHA has long promoted the path to becoming a high reliability
    organization, with an obsessive attention to accuracy and avoidance of
    clinical errors, in a climate of psychological safety that encourages
    reporting of mistakes and ``near misses'' in a concerted effort to
    prevent patient harm. Unfortunately, these principles appear to be in
    abeyance at present. Clinicians are anxious about the security of their
    jobs due to real or threatened staffing reductions or reassignments,
    are stretched thin due to increased vacancies that go unfilled
    following staff departures, and in some cases are forced into cramped,
    inadequate space in overcrowded VA medical centers due to the return to
    office mandate. Restoration of psychological safety and a positive
    workplace culture and environment will ensure optimal safety for all
    Veterans cared for in VHA facilities.
        In closing, the Neurology Centers of Excellence function as force
    multipliers within the Veterans Health Administration. They standardize
    care across a vast national system, extend subspecialty expertise to
    rural communities, translate research into clinical practice,
    strengthen patient safety, and support interdisciplinary, lifelong
    management of traumatic brain injury. TBI is not simply an acute event;
    for many Veterans, it is a lifelong condition. It is an obligation to
    provide coordinated, evidence-based neurological care that honors their
    service and addresses both immediate and long-term needs. The neurology
    Centers help Veterans with TBI on their journey from disability to
    fully functional, employed, and productive members of their
    communities. Adequate funding of the Centers, appropriate hiring
    authority for Center staff, and an improved work culture and
    environment generally, are required to allow the Centers to continue to
    provide optimal care to all Veterans in need of their expertise,
    including those with a history of TBI.
        Thank you for your continued oversight and support of Veteran
    healthcare.

                 Prepared Statement of Wounded Warrior Project

        Chairwoman Miller-Meeks, Ranking Member Brownley, and Members of
    the Subcommittee - thank you for inviting Wounded Warrior Project to
    share our perspective on Department of Veterans Affairs (VA) care for
    veterans with traumatic brain injury (TBI). Supporting veterans and
    Service members with invisible wounds like TBI and post-traumatic
    stress disorder (PTSD) has been central to our mission to honor wounded
    warriors, and our advocacy before Congress has been shaped by our
    experience delivering life-changing and life-saving care to this
    community.
        Wounded Warrior Project (WWP) is built upon our promise to meet the
    needs of warriors and family support members no matter what. Since
    2003, that promise has included programming designed to assist
    catastrophically disabled warriors with moderate and severe TBI. In
    Fiscal Year 2025, we delivered nearly 285,000 hours of in-home and
    local care through our Independence Program. This program provides
    personalized care and ongoing, innovative support to help these
    warriors remain at home and live more independent lives for as long as
    possible. Currently serving nearly 1,000 warriors, the Independence
    Program (IP) is a small but critical part of a larger ecosystem of care
    and support that spans a wide range of needs veterans have now and will
    have into the future.
        Nearly one in five post-9/11 veterans sustained at least one TBI,
    and over 500,000 TBIs have been diagnosed in Department of Defense
    (DoD) personnel since 2000.\1\ Research indicates that this figure
    could be even higher due to undocumented injuries in Iraq and
    Afghanistan before improvements in documentation implemented in
    November 2006.\2\ Most of these individuals make a full recovery from
    their injuries, especially if they only had a single mild TBI, but some
    require lifelong care and support. At least one report has concluded
    that 1 in 4 veterans who have been hospitalized with TBI will develop
    long-term disability.\3\
    ---------------------------------------------------------------------------
        \1\ DEF. HEALTH AGENCY, U.S. DEP'T OF DEF., https://www.health.mil/
    Military-Health-Topics/Centers-of-Excellence/Traumatic-Brain-Injury-
    Center-of-Excellence/DOD-TBI-Worldwide-Numbers (last visited Jan. 9,
    2026).
        \2\ Rachel P. Chase & Remington L. Nevin, Population Estimates of
    Undocumented Incident Traumatic Brain Injuries Among Combat-Deployed US
    Military Personnel, 30 J. HEAD TRAUMA REHAB. E57 (2015) (available at
    https://journals.lww.com/headtraumarehab/Abstract/2015/01000/
    Population_Estimates_of_UndocumentedIncident.14.aspx).
        \3\ Yll Agimi et al., Estimates of Long-Term Disability Among US
    Service Members With Traumatic Brain Injuries, 36 J. HEAD TRAUMA REHAB.
    1 (2021) (available at https://pubmed.ncbi.nlm.nih.gov/32472830/).
    ---------------------------------------------------------------------------
        Injury data like the above is underscored by the fact that modern
    medicine and recent improvements to the delivery of in-theater care
    have saved more lives than ever before.\4\ Yet while many survived
    their wounds on the battlefield, recent scholarship has found excess
    mortality rates among post-9/11 veterans compared with the general U.S.
    population, particularly among veterans with TBI. Research funded by
    DoD and the Department of Veterans Affairs (VA) concluded that post-9/
    11 veterans have higher death rates than expected, and those who had
    traumatic brain injuries had an even greater risk of dying. More
    specifically, ``[w]hile veterans exposed to moderate/severe TBI
    accounted for only 3 percent of the total post-9/11 Veteran population,
    they accounted for 34 percent of total excess deaths observed, which
    was 11-fold higher than would otherwise be expected.'' \5\ This study
    and others draw particularly close attention to the elevated risk of
    suicide that veterans face after TBI, particularly if those injuries
    are more severe.\6\
    ---------------------------------------------------------------------------
        \4\ Valecia Dunbar, Trauma Registry Yields Significant Increase in
    Traumatic Injury Survival Rates, U.S. ARMY (June 25, 2015), https://
    www.army.mil/article/150990/
    trauma_registry_yields_significant_increase_in_traumatic_injury_survival
    _rates.
        \5\ Jeffrey Howard et al., Association of Traumatic Brain Injury
    With Mortality Among Military Veterans Serving After September 11,
    2001, 5 JAMA NET. OPEN (2022) (available at https://doi.org/10.1001/
    jamanetworkopen.2021.48150).
        \6\  Lisa Brenner et al., Associations of Military-related
    Traumatic Brain Injury with New-onset Mental Health Conditions and
    Suicide Risk, 6 JAMA Net. Open (2023) (available at https://
    jamanetwork.com/journals/jamanetworkopen/fullarticle/2807787); Jeffrey
    Howard et al., Suicide Rate Trends for Post-September 11, 2001, US
    Military Veterans, 8 JAMA NET. OPEN (2025) (available at https://
    jamanetwork.com/journals/jamanetworkopen/fullarticle/2838445); Kayla
    McIntire et al., Factors Increasing Risk of Suicide After Traumatic
    Brain Injury, 35 BRAIN INJ, 151-63 (2020) (available at https://
    doi.org/10.1080/02699052.2020.1861656).
    ---------------------------------------------------------------------------
        As these figures illustrate, we believe that TBI care must continue
    to be an area of critical focus for Congress, VA, and other community
    stakeholders. We are pleased to direct particular attention to several
    key areas where near-term action will create the long-term support and
    sustainability that so many need.

    Care Journey Overview: The Phases of TBI Care

        The continuum of care for TBI spans acute care to long-term
    support. While TBIs are generally diagnosed along a spectrum of mild,
    moderate, and severe, this classification based on the severity of the
    injury does not necessarily correlate to the nature of symptoms or
    recovery prognosis. Each TBI patient's journey will have unique
    combinations of mental, physical, behavioral, and cognitive impacts
    alongside decisions about when, where, and how frequent health care
    interventions take place.
        In ideal scenarios, veterans will have access to a continuum that
    integrates clinical treatments with supportive services, but veterans
    often experience regressions. Issues can arise due to improper
    diagnoses (perhaps due to a shortage of specialized TBI care
    providers), inconsistent follow-up care (routinely associated with a
    multi-disciplinary care approach versus more coordinated
    interdisciplinary care), delays in intervention, and general lack of
    knowledge of how and where to access the most appropriate level of care
    and resources. As observed by the National Academies, ``[f]or many
    people with TBI and their families, a `continuum of care' does not
    exist. Their journey is more aptly characterized as a fragmented series
    of silos (prehospital assessment, potential emergency department or
    hospital-based acute care, perhaps inpatient or outpatient
    rehabilitation, and possibly additional community or long-term services
    and supports) [...].'' \7\
    ---------------------------------------------------------------------------
        \7\  NAT'L ACADS. OF SCIENCES, ENG'G, AND MED., TRAUMATIC BRAIN
    INJURY: A ROADMAP FOR ACCELERATING PROGRESS 167 (2022).
    ---------------------------------------------------------------------------
        Despite this observation, an overview of stages in the TBI care
    continuum can help frame areas for congressional action:

          Acute Phase: The immediate care provided in trauma
    centers that focus on stabilization. Interventions like surgery and
    pain control are most often provided at military treatment facilities
    and the VA's network of Polytrauma Rehabilitation Centers.

          Post-Acute Rehabilitation Phase: After stabilization
    care, veterans and Service members may receive rehabilitation to
    restore function, addressing cognitive and behavioral deficits and
    comorbidities. This stage may last weeks, months, or even years,
    depending on the severity of the injury and incorporate elements of
    physical therapy, occupational, therapy, speech and language therapy,
    cognitive rehabilitation therapy, and psychological support. For
    veterans using VA, this care can take place in intensive inpatient and/
    or outpatient settings or Polytrauma Rehabilitation Centers.

          Long-Term Phase: During this segment, patients will focus
    on maintenance of therapies, as well as home and/or institutional
    support to regain or maintain independence and fulfill behavioral
    plans. This phase may involve VA home and community-based services
    including Home Based Primary Care, Adult Day Health Care, and Skilled
    Home Health Care, as well as VA-purchased care services like Homemaker/
    Home Health Aide, Veteran Directed Care, and Medical Foster Homes. For
    complex cases, residential-based care may be provided at VA Community
    Living Centers, Skilled Nursing Facilities, or at community-based
    nursing homes.

          Community Reintegration: As care becomes more familiar,
    veterans may move on to focus on independence, addressing isolation and
    other health issues, while incorporating active and ongoing case
    management. Aside from health care support, some veterans may benefit
    from VA services like the Veteran Readiness & Employment program to re-
    enter the workforce in a new capacity.

            While survival and early rehabilitation outcomes have improved,
            the continuum of care has not evolved to address the lifelong
            needs of this population. When long-term needs are not
            addressed, predictable downstream impacts occur including:

          Functional regression and loss of independence resulting
    from discontinuation of ongoing rehabilitation and long-term supports;

          Higher long-term system costs driven by crisis-based
    care, emergency department utilization, and avoidable hospitalizations;

          Increased caregiver burden and burnout as veterans' needs
    increase and caregivers age alongside them, often impacting the entire
    family unit;

          Premature or inappropriate placement in institutional
    settings that are not designed to meet the clinical, behavioral, or
    rehabilitative needs of younger and mid-life veterans with TBI and lack
    proper government oversight and support personnel; and

          Increased social isolation and elevated suicide risk,
    with TBI recognized as an independent risk factor for mortality.

        Based on these assessments and considerations above, we offer
    several areas where congressional action can improve the TBI continuum
    of care.

    Improving Case Management

        Service members and veterans living with severe injuries or
    multiple comorbid conditions often navigate some of the most fragmented
    care systems in the country. Many rely on multiple Federal and State
    programs at the same time, receiving care through Military Treatment
    Facilities (MTFs), TRICARE, VA, Medicare, Medicaid, private insurance,
    and local programs - each with its own eligibility requirements,
    coverage limits, and care-coordination processes. Without consistent,
    knowledgeable case management, transitions between these systems
    frequently lead to gaps in services, delayed treatment, and increased
    strain on caregivers. For veterans with TBI or complex neurological
    conditions, these disruptions can undermine health, independence, and
    long-term stability.
        In a pair of 2007 memorandums of understanding, DoD and VA launched
    the Federal Recovery Coordination Program (FRCP) and designated Federal
    Recovery Coordinators as the ``ultimate resource'' for monitoring the
    implementation of services for wounded, ill, and injured Service
    members. At the time, these actions recognized that because of the
    dramatic changes in military battlefield medicine and rapid evacuation
    from the combat theatre, many returning Service members, and
    subsequently veterans, have multiple complex medical and mental health
    problems, including TBI, SCI, amputations, burns, and PTSD. Due to the
    complex nature of their benefits and health care needs, these warriors
    may receive care from many providers in multiple facilities, including
    MTFs, VA Medical Centers (VAMCs), private hospitals, rehabilitation
    facilities, or through home health agencies. Transitions among these
    facilities and providers, absent coordination, can result in care and
    benefits gaps.
        The challenges that existed then persist to this day, and health
    systems must remain committed to uniform training for recovery
    coordinators and medical and non-medical care/case managers, efficient
    tracking systems, and commitments to comprehensive plans for the
    seriously injured. As time has passed however, the FRCP was
    consolidated into the Federal Recovery Consultant Office (FRCO) in
    February 2018 in response to the Presidential Executive Order,
    ``Comprehensive Plan for Reorganizing the executive branch.'' While
    this shift may have created some efficiencies, WWP encourages a fresh
    assessment of whether the FRCO is sufficiently resourced to address the
    reforms that have not been fully realized. Additionally, we believe
    that similar efforts can be undertaken to support a broader population
    of veterans with complex needs and should include steps to ensure
    central oversight of policy implementation.
        VA's Spinal Cord Injury/Disorder (SCI/D) System of Care offers a
    parallel approach that may be considered and illustrates an established
    example of how a condition-specific, lifelong care continuum can be
    structured within the Veterans Health Administration. The SCI/D model
    works through a hub-and-spokes network of 25 regional centers
    (``hubs'') supported by local VA facilities (``spokes''), allowing
    highly specialized, interdisciplinary care to be delivered close to
    where veterans live while maintaining access to expert clinical teams
    and necessary services.
        These centers provide comprehensive, lifelong care spanning acute
    medical and surgical treatment, intensive rehabilitation, outpatient
    follow-up, home care programs, annual evaluations, and tailored long-
    term support aimed at maximizing independence and quality of life.
        Care is coordinated across medical, psychosocial, vocational, and
    rehabilitation domains, with dedicated providers trained in the unique
    needs of spinal cord injury and disorder populations. Both primary and
    specialty care services remain integrated throughout the veteran's
    lifespan, with interdisciplinary teams actively managing and
    anticipating evolving needs over time. This structure not only supports
    continuity of care after initial injury but also promotes community
    reintegration, functional maintenance, and sustained caregiver support.
    A similar dedicated program for TBI could help address current
    fragmentation in care pathways, improve long term outcomes, and ensure
    that veterans with brain injury have access to care that is both
    specialized and continuous rather than episodic or plateau-driven
    within traditional silos.

    Expanding Access to Assisted Living

        While many veterans and families prefer aging in place, home-based
    care is not safe or feasible for all individuals due to co-occurring
    behavioral and cognitive challenges, increasing medical complexity,
    aging caregivers, and limited natural support networks. When aging in
    place is no longer appropriate, families are often forced to make care
    decisions in crisis. In the absence of viable alternatives, families
    face an unacceptable binary choice: remain at home beyond what is safe
    or appropriate, or enter traditional geriatric nursing facilities that
    are ill-equipped to meet the clinical, behavioral, rehabilitative, and
    social needs of younger and mid-life veterans with TBI.
        Wounded Warrior Project's current service to nearly 1,000 severely
    wounded veterans with moderate or severe TBI has shown us that phases
    of progressive independent living are missing as care options.
    Currently, slightly more than 7 percent of our Independence Program
    participants (average age 45.6) reside in nursing homes/institutions,
    highlighting the likelihood of an inappropriate placement due to age-
    generational gap, inability to find an age-suitable facility and/or
    inability of an institutional or non-institutional caregiving network
    to provide for the individuals in a safe or effective manner.
    Traditionally, VA provides clinical services to veterans who suffer the
    effects of TBI; however, many veterans with TBI may benefit from
    treatment in an intensive rehabilitation facility to assist with skills
    allowing for increased independence. Because the facilities are
    generally residential and the VA does not provide veterans with housing
    (with some exceptions), accessibility to such programs is limited or
    requires subsidized payment from other sources to cover the ``housing''
    expense.
        The Assisted Living for Veterans with TBI (AL-TBI) pilot program,
    which ran from 2009 to 2018, provided some of these veterans with
    placement in private TBI rehabilitation facilities and assumed the
    living costs that may have otherwise put this treatment beyond their
    reach. After the program ended, an evaluation by VA concluded that
    participants had experienced improvements in physical and emotional
    health, TBI symptoms, and other outcomes. In its place, VA now offers a
    TBI-Residential Rehabilitation Program, but enrollees must pay for
    their own room and board, something many veterans cannot afford.
        Solutions to remove this financial barrier - and to improve the
    associated care coordination that can span several systems - are sorely
    needed. TBI rehabilitation facilities provide a variety of services,
    primarily therapy in individual and group settings. At the same time,
    the facilities vary widely in other offerings and lack standardization
    because individual injuries and the effectiveness of each treatment can
    vary so significantly.\8\ The tools used to measure progress as well as
    the methods by which therapy is provided or defined may also contain
    nuance and disparity between facilities.\9\ These nuances induce
    ``difficulties [with] outcome analysis related to the blurring of
    program labels, categories, and definitions'' while limited uniform
    populations make randomized trials and studies nearly impossible.\10\
    Studies indicate that treatment standardization and standard
    measurements of progress would assist in formalized rehabilitation
    programs with improved overall treatment.\11\ Further, anecdotal
    feedback suggests that veterans are most likely to benefit from
    particular facilities that can accommodate the difficulties associated
    with behavioral problems (often rooted in physical injury to the brain)
    in addition to other TBI symptoms. Such facilities are very limited but
    are best positioned to support veterans' needs.
    ---------------------------------------------------------------------------
        \8\ See, e.g., Tina Trudel, et al., Brain Injury Treatment Models
    and Challenges for Civilian, Military and Veteran Populations, 44 J.
    REHAB. RESEARCH & DEV. 1007 (2007) (available at https://
    www.brainline.org/article/brain-injury-treatment-models-and-challenges-
    civilian-military-and-veteran-populations).
        \9\ Id.
        \10\ Id.
        \11\ Id.
    ---------------------------------------------------------------------------
        In sum, the AL-TBI pilot program provided a beneficial service to
    warriors and caregivers during its tenure but has left a gap to be
    filled by families, private and other non-VA care, often putting the
    financial burden on the warrior and/or caregiver. Additional urgency is
    created by the fact that many of these caregivers are aging beyond
    their ability to provide the necessary support at home. These
    challenges continue to highlight the need for durable, well-
    coordinated, and adequately resourced programs capable of supporting
    veterans with lifelong injuries, not only for months or years, but over
    a full lifespan.

    Increasing Special Monthly Compensation

        The Sharri Briley and Eric Edmundson Veterans Benefits Expansion
    Act represents one of the most meaningful opportunities in decades to
    strengthen financial security for the Nation's most severely disabled
    veterans. A key provision of this legislation would increase the amount
    of Special Monthly Compensation (SMC) by $10,000 annually for the most
    severely disabled veterans - those who depend on regular aid and
    attendance of another, including for residuals of TBI. SMC is arguably
    the most important ancillary benefit for veterans with severe, service-
    connected disabilities. SMC-T in particular, which is provided to
    veterans with TBI, can help offset caregiver burden and the increasing
    costs of high-quality care - both of which can keep veterans at home
    and of institutional living.
        Wounded Warrior Project supports this legislation because it
    reflects the core principle that those who sacrificed the most deserve
    the strongest safety net. Far too many families shoulder around-the-
    clock caregiving responsibilities with inadequate financial support,
    particularly families like the Edmundsons, whose daily lives revolve
    around complex medical needs following devastating combat injuries.

    Coordinating Action on Blast Overpressure

        Military service often exposes Service members to blast
    overpressure, a rapid increase in air pressure generated by explosions
    or blast waves that exceed normal atmospheric conditions. Both high-
    intensity and/or repeated exposures are increasingly associated with
    cumulative neurological effects, including neuroinflammation, cognitive
    decline, elevated risk of traumatic brain injury, and co-occurring
    mental health conditions.\12\ Those at highest risk include armorers,
    artillery and gunnery personnel, combat engineers, explosive ordnance
    disposal specialists, special operations forces, and medical personnel
    assigned to expeditionary units - as well as individuals working with
    shoulder-mounted weapons, .50 caliber systems, and indirect fire
    platforms. While the DoD has taken important steps to reduce blast
    exposure during training through increased standoff distances, limits
    on live-fire events, and protective equipment, these measures largely
    focus on prevention for active-duty personnel, and do not address the
    long-term health consequences for Service members and veterans already
    affected.
    ---------------------------------------------------------------------------
        \12\ See, e.g., Andrea Diociasi et al., Distinct Functional MRI
    Connectivity Patterns and Cortical Volume Variations Associated with
    Repetitive Blast Exposure in Special Operations Forces Members, 315
    Radiology (2025) (available at https://pubmed.ncbi.nlm.nih.gov/
    40167438/); Kyle Bourassa et al., Traumatic Brain Injury and
    Accelerated Epigenetic Aging Among Post-9/11 Members, J. HEAD TRAUMA
    REHAB. (2025) (available at https://pubmed.ncbi.nlm.nih.gov/40828005/).
    ---------------------------------------------------------------------------
        The Blast Overpressure Research and Mitigation Task Force Act (H.R.
    6444) would strengthen coordination between the DoD and VA through a
    Joint Executive Committee (JEC) task force. By mandating annual
    reports, cross-agency coordination, and integration of mobile,
    longitudinal diagnostics, the bill would create the infrastructure
    needed to translate emerging evidence into standardized screening,
    targeted mitigation strategies, and benefits adjudication for blast-
    exposed veterans. Further, the inclusion of Task Force recommendations
    related to VA claims processing and disability evaluations hold the
    promise of ensuring that veterans affected by blast overpressure
    injuries are connected to the care and support they have earned through
    their service.

    Increasing Commitment to TBI Research

        The congressionally Directed Medical Research Programs (CDMRP)
    represent a proven and accountable model for investing Federal research
    dollars to achieve high-impact outcomes. Through its unique,
    coordinated approach, CDMRP has accelerated advances in patient care,
    driven breakthrough technologies, and delivered tangible results in
    areas of critical need - particularly with diseases and conditions that
    have historically received limited research attention. Congress'
    sustained investment of more than $2.5 billion in the Traumatic Brain
    Injury and Psychological Health Research Program, led by the Military
    Health System\13\, has resulted in the award of over 297 research
    studies for nearly 500,000 Service members diagnosed with traumatic
    brain injury.\14\ These efforts have strengthened DoD's ability to
    prevent, detect, treat, and rehabilitate TBI, while improving
    psychological health outcomes essential to force readiness and long-
    term veteran well-being. Continued congressional support for CDMRP is
    essential to maintain momentum, protect prior investments, and ensure
    that the DoD can meet its obligations to Service members and their
    families through evidence-based solutions to TBI and psychological
    health challenges.
    ---------------------------------------------------------------------------
        \13\ Cong. Directed Res. Prog., Traumatic Brain Injury and
    Psychological Health Research Program, U.S. DEP'T OF DEF. (2025),
    https://cdmrp.health.mil/tbiphrp/pbks/TBIPHRP %20Summary
    %20Sheet_22July25.pdf.
        \14\ Cong. Directed Res. Prog., Traumatic Brain Injury and
    Psychological Health, U.S. DEP'T OF DEF. (2025), https://
    cdmrp.health.mil/tbiphrp/default.

    ---------------------------------------------------------------------------
    Precision Medicine for TBI Care

        Despite increased awareness, substantial gaps remain in
    understanding the long-term effects of repetitive low-level blast
    exposure and chronic mild TBI. Emerging evidence links these exposures
    to measurable brain changes, impairments in balance and gait, and
    increased risk of suicide among veterans. Individuals diagnosed with
    TBI may continue to suffer from lasting effects that overlap with
    mental health conditions, substance use disorders, and chronic physical
    symptoms. These complex and interconnected challenges demand a more
    precise, data-driven approach to care.
        Precision medicine tailors healthcare treatments and interventions
    to each patient's unique characteristics, including their genetic
    makeup, lifestyle, and environment. Instead of a one-size-fits-all
    model, precision medicine uses advanced diagnostic tools - such as
    genetic testing, biomarker analysis, and imaging techniques - to
    identify the most effective therapies for individuals. In brain health,
    this approach takes a specialized form, focusing on neurological and
    psychiatric conditions. Clinicians analyze a patient's brain structure,
    function, genetic profile, and cognitive patterns to create targeted
    treatment plans for conditions like Alzheimer's disease, Parkinson's
    disease, depression, and TBI. This personalized strategy enhances
    therapeutic outcomes, reduces side effects, and ensures lasting
    benefits. Specifically for veterans, this approach can help identify
    those at higher risk for long-term neurological or psychological
    effects, such as chronic traumatic encephalopathy (CTE), PTSD, and
    cognitive decline. The Precision Brain Health Research Act (S. 800)
    would advance a more systematic and longitudinal approach by directing
    VA to implement a coordinated 10-year research strategy and establish a
    structured data sharing partnership with the DoD. This framework
    utilizes the promise of precision medicine and would improve tracking
    of exposure history, support identification of biomarkers associated
    with brain and mental health conditions, and strengthen VA's ability to
    deliver earlier, more accurate diagnoses.

    Concluding Remarks

        Wounded Warrior Project extends our gratitude to the Committee for
    its sustained focus on TBI research, treatment, and long-term support.
    A TBI is not an isolated event, it is a chronic condition that requires
    lifelong management. journey that requires a coordinated continuum of
    care, strong case management, appropriate residential and community-
    based options, meaningful financial support for families, and continued
    investment in cutting-edge research. From strengthening recovery
    coordination and restoring viable assisted living pathways, to
    advancing Special Monthly Compensation and deepening our understanding
    of blast overpressure and precision brain health, your leadership
    shapes whether veterans with TBI experience fragmented systems or
    integrated, life-sustaining care. We are particularly encouraged by
    congressional efforts to modernize research through precision medicine
    and cross-agency collaboration, ensuring that emerging science
    translates into earlier diagnoses, targeted interventions, and improved
    long-term outcomes.
        The men and women who have sustained these invisible wounds in
    service to our Nation deserve nothing less than a system built for
    durability, dignity, and lifelong support. We stand ready to work
    alongside you to ensure that policies enacted today create a
    sustainable, evidence-based framework of care that honors their
    sacrifice not only in the immediate aftermath of injury, but across the
    full span of their lives. Thank you for your continued commitment to
    these warriors and the families who remain steadfast beside them.

              Document for the Record Submitted by Julia Brownley
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

              Prepared Statement of American Academy of Neurology
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                Document for the Record Submitted by Greg Murphy
    [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

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