[House Hearing, 119 Congress]
[From the U.S. Government Publishing Office]
HIDDEN WOUNDS: EFFECTIVELY
SUPPORTING VETERANS WITH TBI
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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
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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
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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
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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
=======================================================================
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
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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\
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\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\
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\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\
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\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.
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\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.
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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.
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\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/).
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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.
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\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.
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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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