Hidden Wounds: Effectively Supporting Veterans with TBI

1[House Hearing, 119 Congress]2[From the U.S. Government Publishing Office]34                       HIDDEN WOUNDS: EFFECTIVELY5                      SUPPORTING VETERANS WITH TBI6=======================================================================78                                HEARING910                               BEFORE THE1112                         SUBCOMMITTEE ON HEALTH1314                                 OF THE1516                     COMMITTEE ON VETERANS' AFFAIRS1718                     U.S. HOUSE OF REPRESENTATIVES1920                    ONE HUNDRED NINETEENTH CONGRESS2122                             SECOND SESSION2324                               __________2526                        THURSDAY, MARCH 5, 20262728                               __________2930                           Serial No. 119-503132                               __________3334       Printed for the use of the Committee on Veterans' Affairs3536[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]3738                    Available via http://govinfo.gov39                               __________4041                     U.S. GOVERNMENT PUBLISING OFFICE4263-371                       WASHINGTON : 202643=======================================================================4445                     COMMITTEE ON VETERANS' AFFAIRS4647                     MIKE BOST, Illinois, Chairman4849AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking50    American Samoa, Vice-Chairwoman      Member51JACK BERGMAN, Michigan               JULIA BROWNLEY, California52NANCY MACE, South Carolina           CHRIS PAPPAS, New Hampshire53MARIANNETTE MILLER-MEEKS, Iowa       SHEILA CHERFILUS-MCCORMICK,54GREGORY F. MURPHY, North Carolina        Florida55DERRICK VAN ORDEN, Wisconsin         MORGAN MCGARVEY, Kentucky56MORGAN LUTTRELL, Texas               DELIA RAMIREZ, Illinois57JUAN CISCOMANI, Arizona              NIKKI BUDZINSKI, Illinois58KEITH SELF, Texas                    TIMOTHY M. KENNEDY, New York59JEN KIGGANS, Virginia                MAXINE DEXTER, Oregon60ABE HAMADEH, Arizona                 HERB CONAWAY, New Jersey61KIMBERLYN KING-HINDS, Northern       KELLY MORRISON, Minnesota62    Mariana Islands63TOM BARRETT, Michigan6465                       Jon Clark, Staff Director66                  Matt Reel, Democratic Staff Director6768                         SUBCOMMITTEE ON HEALTH6970               MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman7172JACK BERGMAN, Michigan               JULIA BROWNLEY, California,73GREGORY F. MURPHY, North Carolina        Ranking Member74DERRICK VAN ORDEN, Wisconsin         SHEILA CHERFILUS-MCCORMICK,75JEN KIGGANS, Virginia                    Florida76ABE HAMADEH, Arizona                 MAXINE DEXTER, Oregon77KIMBERLYN KING-HINDS, Northern       HERB CONAWAY, New Jersey78    Mariana Islands                  KELLY MORRISON, Minnesota7980Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public81hearing records of the Committee on Veterans' Affairs are also82published in electronic form. The printed hearing record remains the83official version. Because electronic submissions are used to prepare84both printed and electronic versions of the hearing record, the process85of converting between various electronic formats may introduce86unintentional errors or omissions. Such occurrences are inherent in the87current publication process and should diminish as the process is88further refined.89                         C  O  N  T  E  N  T  S9091                              ----------9293                        THURSDAY, MARCH 5, 20269495                                                                   Page9697                           OPENING STATEMENTS9899The Honorable Mariannette Miller-Meeks, Chairwoman...............     1100The Honorable Julia Brownley, Ranking Member.....................     3101102                               WITNESSES103                                Panel I104105Dr. Rachel McArdle, Ph.D., Deputy Executive Director,106  Rehabilitation and Prosthetic Services, U.S. Department of107  Veterans Affairs...............................................     5108109        Accompanied by:110111    Dr. Joel Scholten, Executive Director, Physical Medicine and112        Rehabilitation, U.S. Department of Veterans Affairs113114                                Panel II115116Mr. Al Johnson, Army Veteran, Flight Surgeon.....................    19117118Mr. Buster Miscusi, Marine Corps Veteran, Graduate of Operation119  Mend...........................................................    21120121Dr. Russell Gore, MD, FAAN, Chief Medical Officer, Avalon Action122  Alliance.......................................................    23123124                                APPENDIX125                    Prepared Statements Of Witnesses126127Dr. Rachel McArdle, Ph.D. Prepared Statement.....................    41128Mr. Al Johnson Prepared Statement................................    44129Mr. Buster Miscusi Prepared Statement............................    55130Dr. Russell Gore, MD, FAAN Prepared Statement....................    58131132                       Statements For The Record133134Association of VA Neurology Services (AVANS) Prepared Statement..    67135Wounded Warrior Project Prepared Statement.......................    69136Document for the Record Submitted by The Honorable Julia137  Brownley, U.S. House of Representatives, (CA-26)...............    76138American Academy of Neurology Prepared Statement.................    85139Document for the Record Submitted by The Honorable Greg Murphy,140  U.S. House of Representatives, (NC-03).........................    88141142                       HIDDEN WOUNDS: EFFECTIVELY143                      SUPPORTING VETERANS WITH TBI144145                              ----------146147                        THURSDAY, MARCH 5, 2026148149                    Subcommittee on Health,150                    Committee on Veterans' Affairs,151                             U.S. House of Representatives,152                                                    Washington, DC.153    The subcommittee met, pursuant to notice, at 10:15 a.m., in154room 360, Cannon House Office Building, Hon. Mariannette155Miller-Meeks [chairwoman of the subcommittee] presiding.156    Present: Representatives Miller-Meeks, Bergman, Murphy,157King-Hinds, Brownley, Cherfilus-McCormick, Conaway, and Dexter.158    Also present: Representative Stauber.159160   OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN161162    Ms. Miller-Meeks. The Subcommittee on Health will now come163to order. Without objection, the chair may declare recess at164any time.165    Before we begin, please join me in keeping the166servicemembers deployed to the Middle East and in harm's way in167our thoughts, as well as the families of the courageous168servicemembers who recently gave their lives, to keep them in169our thoughts and our prayers. Two of those individuals are from170Iowa and deployed with the 103d Sustainment Command out of Des171Moines.172    I would like to welcome all members and witnesses to173today's hearing. March is Brain Injury Awareness Month, so this174is very timely and it is why I am also proud to be leading this175hearing on how the U.S. Department of Veterans Affairs (VA) can176continue to lead the way in the care for traumatic brain177injury, or TBI. In a budget briefing last summer, the VA shared178that TBI is the top clinical, legislative, and agency priority.179I look forward to hearing how the VA has prioritized TBI so far180and what we can expect for the rest of the year.181    I am confident that the VA has all the data, legal182authority, and funding it needs to effectively treat TBI. Right183now, I believe the VA's main objective should be to build on184the quality of data and the quality of care for the veteran.185    Here is what the VA does best: specialized treatment,186rehabilitation, and research. After enrollment in VA187healthcare, veterans are assigned to a primary care team. These188primary care staff are trained on the issues unique to post-189deployed veterans, and that includes TBI. I am pleased that TBI190and other issues unique to veterans are part of the primary191care experience at the VA, not a specialty that requires extra192steps.193    VA polytrauma centers are a key resource for veterans with194TBI. At these centers, the VA is not just treating, but leading195in outpatient and inpatient care for veterans with TBI and, in196fact, their treatment model will probably become state-of-the-197art across the United States. The centers in Richmond, Tampa,198Minneapolis, Palo Alto, and San Antonio are knowledge hubs for199other facilities treating polytrauma nationwide. This is200important infrastructure to treat veterans diagnosed with201complex multi-trauma injuries, including TBI.202    The VA's research enterprise is also unmatched. One203longitudinal research program, LIMBIC, examines the effects of204and treatment for service-connected TBI with a focus on long-205term effects of mild TBI. The LIMBIC goals are, one, to learn206more about how concussion affects the brain; two, find out207effects of concussion later in life, such as risk for dementia;208three, see if some servicemembers and veterans are more likely209to be affected or have a predilection for; and, four, identify210the best treatments for concussion.211    VA researchers at this center have documented links between212combat concussions and dementia, Parkinson's disease, chronic213pain, opioid use, and suicide risk. They have also developed214specialized diagnostic tests using questionnaires, physical215exams, brain imaging, fluid biomarkers, and electrophysiology216to probe how the brain recovers from injury. With these systems217in place, as a physician, I believe the VA can evaluate218veterans with TBI and can enact intervention earlier.219    I have heard many veterans share their positive experiences220with the VA. Indeed, a report by the VA Office of Inspector221General (OIG) about TBI treatment at one facility revealed that222the facility was provided needed care for veterans with TBI.223Unfortunately, I have also heard from veterans that that has224not been their experience at the VA. Here is where I have seen225the VA needs improvement: consistent quality in patient care226and data.227    In January, the VA OIG released a report about a patient228who died by suicide after receiving mental healthcare at a VA229facility. Among the reviewed concerns, the VA OIG found that230the VA facility did not provide adequate follow up for the231patient's TBI. This veteran was a middle-aged male with a232history of mental illness, migraines, chronic pain, and gait233disturbances with documented falls. In other words, his was the234classic clinical picture of an individual with TBI. Yet somehow235the patient did not receive follow ups specific to TBI and his236mental health only declined until the end.237    Fortunately, the facility in question now requires annual238training on TBI screening and care consultations. I wish this239had been the case sooner, but at least it is the case now.240    At another facility, the OIG found that a veteran who had241screened positive for TBI and died by suicide failed to receive242adequate care at the VA. Among other issues, faculty staff did243not submit a consultation for a TBI evaluation following the244veteran's positive TBI screen, even though a consult is245required.246    This is not acceptable. These veterans earned TBI care at247the VA and their service demands better from all of us. Their248service demands consistency and quality care. They deserve to249know that the VA has their back. While quality inpatient care250is the most urgent need, quality and data is also necessary. In251the past, annual congressional reports have reflected outdated252information and the number of inpatient beds dedicated to TBI.253Reports have also omitted key spending information and the254number of veterans with TBI treated annually.255    Some might say, does it matter? Well, these numbers show256the VA's capacity to provide care. These numbers should reveal257the needs of the patient population and how a medical center is258able to meet those needs. Congress needs this information to259know what resources to allocate to the VA for TBI care. The VA260also needs to get these numbers to determine the resources a261hospital should get.262    I know the VA has the capability to report this kind of263data. Like I said, VA has all the data it needs. It must264capture that data consistently and then be able to translate265that information into clinical practice. Otherwise, wrong data266takes resources away from areas of need, and I look forward to267hearing from the VA about how they are going to put this into268practice.269    Under my leadership, veterans health has always been this270subcommittee's priority. We must eliminate preventable errors.271As a practitioner and a 24-year Army veteran, I know excellence272is possible and it is imperative. The one who bears the cost of273shortfalls is always, always the veteran.274    This also means positioning the VA to support the veteran275of contemporary and future warfare. This is where I see276opportunities for the VA. We may not know the landscape of277tomorrow's battlefield, but with the right systems and the278right people in place, the VA can navigate and pivot to279whatever lies ahead.280    Finally, while we may not discuss it extensively today, I281want to recognize the veterans who use residential282rehabilitation for TBI. This population is small, but it is far283from invisible. I appreciate efforts by the VA's geriatrics and284Extended Care Program to address the needs of these veterans,285and I will take the opportunity I can, to ensure that these286veterans get the care they deserve from the VA.287    Under the leadership of Chairman Bost, President Trump, and288Secretary Collins, I am confident that the VA's role as a289premium care provider for veterans with TBI. While the VA is on290mission, it is the best in the business for veterans with291chronic and sometimes catastrophic injuries, visible and292hidden.293    I now yield to Ranking Member Brownley for any opening294remarks she may have.295296      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER297298    Ms. Brownley. Thank you, Madam Chair, and thank you for299your words with regards to our six servicemembers who died300proudly serving our country. I appreciate it very, very much.301    Traumatic brain injuries are one of the most common302service-related injuries facing veterans today. Even mild TBIs303can lead to lifelong complications and challenges for veterans304who have sustained them. As our understanding of TBIs and their305risk and our ability to diagnose them, we must ensure that VA306is equipped to treat and care for veterans with TBIs at all307points of their recovery journey. I am looking forward to308hearing more from our VA witnesses about the current approach309to care and a treatment, as well as future developments the VA310is working toward.311    TBI is not an illness that goes away with medicine, nor is312it an injury that heals with bandages. It is a long-term313chronic condition for which many veterans need ongoing,314integrated, and well-coordinated care to manage symptoms and315make strides toward recovery. That is why, as the largest316integrated healthcare system in the United States, VA is well317suited to provide the level of care that veterans with TBI318need.319    Through its Polytrauma System of Care, veterans receive320specialized, interdisciplinary, customized care for any and all321injuries and conditions related to their service, including TBI322and any co-occurring conditions. With its tiered hub-and-spoke323model, the system is designed to provide care to veterans324wherever they are and whatever level of care is appropriate for325them.326    I expect we will hear from some witnesses today that327legislation like the Veterans TBI Breakthrough Exploration of328Adaptive Care Opportunities Nationwide (BEACON) Act is329necessary to fill gaps in VA's care. I do not disagree that330veterans may need support from several different avenues to331support their recovery journeys, and I do not discount the role332that nonprofits and academic affiliates play in facilitating333and supporting that care. However, I need to draw the line at334legislation that will take money from existing VA programs and335redirect it to outside organizations and providers to do336essentially the very same thing VA is already doing, but with337fewer guardrails and fewer requirements to ensure quality of338care.339    The BEACON Act contains several concerning provisions.340First, the bill would divert funding from both VA general341mental healthcare programs and the National Center for Post-342Traumatic Stress Disorder (PTSD) to establish grant programs343for outside entities. This funding is intended for both the344provision of mental healthcare and to advance the study and345treatment of PTSD. Although many veterans with TBI also suffer346from associated mental health conditions or PTSD, it is simply347not appropriate to fund outside entities to provide care using348these sources.349    It is very difficult to understand this funding structure350as anything other than a drain on the resources that VA can use351to provide direct care to veterans who need it. One of the352grant programs even requires VA to contract with a third party353entity modeled after its own National Center for PTSD to354administer the grants. If we are serious about expanding TBI355treatment funding and research for veterans, why are we asking356a third party entity to copy what VA is already doing instead357of giving VA the resources it needs to do this itself?358    Second, eligible entities are expected to use the funding359under these grant programs to conduct clinical trials related360to TBI. However, the bill does not establish sufficient uses of361funds or require sufficient scientific rigor to ensure the362outcomes of the clinical trials are usable. Further, not only363all of the eligible entities are equipped or have the necessary364experience to conduct robust clinical trials.365    VA's existing research infrastructure is better suited to366conduct these trials and already does. There is nothing367stopping academic institutions and community providers who wish368to treat veterans from working with VA through its academic369affiliate network or the Community Care Program.370    Taken together, these concerning provisions of the BEACON371Act represent an effort to diminish VA's direct care program372and research enterprise and create no strings attached handouts373of VA's funding to private companies. Not only is this wasteful374and duplicative, but it could lead to a further fracturing of375continuity of care for veterans.376    On that note, I ask unanimous consent to enter into the377hearing record this article from the American Prospect that378expands on many of the concerns I have just raised.379    Ms. Miller-Meeks. No objection.380    Ms. Brownley. As our understanding of TBI's diagnosis and381how to treat it evolves, I am confident that VA's TBI model of382care will evolve with it. In fact, I believe that many383colleagues on this committee will continue to provide robust384oversight and direction to ensure that it does. What VA does385need is the resources and support to continue to build on its386existing System of Care. Legislation like the BEACON Act will387only run counter to those efforts.388    This hearing is an excellent opportunity to hear directly389from veterans with TBI about their experiences and where VA's390care can improve. I look forward to hearing from the witnesses391on Panel 2 about how we can achieve our shared goal of392improving TBI care at VA. I hope we will all keep in mind that393the investment we need to make in VA's existing care model to394achieve that goal.395    With that, Madam Chair, I yield back.396    Ms. Miller-Meeks. Thank you, Ranking Member Brownley.397    I would now like to introduce the first panel. Testifying398before us on behalf of the VA, we have Ms. Rachel McArdle,399deputy executive director of Rehabilitation and Prosthetic400Services at the VA. She is accompanied by Dr. Joel Scholten,401executive director of Physical Medicine and Rehabilitation402Services at the VA.403    Dr. McArdle, you are now recognized for 5 minutes to404present your testimony.405406                  STATEMENT OF RACHEL MCARDLE407408    Dr. McArdle. Chairwoman Miller-Meeks, Ranking Member409Brownley, and members of the subcommittee, thank you for the410opportunity to speak with you today about the Department of411Veterans Affairs' efforts to support veterans living with412traumatic brain injury, or TBI. I am joined today by Dr. Joel413Scholten, executive director of Physical Medicine and414Rehabilitation. Together, we are honored to share how VA is415addressing the complex, lifelong needs of veterans with TBI416through comprehensive care, research, and innovation.417    TBI remains one of the most challenging injuries faced by418our veteran population. It can occur from a blow to the head,419rapid acceleration, deacceleration, or blast exposure, and Its420effects vary widely, from headaches and dizziness to memory421problems, mood changes, and physical impairments. TBI rarely422occurs alone. Many veterans experience co-occurring PTSD,423chronic pain, or sleeping difficulties, which complicate424diagnosis and treatment. Understanding these overlapping425conditions, if we are to effectively support veterans at every426stage of their lives, is essential.427    We also recognize the growing significance of military428occupational blast exposure, or MOBE, repeated exposure to429jets, artillery fire, or breaching operations. While these430exposures may not cause immediate symptoms, they can have431cumulative effects that resemble TBI and lead to long-term432challenges with employment, driving, and interpersonal433relationships. As we better understand the scope of MOBE, VA is434committed to adapting our care system to meet these evolving435needs.436    VA has built an integrated nationwide system to ensure437veterans with TBI receive comprehensive personalized care. At438the center of the effort is the Polytrauma System of Care,439which includes 5 Polytrauma Rehabilitation Centers, 23440Polytrauma Network sites, and numerous polytrauma support441clinics. Together they support over 110 TBI teams across VA.442    Since 2007, VA has screened 1.8 million veterans, post 9-11443veterans, for TBI, connecting them with specialists for444evaluation and treatment. In Fiscal Year 2025 alone, VA treated445more than 160,000 veterans with TBI-related conditions. Every446veteran receives an individualized plan addressing physical,447cognitive, and emotional needs, often integrated with mental448health services and patient-centered care approaches to support449recovery and resilience.450    We are expanding access to care through tools like VA's451Concussion Coach Mobile app as well as telehealth and virtual452rehabilitation programs that ensure veterans, including those453in rural or underserved areas, can achieve TBI care when they454need it.455    VA's commitment extends beyond clinical care. Research and456innovation remain central to improving long-term outcomes for457veterans with TBI. VA supports multiple research programs,458including Long-Term Impact of Military Relevant Brain Injury459Consortium and the Translational Research Center for TBI and460Stress Disorders. These efforts advance precision diagnostics,461identify biomarkers, and develop interventions, including462understanding the cumulative effects of repeated blast463exposure.464    The Brain Health Coordinating Center serves as VA's central465hub for advancing brain health. It integrates data from across466our medical centers to identify risk factors, track outcomes,467and support new clinical trials in diagnostics and468therapeutics. Our academic affiliations and participation in469TBI model systems ensure VA remains a leader in evidence-based470rehabilitation and that new research is rapidly translated into471better care for veterans.472    Despite these advancements, challenges remain. There is473still no single test capable of distinguishing symptoms caused474from TBI from those caused by other health conditions and many475veterans with mild or repeated TBIs continue to experience476persistent symptoms that are difficult to treat. To address477this, VA is advancing Total Brain Diagnostics, a precision478brain health initiative to identify and validate biomarkers479that improve diagnosis of complex conditions, including TBI.480    Looking ahead, VA will continue to enhance blast exposure481documentation, expand brain health approaches, strengthen482telehealth and intensive outpatient rehabilitation programs,483and deepen relationships with academia, Veterans Service484Organizations (VSO), nonprofits, and the Department of War.485Above all, we remain committed to proactive veteran-centered486care that supports long-term health and prevents functional487decline.488    In closing, VA is steadfast in our commitment to delivering489world-class care, advancing research, and supporting veterans490and families affected by TBI.491    Thank you for your leadership and for your continued492support. We look forward to your questions.493494    [The Prepared Statement Of Rachel McArdle Appears In The495Appendix]496497    Ms. Miller-Meeks. Thank you very much.498    As is my typical practice, I will reserve my time until all499other members have had a chance to ask their questions.500    I now recognize Ranking Member Brownley for 5 minutes for501any questions she may have.502    Ms. Brownley. Thank you, Madam Chair, and thank you for503your testimony this morning.504    Dr. McArdle, what are some examples of things VA would be505able to do within a--pardon me?506    Ms. Miller-Meeks. I wanted to recognize your member.507    Ms. Brownley. Oh, go right ahead.508    Ms. Miller-Meeks. It is already done.509    Ms. Brownley. Oh, okay. I will start from the top. What are510some examples of things VA would be able to do with an511additional $60 million in funding to advance the care provided512to veterans with TBIs?513    Dr. McArdle. Thank you for the question, Ranking Member514Brownley. It sounds like you may be referring to the pending515legislation that VA testified on in January. As to how would VA516spend an additional 60 million, we are grateful for the support517of this committee. I will take that question back for the518record in order to conduct a full and appropriate review of our519programs for you.520    Ms. Brownley. Would you say that VA needs $60 million521additionally to properly serve our veterans?522    Dr. McArdle. I appreciate the question. My focus today is523to share with you what we are doing in TBI and I will follow up524with your office.525    Ms. Brownley. Okay. All right.526    Dr. Scholten, can you expand on VA's integrated approach to527treat both TBI and co-occurring conditions, including PTSD? How528does this affect veterans' outcomes, and I want--and this is529the important part of the question, especially compared to530individuals who may be navigating care outside of the VA?531    Dr. Scholten. Thank you for that question, Ranking Member532Brownley. As you point out, TBI and PTSD commonly co-occur in533veterans. VA research has shown that veterans who participate534in evidence-based therapies for PTSD also show improved535cognitive functioning both in regards to their PTSD and/or TBI536symptoms. This highlights the importance of our approach of537developing an individualized plan of care for every veteran538with traumatic brain injury.539    As each veteran has a unique presentation, therefore their540plan of care should be individually developed. Any efforts we541can do to better integrate care delivery will likely result in542greater impact on symptom reduction and treatment reduction.543    I would also like to point out that it is incredibly544important to engage with a veteran's family and their545caregiver. Integrated care relies on keeping the veteran546informed and at the center of the care plan with input and547assistance from their caregivers and families. That care is548obviously easier to provide when it is provided within the VA549healthcare system, as we are focused on providing wraparound550services for veterans with traumatic brain injury.551    Ms. Brownley. Thank you. Can you describe VA's approach to552addressing the differences in TBI symptoms and experiences553between men and women veterans?554    Dr. Scholten. Thank you for the question. Yes, we have a555very large research program. As was mentioned earlier, VA556allocates over $50 million to research in Fiscal Year 2025 to557175 research programs. A specific example that we have learned558from our VA research includes understanding the unique effects559that women might experience compared to their male560counterparts.561    One significant difference is the cumulative trauma562exposure. We have found that female veterans have a much higher563trauma burden, disproportionately affected by military sexual564trauma and intimate partner violence (IPV). Therefore, we need565to screen for military sexual trauma as well as IPV, and better566incorporate mental health treatments into the individualized567care plan.568    In addition, the LIMBIC study, which was mentioned earlier569in the opening statements, has shown that female veterans with570a history of at least one TBI present with worse psychological571health outcomes in the areas of PTSD, depression, TBI symptoms,572and quality of life, again highlighting the importance of an573individualized care plan that addresses the unique needs of574that veteran.575    Ms. Brownley. Thank you for that and I yield back.576    Ms. Miller-Meeks. Thank you, Ranking Member Brownley.577    The chair now recognizes Representative King-Hinds for 5578minutes for any questions she may have.579    Ms. King-Hinds. Thank you, Chair. Thank you to you, Dr.580McArdle and Dr. Scholten, for being here and hopefully have a581conversation about this future of some of these research582programs that are on the way.583    I had prepared remarks, but I was coming here, this very584decorated war hero from the Northern Marianas came to mind. He585is actually a good friend. He is my neighbor and he is586suffering from TBI, but he is having a challenge connecting the587TBI to his service. He served in the Iraq War and he was588exposed to a lot of toxins, which he believes has contributed589to some of his injuries. The last time I saw him, you know, he590was sharing that if you were to describe his pain level 1 to59110, it is a 12. You know, the solution that is given to him is592just more pain meds. Right?593    I kind of wanted, because we are talking about advancing594research, I kind of wanted to hear a little bit more from you,595whether you are considering whether traumatic brain injury596linked to toxic exposure should be evaluated for presumptive597service connection. If not, what specific evidentiary threshold598is preventing that? He has been going through this process and599every time he files the claim, it seems like he has run out of600options. I just want to find a way to help him out.601    Dr. Scholten. Thank you for that question and thank you for602sharing that story. First, I would like to point out that I can603talk about the clinical presentation of the individual that you604mentioned. I am unable to comment on the presumptive ratings as605VA has a process that they work through in studying the606research evidence to determine those.607    I will say that veterans--VA screens all post 9-11 veterans608for possible traumatic brain injury. Those individuals with a609positive screen are referred to a TBI specialist to complete a610thorough clinical history and physical examination to document611or come up with a diagnosis. As part of the healthcare system612and as part of that evaluation, an individual plan of care is613developed. Hopefully, that individual will also have completed614the toxic exposure screening that VA offers for every veteran615and repeats every 5 years.616    We know that each individual veteran has a unique617presentation. Toxic exposures and other traumas that veterans618may experience during their military service can affect the619trajectory of their clinical recovery as well as their symptom620presentation. Helping to devise a comprehensive evaluation and621then coming up with a plan that will work for that individual622veteran is essential.623    Ms. King-Hinds. Okay. Can I just ask a more directed624question? Is there research currently underway examining625whether toxic exposures, including burn pits, can contribute to626a worsening brain injury--to a worse brain injury?627    Dr. Scholten. I cannot--yes, there are certainly a number628of research projects that are ongoing about long-term effects629of toxic exposures. We can work with our colleagues back at630Veterans Health Administration (VHA) to provide you a complete631list.632    Ms. King-Hinds. Okay. That would be great. Just for my633personal clarity, at what point in the primary care process is634a veteran referred to a specific TBI treatment?635    Dr. Scholten. That would occur on the veteran's first636entrance into VHA for healthcare. The TBI screen would be637completed and then that would trigger the evaluation or638referral to a TBI specialist.639    Ms. King-Hinds. Okay. Just one last question. How could we640better support your efforts to be able to better screen and641provide the services that our vets need?642    Dr. Scholten. I would say that this hearing is a perfect643example, raising awareness of TBI and veterans. Also,644acknowledging that, as was mentioned, March is TBI Awareness645Month, and we would appreciate your assistance in encouraging646all veterans to enroll in VHA for healthcare. We know that not647all veterans do take advantage of that opportunity, but we648would encourage you to help us spread that message to choose VA649for healthcare.650    Ms. King-Hinds. Thank you for your time.651    I yield back.652    Ms. Miller-Meeks. Thank you, Representative King-Hinds.653    The chair now recognizes Dr. Conaway for 5 minutes for any654questions he may have.655    Mr. Conaway. Thank you. Thank you, Chairman Miller-Meeks656and Ranking Member Brownley, for gathering us here today to657discuss the treatment of traumatic brain injuries.658    As traumatic brain injuries become more common in the659veteran population due to more exposure to service-related risk660factors, like blast injuries, it is crucial that we discuss how661to advance TBI treatment at the VA. The VA has a long history662of medical breakthroughs and innovation. VA, in fact, ranks as663a top research institution and, for the last 20 years, has664conducted significant research relating to TBIs. Additionally,665through its Polytrauma System of Care, VA can provide666integrated care to address TBI as well as co-occurring injuries667and conditions, including mental health conditions.668    Dr. McArdle, can you explain how the VA's tiered Polytrauma669System of Care is well suited to address the healthcare needs670of veterans with TBI, even in areas that do not have a671Polytrauma Rehabilitation Center in the immediate area?672    Dr. McArdle. Thank you for the question. VA Polytrauma673System of Care has been in existence for over 20 years and was674designed to ensure all veterans who are enrolled in VA675healthcare have access to TBI experts. This System of Care has676over 110 TBI clinical teams across VHA providing individualized677care for veterans with TBI. For veterans who are in more rural678or highly rural areas, we also utilize virtual care to expand679the availability of services through the lifetime of a veteran680who is dealing with the chronic symptoms associated with TBI.681Our primary focus is on making sure veterans get the care they682need, whether that care is direct care or care provided by the683community.684    Mr. Conaway. Thank you. Can you elaborate on some of the685advances? Again, a large research institution with a huge686patient population and big data that can be brought to bear.687Can you talk about how the standard of care for diagnosis and688treating traumatic brain injuries has resulted from the VA's689own research?690    Dr. McArdle. I will let Dr. Scholten, who oversees the691polytrauma TBI System of Care and is a practicing TBI692physician, provide you more information.693    Mr. Conaway. Thank you. Doc.694    Dr. Scholten. Thank you for that question. Again, I would695like to recognize the incredible research infrastructure that696VA does possess.697    A number of findings have emerged over the course of the698last 20 years of the VA's research portfolio. We have699identified a number of areas to improve veteran access for700care. One of the things we--in research findings and knowing701the high prevalence of TBI exposure for veterans returning from702the post 9-11 conflicts, VA implemented the TBI screen and703evaluation process to make sure that any veteran who served704after September 11, 2001, was actually screened for possible705TBI, and then evaluated by a specialist to ensure that their706medical record was documented with a specific diagnosis and707individualized treatment plan.708    We have leveraged emerging findings showing that we do know709veterans with TBI, compared to their civilian counterparts,710have a higher comorbidity of mental health conditions. That has711led our efforts to beef up our mental health integration within712our TBI and polytrauma teams. We are really trying to, in that713effort, normalize or destigmatize the fact that mental714healthcare is required for physical rehabilitation. We have715also found with the heavy symptom burden, particularly for some716of our special operators who experience rapid deployments in717complex combat operations, that they require intensive718evaluation and treatment.719    VA stood up with a combination of those research findings,720the Intensive Evaluation and Treatment Programs (IETP) at our721five Polytrauma Rehab Centers. We have expanded that over the722past 5 years to ensure--or to improve access to those that723intensive programming for veterans and servicemembers who need724it.725    Mr. Conaway. Thank you for that. I will have to run to726another hearing, but I did want to just raise some issues about727how certain programs are funded. The BEACON Act, which will be728discussed by our second panel. Unfortunately, I might not be729here for all of it. One of the grant programs would award730eligible grantees $5 million per year to conduct research for731TBI veterans. The second grant program would require the VA to732enter into an agreement with a further third party organization733to administer a grant program to study and implement treatments734of TBI veterans. The program will be funded by diverting735existing VA clinical care funds. We know the VA has already736undertaken clinical trials and research into new TBI737treatments.738    When considered, I will ask and get to it, and that is the739diversion of funds within the VA to other programs does concern740us. Do you have a concern that these diversions would interfere741with the work that the VA is doing? That is, I would rather see742you get the additional funds rather than diverting funds from743other VA programs. Any thoughts on that?744    Dr. McArdle. We appreciate the question, Congressman. We745will have to take that for the record.746    Mr. Conaway. Thank you.747    Ms. Miller-Meeks. Thank you very much, Dr. Conaway.748    The chair now recognizes Dr. Murphy for 5 minutes for any749questions he may have.750    Mr. Murphy. Thank you, Madam Chairman. Got a lot to cover751real quick.752    Dr. Scholten, you said you practice, correct?753    Dr. Scholten. Yes, I do.754    Mr. Murphy. What do you do for TBI and PTSD patients who755have basically failed your cut and--cookie-cutter approach to756just TBI? What do you do when people come to the end?757    Dr. Scholten. Well, I personally, in my clinical practice,758again, as was mentioned earlier, do a thorough history and759evaluation, come up with a definitive diagnosis, and then760develop an individualized treatment plan. That plan considers761what interventions--first it considers which symptoms are most762problematic for the individual veteran based on their763functional ability, their ability to work and access the764community. Then we discuss what interventions have been tried765and what other opportunities----766    Mr. Murphy. Let me just get to the chase. What therapies do767you offer these people that basic therapies do not work?768    Dr. Scholten. Well, the therapies that are most commonly769offered are the standard rehabilitation therapies of physical770therapy, occupational therapy, and speech therapy. It is771critical to encourage or to evaluate the impact of mental772health conditions and then offer appropriate evidence-based773therapies to help with any diagnoses such as PTSD.774    Mr. Murphy. All right. Let me just get to the chase at an775end. We get to the point where there is not really much that we776offer to patients. Sadly enough, this is the part where777suicide, this is the part where tragedy occurs with family. I778think this is where personally I think the VA is failing to779come into the 21st century and understand that there are780modalities of treatment.781    Are you by any chance familiar with the work of Dr. Shai782Efrati in Israel with Hyperbaric Oxygen Therapy (HBOT) and783PTSD, the voluminous work that he has with trauma with PTSD784using hyperbaric oxygen?785    Dr. Scholten. Yes, I have read some of those articles.786    Mr. Murphy. Your opinion?787    Dr. Scholten. My opinion, along with that of VA and788Department of War, is after thorough review of evidence on789hyperbaric oxygen therapy, while there are a number of studies790that have happened, the guidelines, current clinical791guidelines, do not find sufficient evidence to offer HBOT for792use of TBI. We can----793    Mr. Murphy. Are you familiar by any chance of the work of794Dr. Joseph Maroon at the University of Pittsburgh who does the795same work?796    Dr. Scholten. I am not familiar with his part.797    Mr. Murphy. All right. Please, if you will, for798professional education, please familiarize yourself with his799work.800    I would like to submit for the record a meta analysis done801in the Frontiers of Neuroscience in October 2023, talking about802the multiple, multiple studies that show hyperbaric oxygen for803veterans for PTSD shows an improvement not only in clinical804data and clinical wellness, but in physiological achievements.805    Ms. Miller-Meeks. No objection.806    Mr. Murphy. You know, the American Academy of Pediatrics,807in my opinion, was negligent in the fact that they created an808institution, a generation of children, now adults, who are809allergic to peanuts, because they refused, through their810hubris, through their arrogance, to go back and see data was811wrong. They for 20 years did not go back and do this. Same812thing with National Institutes of Health (NIH), with the fact813that we deprived women of getting Premarin and estrogen814replacement, increase in cardiovascular disease, bone loss, and815so many of these other things.816    I believe the VA is being absolutely negligent and still817living in 1950's and 1960's and 1970's science and not looking818at real data in an era where we are failing our veterans that819are, in my opinion, conducive--presenting conducive820environments and allowing our veterans in an environment that821creates for suicide. We are stuck back in saying that we are822not right now. The VA may have had data back years ago, but823look, I want you personally to read this paper. We are being--824the VA is being negligent and not allowing veterans access to825this treatment.826    In North Carolina, there is an institution called HBOT for827Heroes. They have treated over 250 veterans with, in my828opinion, my clinical objective opinion, because I have scrubbed829this data because as a surgeon, I am a skeptic first, that they830have helped a tremendous number of our veterans where nothing831else worked. I am tired of the cubicle captains at the VA still832repeating the same rows over and over and over again, saying833this does not work, when clinical data shows otherwise. You834guys have a duty to our veterans to stop this massive suicide835rate when we can intervene.836    With that, I will yield back.837    Ms. Miller-Meeks. Thank you, Dr. Murphy.838    The chair now recognizes Dr. Morrison for 5 minutes for any839questions she may have.840    Ms. Morrison. Thank you, Madam Chair. Thank you, Ranking841Member Brownley. Thanks to our witnesses for being here today842and for the work that you do on behalf of our veterans living843with traumatic brain injury.844    Dr. Scholten, you understand well that traumatic brain845injury rarely exists as a single diagnosis. In practice what we846see are veterans who are navigating a variety of challenges:847cognitive symptoms, headaches, sleep disruption, chronic pain,848depression, PTSD, and difficulties with memory, concentration,849and executive function. A trend we have observed across850patients is increasing medical complexity.851    Veterans understand from their own lived experience that852conditions often overlap and reinforce each other and evolve853over time. Treating one in isolation can fall short of truly854addressing their needs. That is why the model of care is so855critical. One of VA's strengths is that it was built to address856complex service-oriented conditions across a veteran's857lifetime.858    When we talk about TBI care at VA, we are not just talking859about a neurology visit or a rehabilitation consult. We are860talking about a system that integrates rehabilitation medicine,861neurology, behavioral health, pain management, and social862support. That integrated approach is especially important when863we think about the kinds of injuries prevalent in modern864military service. Many vets are exposed to blast injuries,865repeated concussive events, and operational stressors.866    The non-VA health systems do not have the expertise to867anticipate or to understand. Understanding how the various868exposures interact with mental health and other service-869oriented--service-connected conditions is essential to870providing effective care. The VA has built a system871specifically designed for that challenge. Through the872Polytrauma System of Care, veterans with complex injuries can873access specialized rehabilitation centers, network sites, and874support clinics that work together across disciplines.875    From a clinical standpoint, that kind of coordination is876rare and incredibly valuable. Those who have spent time877navigating our health system know exactly how difficult it can878be for patients to navigate fragmented systems where different879specialties are all operating in silos. For veterans with TBI,880fragmentation and a lack of military-informed treatment can881mean delayed diagnosis, incomplete treatment, or symptoms that882fall through the cracks entirely.883    Another important part of this conversation is884identification and long-term management. Over the past two885decades, VA has screened large numbers of post 9-11 veterans886for traumatic brain injury and continues to treat a significant887population of veterans living with TBI-related conditions. Many888vets experience symptoms that fluctuate or become more apparent889years after the original injury. This makes continuity of care890and longitudinal follow up critically important and it also891highlights why military-informed care is so essential.892Providers need to understand the exposures veterans experienced893in training and combat, the cultural context of military894service, and the ways those factors influence both diagnosis895and recovery.896    Dr. Scholten, how important is it that traumatic brain897injury care be integrated with treatment for other common co-898occurring conditions?899    Dr. Scholten. Thank you for the question. It is incredibly900important that all of the factors, all the diagnoses, all the901trauma and the exposures, that that individual veteran brings902to the table that may affect their traumatic brain injury.903    One thing I did not mention on the earlier question with904research findings is that TBI is viewed now as a chronic905condition, thanks in a large part to the ongoing research906efforts through VA. What that means is that a TBI is not just a907point in time. Veterans do not just come to a TBI908rehabilitation clinic and have a silo of care and then move on909and live the rest of their life. Instead that intensive910evaluation and skilled treatment is focused on improving the911veteran's symptoms, improving their functional ability and912their ability to communicate, or participate in community913activities.914    Then when that has ended, we help transition veterans915toward wellness activities because we know very well that long-916term brain health is affected by a number of factors. In917mitigating the chronic effects of a traumatic brain injury, it918is essential to transition into a long-term brain health919wellness plan or a brain health prescription, which we have920recently developed and deployed through the VA.921    Ms. Morrison. Thank you for that answer.922    Dr. McArdle, in your testimony you described VA's923Polytrauma System of Care. What advantages does that model924provide for veterans with complex injuries compared to more925fragmented systems of care?926    Dr. McArdle. Thank you for the question. VA's Polytrauma927System of Care, the way it was established, to provide the928individualized team-based care in the case management that929comes with that. We utilize the wraparound care, the primary930care, the mental healthcare, other specialties to optimize931their entire care in order to optimize the outcomes that also932are associated with TBI. The VA is uniquely set up to be able933to do all of this in a single system.934    Ms. Morrison. Thank you. Really quickly----935    Ms. Miller-Meeks. Thank you.936    Ms. Morrison. Oh, I am past my time.937    Ms. Miller-Meeks. Your time has expired.938    Ms. Morrison. Thank you both for your service to our939veterans.940    Thank you, Madam Chair. I yield back.941    Ms. Miller-Meeks. Thank you very much.942    I now yield myself 5 minutes for any questions that I might943have.944    Dr. Scholten, how long does a typical TBI screening take?945    Dr. Scholten. Thank you for the question, Chairwoman. The946TBI screen takes possibly 30 to 60 seconds to complete.947    Ms. Miller-Meeks. Is this--the TBI screening that is done948at the VA, is that similar to what you would do at Active Duty?949Is it similar to what is done in the civilian workplace? As we950know, TBI can occur from a variety of occurrences, not just951those that are acquired in the military.952    Dr. Scholten. Yes, our screen that we use in VA is similar953to the screen used at the Department of War. It is different954compared to the community because our patient population has955typically sustained their traumatic event months to years956previous. In the community, most TBI care is delivered acutely,957you know, following a concussion or an accident. The screen is958different.959    Ms. Miller-Meeks. Since I am not on House Armed Services960Service Committee (HASC), is Active Duty military, Department961of War, are they now, given the knowledge we have about TBI,962which was not the same when I was a nurse on a neurosurgical963floor or even when I was director of Public Health in Iowa? The964knowledge base has certainly changed. With that is the965Department of War, are they screening for TBIs for those966individuals that would be at risk or were in theaters where967they were put at risk so that they have a seamless referral968into the VA system?969    Dr. Scholten. I know Department of War has an entire brain970health program. However, I cannot answer for the that agency.971    Ms. Miller-Meeks. Okay. It gives me another mission to take972on here. What does the TBI treatment look like for future973veterans, which was the genesis of this question, as the974landscape and methods of war are constantly changing?975    Dr. Scholten. Again, that would depend on the individual976veteran, their presenting characteristics and presenting977symptoms, as well as their cumulative trauma exposure as well978as other exposures. The key is really taking that979individualized history, looking at all the available980documentation, coming up with a diagnosis, and then, again,981that individualized treatment plan that is shaped in982collaboration both with the veteran and their caregiver.983    Ms. Miller-Meeks. What treatment protocol have you found to984be the most promising in treating the whole neuropsychological985syndrome of TBI?986    Dr. Scholten. In my experience, and what the scientific987literature would support, is integrated holistic care that is988providing wraparound services. Given team-based care where the989team actually has a chance to meet and discuss along with the990veteran progress, prioritizing goals. Then the other important991piece of that is ensuring that mental health experts are992participating in that plan and supporting the veteran.993    Ms. Miller-Meeks. If a veteran is remotely located from--so994the polytrauma centers are all at major, I am going to say,995academic VA medical centers. If a veteran is remote, i.e., in996Iowa, it could be 2 hours away or 3 hours away or 4 hours away997if they are in northwest Iowa, would this team approach be done998virtually?999    Dr. Scholten. Yes, it certainly can. In our Polytrauma1000System of Care, we see a little over 50,000 veterans in our1001TBI-specific clinics every year. Fifty-four percent of those1002veterans in Fiscal Year 2025 had some type of virtual care1003offered to them throughout the year.1004    Ms. Miller-Meeks. To follow up on that, considering TBI to1005include mTBI, it may be more widespread given now screening,1006more widespread than previously understood. Does VHA have the1007capacity to treat our current and future veterans with the1008highest impact treatment protocol?1009    Dr. Scholten. Thank you for that question. As we mentioned,1010VA has over 110 specialized teams in the Polytrauma System of1011Care that are expert in assessing and--assessing, diagnosing,1012and then treating those veterans. We with those care plans that1013are developed, any care that is not able to be offered to that1014veteran in a timely manner can be utilized through our1015community care partners. Then we will take that information,1016integrate it back into the care plan to ensure a seamless care1017delivery.1018    Ms. Miller-Meeks. Thank you for acknowledging that. My time1019is about to expire, but can you estimate the proportion of the1020veteran population that likely has TBI, but has not been1021evaluated by the VA for TBI?1022    Dr. Scholten. I do not have a good answer for that. I can1023tell you that in the TBI screening and evaluation process,1024about 20 percent of veterans have a positive screen that then1025are referred on for a comprehensive evaluation.1026    Ms. Miller-Meeks. Thank you very much. I yield back my1027time.1028    The chair now recognizes General Bergman for 5 minutes for1029any questions he may have.1030    Mr. Bergman. Thank you, Madam Chair, and my apologies for1031being late. I was on the floor doing a memorial speech for a1032leader in my district who passed and who also happened to be my1033first cousin. If I sound a little--I do not have an emotional1034bone in my body, so I have been told, but I do have a lot of1035passion.1036    The passion is running hot right now, especially as I was1037coming up here finding out that some of my colleagues were1038attacking the BEACON Act. I am, you know, in God's grace and1039forgiveness, I will not talk about either a person's inability1040to comprehend what we are trying to do or a bias to prevent1041good things from happening. That will sort itself out in life.1042We all know who, if you spoke the words, you spoke the words.1043They are recorded.1044    I think about 20-plus years ago, when we had four1045polytrauma centers: Palo Alto, Minneapolis, Richmond, Tampa,1046the original four. When I was in uniform, I traveled to all of1047them because some of my Marines were in there for treatment1048during the time. When we think about here we are 20-plus years1049later, still trying, having made some advancements, but not1050nearly enough for the need and what the Veterans Administration1051is trying to do and what the BEACON Act does to help the1052Veterans Administration in a very positive way.1053    Anybody who uses the word ``privatize'' obviously has1054either no creative thought, no historical knowledge, or no1055vision of the future when it comes to treatment for veterans or1056the population in general. Because of the factor that if we are1057going to solve--and I do not know if solve is the right word,1058if we are going to diagnose and treat and the future treatments1059going forward for traumatic brain injury, we need to have all1060hands on deck. Anybody who uses the word ``privatize''1061obviously either does not care or has an alternative agenda. As1062my mother would say, shame on them.1063    Now, enough of that, because I was always taught to be1064positive. Let me ask you a question. Okay. Thanks to our1065doctors for being here.1066    Dr. McArdle, you describe the five Polytrauma1067Rehabilitation Centers and also a broader network, polytrauma1068network sites, support clinics, and over 110 TBI teams. What is1069the real difference in care a veteran gets at a Polytrauma1070Rehabilitation Center versus those other sites?1071    Dr. McArdle. Thank you for the question. I am going to1072defer it to Dr. Scholten who oversees the Polytrauma Network.1073    Mr. Bergman. Okay.1074    Dr. Scholten. The difference in the care provision at some1075of our larger centers is there are more rehabilitation and TBI-1076related assets, more intensive programming. Most of our1077intensive inpatient treatment programs are located at those1078five centers. That allows us to leverage the huge amount of1079expertise in clinical care not only for TBI, but also in1080expertise in other clinical areas to include neurosurgery,1081internal medicine, orthopedic surgery, and mental health to1082provide that intensive and expert level of care. Once if a1083veteran is not from that area and accesses one of those1084Polytrauma Rehab Centers, once they transition back to their1085home area, the System of Care is set up to have--to remain1086connected to that veteran so that they can return to their home1087area, access primary care and other specialties.1088    Mr. Bergman. Not to put words in your mouth, this is truly1089developing a network, a broad-based network of care. When you1090think about before the early 1980's, surgery centers did not1091exist. Pretty much if you wanted any type of surgery, no matter1092how minor, you had to go to a hospital, pretty much. Surgery1093centers that now do everything from lower back surgery to1094cataract surgery to all of those different things and have1095brought the care to the community in such a way that the1096patient result is better, the accumulation of knowledge in the1097providers is better. It is a success story. Anybody who opposes1098the BEACON Act in this case is seeking to, whether it is1099intentionally or accidentally, prevent better care for1100veterans.1101    With that, I yield back.1102    Ms. Miller-Meeks. Thank you, General Bergman.1103    The chair now recognizes Representative Cherfilus-McCormick1104for 5 minutes for any questions she may have.1105    Ms. Cherfilus-McCormick. Thank you so much, Madam1106Chairwoman. Thank you so much for being here.1107    This is like one of the main issues we have been having. In1108My VA, we had several suicides and making sure, our veterans1109can actually get the care they need is so important to us. We1110also have some concerns also when it comes to making sure the1111cultural competency that comes to the--our soldiers and our1112veterans are there and they are being provided. My question for1113you as we are looking at that, do you have any concerns and how1114would you address those concerns to make sure that every1115practitioner can actually be aware and to recognize certain1116things that are specific to our veterans?1117    Dr. Scholten. Thank you for that question. Cultural1118competency when it comes to healthcare delivery is critical. We1119know that in VA we have--we feel we have better veteran1120awareness or better awareness of military-specific issues. Our1121System of Care is developed so that it provides these1122wraparound services that can address those military-and1123veteran-specific issues.1124    As you know, suicide prevention is one of the--is our1125highest clinical priority within VA. Our Office of Suicide1126Prevention as well as our Office of Research and Development1127has focused their efforts in better understanding suicide risk1128as well as better understanding interventions to decrease--or1129to promote suicide prevention efforts. In our integrated system1130we can enhance as well as deliver that enhanced screening and1131treatment for trying to minimize the suicide risk for our1132veterans.1133    Ms. Cherfilus-McCormick. Well, that is also my question.1134When it comes to the screening process, it seems like the1135screening tools that lack reliability and biomarkers, what is1136the VA doing to improve diagnostic accuracy so veterans are not1137misdiagnosed or missed entirely and whereas veterans still are1138falling through the cracks?.1139    Dr. Scholten. As we mentioned earlier, VA's Office of1140Research and Development allocated 50 million in direct1141research funding for Fiscal Year 2025 research projects for1142traumatic brain injury. Part of those efforts are aimed at1143developing better biomarkers not only for traumatic brain1144injury, but also other co-occurring mental health diagnoses. As1145we work to better understand and better identify biomarkers not1146only for TBI, but also looking at those associated or1147affiliated risk factors that can enhance suicide risk, we will1148better be able to care for veterans as we take that information1149and turn it back into our healthcare system.1150    Ms. Cherfilus-McCormick. My next question is that the1151BEACON Act would establish new grant programs that shift1152funding to non-VA entities for TBI research and treatment. Why1153should Congress divert resources outside the VA instead of1154strengthening the VA's existing research infrastructure? How1155could outsourcing care impact continuity and suicide prevention1156efforts while also taking into context that cultural competency1157for our community care providers?1158    Dr. Scholten. Thank you for that question. VA does its best1159to provide that integrated care. However, there are times when1160the expertise does not exist in the VA or cannot be provided in1161a timely manner. It is important then that we do--where it is1162time-sensitive, where we do work with our community partners to1163get veterans in the community care network to get that piece of1164their care provided in the community. We need to integrate1165those results back into their treatment plan.1166    Ms. Cherfilus-McCormick. Now, do you believe that there is1167an advantage to having services done at the VA and that there1168is a way we can actually harmonize the two? Because the1169expertise, I guess the concern is that the expertise of the VA1170might be lost when our soldiers go--our veterans go into the1171community. Do you believe there is a way we can harmonize the1172two so we are not losing any expertise?1173    Dr. Scholten. As a 28-year employee of the Department of1174Veterans Affairs, as a healthcare provider, I think we are well1175positioned to--very well positioned to provide that wraparound1176care and leverage that military and veteran competency to1177maximize the results.1178    Ms. Cherfilus-McCormick. Now, are there any specific steps1179you would like to see Congress take to make sure that exists in1180all situations?1181    Dr. Scholten. As I mentioned earlier, we appreciate the1182ability to testify here today on VA's TBI programs. We1183appreciate the fact that this is helping to spread awareness1184about TBI and veteran-specific injuries, especially since March1185is TBI Awareness Month. We appreciate your help in encouraging1186veterans to enroll in VHA for care or to choose VHA for their1187healthcare.1188    Ms. Cherfilus-McCormick. Thank you. I yield back.1189    Ms. Miller-Meeks. Thank you, Representative Cherfilus-1190McCormick.1191    On behalf of the subcommittee, I want to thank you all for1192your testimony and for joining us here today. You are now1193excused and we will wait for a moment as the second panel comes1194to the witness table.1195    Welcome to all of our witnesses and thank you for your1196participation today testifying on such an important matter. In1197accordance with committee rule 5(e), I ask unanimous consent1198that Representative Stauber, who is not here yet, from1199Minnesota, be permitted to participate in today's subcommittee1200hearing. Without objection, so ordered.1201    On our second panel, we have Mr. Al Johnson, retired U.S.1202Army lieutenant colonel and a flight surgeon, who was present1203when the Iranians attacked Al-Asad Air Base in retaliation to1204neutralizing the Islamic Revolutionary Guard Corp (IRGC)1205terrorist Soleimani; Mr. Buster Miscusi, former U.S. Marine1206Corps sergeant and graduate of Operation Mend; and Dr. Rusty1207Gore, chief medical officer at Avalon Action Alliance. Once1208again, thank you all for your participation in today's hearing.1209    Mr. Johnson, you are now recognized for 5 minutes to1210present your testimony.12111212                    STATEMENT OF AL JOHNSON12131214    Mr. Johnson. Thank you, Chairwoman Miller-Meeks and1215distinguished members of the subcommittee. Thank you for1216inviting me to testify today. My name is Al Johnson. I am a1217retired lieutenant colonel and physician assistant (PA) who1218served in the Army for over 27 years. I am testifying not on1219behalf of the Department of War, but in my personal capacity. I1220speak both as a military medical provider and as a patient that1221suffered TBI, someone whose life was permanently changed by a1222traumatic brain injury, in fact.1223    On January 8, 2020, while deployed to Al-Asad Air Base in1224Iraq, I was injured in one of the largest ballistic missile1225attacks on U.S. forces in the history of war. Iran fired 151226medium-range ballistic missiles at our base, each weighing1227roughly 1,500 pounds. I was sheltered in an indirect fire1228shelter which was not adequate for ballistic missiles. It was1229more designed for rockets and mortars. I have no memory of the1230first three impacts because I was knocked out at impact number1231three. I came to just as impacts number four, five, and six1232were hitting the base. All of these were in very close1233proximity to my position, with No. 6 being 60 feet away from my1234position. That massive percussion wave knocked me unconscious1235for the second time that day.1236    The missiles struck occupied operational areas, resulting1237in damage to critical infrastructure and barracks.1238Environmental testing after the attack detected radioactive1239isotopes, heavy metals, and toxic chemicals at the site.1240    As a result of the missile attack, I have been diagnosed1241with a TBI, PTSD, cranial nerve damage causing double vision,1242insomnia, tinnitus, neck pain, everything that you can imagine1243that would come with a blast injury. I struggle emotionally1244with hypervigilance, depression, a sense of distance from the1245people I love and my friends. I am also in a thyroid1246surveillance program due to multiple thyroid nodules that have1247developed since the attack.1248    After the attack, and despite our own injuries, myself and1249my two medics immediately began treating other servicemembers,1250many who now live with injuries similar or worse than mine. One1251soldier, specifically Specialist Jason Quitugua, suffered a TBI1252that resulted in headaches, insomnia, PTSD, and severe1253depression. Sadly, he died by suicide on October 7, 2021. The1254injuries he sustained during the attack ultimately cost him his1255life.1256    Another was Chief Warrant Officer Thomas Caudill. I1257diagnosed his TBI using the Military Acute Concussion1258Evaluation (MACE) 2 screening tool available to us on the base1259and arranged for his medical evacuation. He was subsequently1260evacuated, had a Computed Tomography (CT) of the brain1261performed which was unremarkable, and returned to duty1262literally the same day back into theater.1263    Many soldiers passed the largely self-reporting screening1264and remained in mission-essential roles due to conscientious1265underreporting. They immediately began to assist in cleanup.1266Many other servicemembers now experience chronic medical and1267mental health conditions, including thyroid disease.1268    I have coauthored two different peer-reviewed studies on1269the servicemembers who were there. One showed that out of 5831270exposed personnel, over 80 percent reported blast exposure and1271nearly half were still symptomatic a month later. Another1272identified 20 percent more TBI diagnosis a month after the1273attack than what were initially thought. People passed early1274screening because these tools often missed or delayed1275cumulative blast injuries.1276    Another soldier, Patrick Benn, was assisting in cleanup,1277ultimately diagnosed with thyrotoxicosis and underwent1278thyroidectomy after being exposed to the toxic chemicals. I am1279aware of multiple similar other cases in that cohort of1280soldiers that were on the base during that attack.1281    While improvements have been made since Al-Asad, prevention1282and early detection must be our first line of defense. Modern1283warfare involves repeated blast exposure in toxic environments,1284and our medical system must evolve to address those concerns1285accordingly.1286    Early identification is not only a medical issue, it is a1287compensation and access to care issue. Servicemembers injured1288in terrorist attacks depend on documentation to qualify for VA1289care and benefits. Due to recent legal rulings, many injured1290veterans are now unable to recover compensation from other1291sources that they once could. While injuries are missed,1292veterans lose both treatment and the support Congress intended.1293That is the commitment we owe the men and women who are injured1294in service to our country. Thank you for your time and1295continued commitment.12961297    [The Prepared Statement Of Al Johnson Appears In The1298Appendix]12991300    Ms. Miller-Meeks. Thank you, Mr. Johnson.1301    Mr. Miscusi, you are now recognized for 5 minutes to1302present your testimony.13031304                  STATEMENT OF BUSTER MISCUSI13051306    Mr. Miscusi. Chairwoman Miller-Meeks and members of the1307subcommittee, thank you for the opportunity to speak today on1308behalf of veterans living with a traumatic brain injury.1309    Each veteran's injury and recovery is unique. They rarely1310follow a straight line. After years of living with this injury1311and walking alongside other veterans who bear a similar burden,1312I have learned that these stories, like history, may not1313repeat, but the patterns tend to rhyme. I am here today because1314my story is one of those patterns and because what helped me1315should not be the exception, but the rule.1316    Before my injury, I could tolerate chaos, process1317information quickly, and stay oriented to my environment and to1318the people around me. These skills were critical not just for1319success in the military, but for being a present husband and1320father. They allowed me to have a clear identity, a clear role,1321and a future that made sense.1322    After my deployment to Afghanistan in 2012, I was diagnosed1323with PTSD. After a brief sequence of cognitive behavioral1324therapy, I learned enough skills to get back in the fight. In13252015, I was diagnosed with Crohn's disease and sent to Wounded1326Warrior Battalion for medical retirement. During that process,1327I was also diagnosed with a traumatic brain injury from low1328blast exposure.1329    At first, I did not believe the TBI diagnosis. I had never1330been in an Improvised Explosive Device (IED) explosion. I had1331never been knocked unconscious. When I first joined the Marine1332Corps and was training to deploy to Afghanistan, low blast1333exposure was not something we talked about. We were not1334screened for it and we were not taught to look for it. Mortars,1335explosives, and overpressure in training environments were just1336part of the job.1337    In the infantry, headaches, confusion, explicit jokes, and1338anger were normal. We joked about bloody noses and ringing1339ears. We laughed off losing our hearing for weeks at a time. We1340assumed our inappropriate jokes and angry outbursts were part1341of the military culture. Back then, there was not anything that1342we thought could not be solved with sufficient nicotine,1343caffeine, and Advil.1344    By the time I reached Wounded Warrior Battalion in 2015,1345the understanding of brain injuries had changed. Now clinicians1346were looking for low blast exposure, and they were able to name1347what I had been experiencing all along. Confusion was not a1348personal shortcoming. It was impairments in memory and1349information processing. Explicit jokes and anger were not part1350of the culture. It was a loss of cognitive filtering.1351    Going forward, the initial treatment plan helped. I was1352medically retired in 2018 and started college. Then everything1353collapsed again. I began having episodes where half my body1354stopped working. My face sagged, my speech slurred. When these1355occurred, I could not walk, talk, or eat. At first, these1356episodes happened almost daily. The VA ruled out a stroke. One1357doctor told me the engine still has power, but the transmission1358just keeps slipping out of gear. It was a good line and, in a1359way, it helped me understand what was happening. Understanding1360alone was not enough to restore function.1361    These episodes were associated with my brain injury and put1362my life on hold. I had to stop driving. I had to leave school.1363My symptoms worsened, and I fell into a deep depression. I1364began to believe I was a burden, that the meaning I had built1365my life around was gone. My wife refused to give up, continuing1366to search for help.1367    Eventually, we found University of California Los Angeles1368(UCLA) Operation Mend. Operation Mend treated my injury1369differently. They did not try to make it disappear. They worked1370with me, not on me, to learn skills and find resources to work1371with my limitations. Most importantly, they included my wife as1372an essential partner, recognizing that this injury does not1373affect one person alone. Previously, my wife had been rejected1374by the VA caregiver support program and struggled with burnout1375and caregiver fatigue. Operation Mend was the first time she1376was Included as an integral part of the care team. Recovery,1377like military operations, is a team effort. They understood1378that.1379    Operation Mend did not cure my TBI. I still live with1380migraines, stroke-like episodes, ringing ears, cognitive1381overload, and emotional volatility. What they restored was my1382sense of agency. My limitations are no longer evidence of1383failure. They are evidence of survival.1384    My story is not unique. Low blast exposure does not require1385an IED, loss of consciousness, or an infantry role. Many1386veterans and families are struggling to find the resources to1387develop the skills to learn to work as a team. Programs like1388Operation Mend, where symptoms are treated as challenges to1389work with rather than obstacles to destroy, and where1390caregivers are honored as integral partners rather than a1391dispensable afterthought, should be the gold standard of care1392across the VA. The capacity to provide this level of care1393already exists within the VA system. What is needed is1394organization, training, and recognition of veterans and1395caregivers as key stakeholders.1396    Who is responsible? The ones who know. I know what this1397injury feels like. I know what helped me and my family. Now1398that you understand it as well, the responsibility to act no1399longer rests with veterans alone.1400    Thank you.14011402    [The Prepared Statement Of Buster Miscusi Appears In The1403Appendix]14041405    Ms. Miller-Meeks. Thank you very much, Mr. Miscusi.1406    Dr. Gore, you are now recognized for 5 minutes to present1407your testimony.14081409                   STATEMENT OF RUSSELL GORE14101411    Dr. Gore. Chairwoman Miller-Meeks, Ranking Member Brownley,1412and members of the committee, thank you for the opportunity to1413testify today. My name is Dr. Russell Gore. I am a veteran. I1414served as an operational flight surgeon in the United States1415Air Force. I am now a neurologist specializing in traumatic1416brain injury.1417    Today and over the past 12 years, my work has focused on1418treating veterans and servicemembers with mild to moderate1419traumatic brain injury and the common co-occurring disorders we1420have discussed today. These are complicated, persistent. These1421result in life impairments that are associated with significant1422impairments throughout the lifespan.1423    I want to start with a simple truth from the clinic and1424from the trenches. TBI is not a single event with a clear1425recovery timeline. For many veterans, it is a chronic condition1426with symptoms that can be delayed, misunderstood, or1427misattributed. Veterans with TBI struggle with impairments1428affecting function in the community and relationships at home1429and at work. These struggles are often invisible but impactful,1430resulting in isolation and fractured relationships, a1431combination leading to a loss of purpose, a loss of1432productivity, and often despair.1433    The VA's 2025 National Suicide Prevention Report states1434that the suicide rate for veterans was 35 per 100,000.1435Critically, the rate for veterans with TBI is much higher. A1436veteran with TBI is more than twice as likely to commit suicide1437than a veteran without TBI. Veterans with TBI are an1438astonishing 5.5 times as likely to commit suicide than the1439average American. TBI and common associated conditions are1440fueling an epidemic of veteran suicide.1441    As Dr. McArdle highlighted earlier, we are just starting to1442understand the scope of this TBI problem. The U.S. Department1443of Defense (DOD) reports 500,000 servicemembers have been1444diagnosed with TBI since 2001, but this number represents just1445the tip the of the iceberg. Many veteran--many injuries go1446unreported, and this number does not account for injuries due1447to repetitive exposure to blasts.1448    U.S. military tactics are highly kinetic and this is a1449battlefield advantage, but the kinetic nature with which we1450train and fight is injuring our servicemembers over time.1451Estimates suggest that 2 million have experienced a TBI, and1452the most robust clinical data available indicates that over 501453percent may experience chronic symptoms.1454    The VA has made meaningful progress addressing veteran TBI1455with some of the current initiatives also outlined by Dr.1456Scholten and Dr. McArdle earlier. I am privileged to serve on1457the Federal Advisory Committee overseeing VA neurotrauma, so I1458have experienced firsthand the compassion and tireless effort1459of VA clinicians managing this epidemic of TBI. Enhanced1460screening efforts in the Polytrauma System of Care have1461certainly helped many veterans.1462    Despite this progress, the VA cares for only two-thirds of1463veterans, and among veterans completing suicide, fewer than 401464percent were seen in the VA the preceding year. Many veterans1465are not accessing TBI care within the VA. The reality is that1466VA TBI care, and indeed TBI care nationally, is currently1467fragmented. Veterans assessed for TBI often receive a series of1468disconnected referrals without a coordinated plan that treats1469the whole person. Veterans with persistent symptoms need an1470integrated pathway, comprehensive evaluation, individualized1471interdisciplinary rehabilitation, and reliable follow up. I see1472firsthand at the Shepherd Center every day what integrated1473brain injury rehabilitation looks like when it is done well.1474    In order to address these challenges, three organizations1475are offering treatment with intensive neurorehabilitation. This1476includes the VA's five polytrauma centers, the Avalon Action1477Alliance, and the Warrior Care Network. These three1478organizations are treating approximately 1,000 veterans with1479mild TBI per year. This is only a small fraction of the1480capacity necessary to treat the veterans who may benefit from1481this care. There is an urgent need to scale capacity. All1482veterans deserve access to evidence-based life-saving care,1483care that helps them return to family roles, school and work,1484care that restores function, care that restores dignity.1485    The BEACON Act offers the opportunity to provide funding1486for the research needed to urgently scale life-saving1487treatment. This legislation is designed to evaluate effective1488treatments and leverage civilian and academic TBI expertise1489that is aligned with the VA's mission. The BEACON Act will help1490us to identify what works, scale it, and make it available to1491more veterans. This is not an attempt to privatize care, but to1492complement VA research and clinical capacity by partnering with1493proven programs to reach veterans who otherwise are not being1494served effectively.1495    Here is what success looks like from my perspective.1496Approval of the BEACON Act to establish the efficacy of the1497intensive neurorehabilitation treatment model. Expand1498partnerships to increase VA capacity. Scale access to this1499treatment through reimbursement from government and private1500payers. Establish this treatment as the standard of care for1501any American suffering from chronic mild TBI.1502    Members of this committee, it is not the responsibility of1503the VA to stop this epidemic. It is our national1504responsibility. The VA should not have to do this alone. With1505smart, coordinated partnerships and targeted investment, we can1506reach more veterans earlier, treat them more effectively, and1507reduce veteran suicide.1508    Thank you for the opportunity to testify. I look forward to1509your questions.15101511    [The Prepared Statement Of Russell Gore Appears In The1512Appendix]15131514    Ms. Miller-Meeks. Thank you, Dr. Gore. I thank all of our1515witnesses for appearing here today.1516    As is my typical practice, I will reserve my time until all1517other members have had a chance to ask their questions.1518    I now recognize Ranking Member Brownley for 5 minutes for1519any questions she may have.1520    Ms. Brownley. Thank you. Thank you to all the witnesses for1521being here and your testimony as well.1522    Mr. Miscusi, in your testimony you say that VA has the1523capacity and the platform to provide the type of care you1524received at Operation Mend. What, from your point of view, is1525holding VA back? Do you think that diverting $60 million from1526existing VA programs as the BEACON Act requires helps or1527hinders VA in implementing intensive outpatient programs like1528the one you have completed? I am grateful that you have had the1529treatment that you need.1530    Mr. Miscusi. Thank you, Ranking Member Brownley. I cannot1531answer to how the money could be used, but I cannot answer to1532whether or not why I think that those resources are available.1533I am not engaged with the veteran--with the Veterans Health1534Administration on the level of understanding how things are1535organized. I do engage directly with their practitioners and I1536receive care from them, so I know that they care deeply. That1537is ultimately what is needed, is people who care deeply.1538    The thing that is missing is organization, I think. If1539these pieces could be organized together, I think that it could1540be effective. Operation Mend is a model of how that1541organization could occur where the money goes. Ultimately, I1542want it to serve veterans. That is what matters most.1543    Thank you.1544    Ms. Brownley. Well, and I appreciate that. I think your1545point about in the VA they care is one of the primary reasons1546why veterans, if they have a choice, would prefer to go to the1547VA other than community care outlets. You know, I do not have1548any data to support that on the TBI issue necessarily, but1549generally, that is what veterans tell me every single day is1550they would prefer to be in the VA and under VA care. I1551appreciate that.1552    You have--you never attempted to try to get care in the VA1553with regards to your situation?1554    Mr. Miscusi. I did receive care and I continue to receive1555care at the VA for the TBI.1556    Ms. Brownley. Okay. Okay, very good.1557    Dr. Gore, in your testimony, you, also--well, you claim1558that the BEACON Act was written to supplement, not supplant,1559VA's existing clinical care and research. The bill is pretty1560clear to me as written that it would divert $60 million from1561the VA National Center for PTSD and Mental Health Services. I1562am trying to understand how that is not supplanting, but it is1563supplementing.1564    Dr. Gore. Thank you for that question. I see this as an1565opportunity for building partnerships, building capacity, and1566for establishing the evidence necessary to shift what we1567consider to be the standard of care for traumatic brain injury.1568This is a national problem. The VA and the work that we are1569doing with veterans is an opportunity to leverage the volume of1570individuals with traumatic brain injury and the resources1571available so that we can demonstrate that the standard of care1572needs to shift.1573    All of the downstream opportunities for folks to receive1574care and access to care are dependent on establishing a1575standard of care. The current standard of care for traumatic1576brain injury in this country, in particular mild to moderate1577injury, is to do nothing. That is scary. Folks in this room,1578your friends, your loved ones are affected by this every single1579day. They get no care when they have these injuries and are1580released from the Emergency Room (ER).1581    All of us are doing an amazing job just because we care and1582we are providing intervention. We need to establish a standard1583of care which is going to improve both VA care and care1584external to the VA.1585    Ms. Brownley. What does that look like?1586    Dr. Gore. What that looks like for me is that veterans have1587an option to seek care in a place that they choose. In my1588experience, veterans are frustrated with the VA care that they1589receive. They receive multiple referrals from very well meaning1590providers, and those referrals are at different locations1591throughout their community. They are poorly coordinated. It is1592very difficult to execute on those plans.1593    This intensive program brings all of those resources under1594one roof and provides care, over 100 visits for care, over a 3-1595to 4-week period. It has been shown to work. The VA has1596actually modeled their IETP program after programs like mine at1597the Shepherd Center. We started doing this in 2006. What we1598have seen is that this seems to work.1599    The problem is the VA is treating fewer than 100 veterans1600per year in the IETP program. I heard 50,000 veterans a year1601are being treated in the VA for TBI. Just my basic math, 801602percent are mild and 50 percent of those have chronic needs.1603That is 20,000 a year that should have access to this care. It1604is less than 100 because most of the folks receiving that care1605are actually Active Duty servicemembers and mostly special1606operators.1607    I see providing access to this life-saving care as my1608personal priority and I hope that you will appreciate that.1609    Ms. Brownley. Thank you. I yield back.1610    Ms. Miller-Meeks. Thank you very much.1611    The chair now recognizes Representative King-Hinds for 51612minutes for any questions she may have.1613    Ms. King-Hinds. I want to start off by saying thank you to1614Mr. Miscusi and Mr. Johnson for your testimony today. I think1615when folks talk about traumatic brain injury, they do not1616really have a full idea of the lived experience. I want to be1617able to give you the opportunity to, one, share your thoughts1618as to if you had just one ask that Congress could do to make1619your life better. As somebody who has TBI, share that thought1620and, you know, give us a day in the life of what it looks like1621to live with this type of injury.1622    I will start with you, Mr. Johnson, and then we can go to1623Mr. Miscusi after.1624    Mr. Johnson. Thank you for your question and your comments,1625Representative King-Hinds. The comments you made earlier about1626the toxic exposure interest me more than you can imagine1627because that is our cohort.1628    Personally, my experience in dealing with my traumatic1629brain injury is I have been working in emergency medicine for--1630you know, in some capacity for 37 years. About 18 of that or 151631of that was as a sole provider in a rural community, which is a1632lot like tailgate medicine that you find on the battlefield.1633After my traumatic brain injury, however, I had to bench myself1634from being the only provider with two nurses in a rural setting1635because of my difficulties in complex--you know, navigating1636complex medical disease pathways and things like that. That is1637how it has affected me personally. I cannot do what I love to1638do anymore.1639    If I had my one ask to Congress, and, believe me, it has1640taken me 6 years of dead end attempts to finally get in front1641of an audience that can maybe help the folks that were on Al-1642Asad that day. The toxic exposure has created a unique1643opportunity along with a traumatic brain injury cohort. You1644have got 147, 150 soldiers that were in one place at one time1645that all experienced the same exposure, blast exposure and1646toxic environment exposure. You talk about a control for a1647research program, you cannot ask for anything better than that.1648    The care that they need, here is the problem. When you have1649a 22-year-old, now separated soldier from the service because1650they were medically retired, that goes to their primary or1651their VA Community-Based Outpatient Clinic (CBOC) and says,1652hey, I think I was exposed, I am not really sure what I was1653exposed to, what do I need to do about it? A lot of times it is1654nothing. These individuals should be getting baseline screening1655for cancers. They should be getting thyroid ultrasounds,1656advanced brain imaging as needed, including Magnetic Resonance1657(MR) venograms, too. I have had a couple of patients, me1658personally, in the ER that have had traumatic brain injuries. I1659end up doing an MRV, which I know none of my partners would do,1660and sure enough, venous sinus thrombosis, which are causing1661their symptoms. I know the research on that is like 4 percent1662of traumatic brain injuries have that, but it could be higher.1663We just do not search for it enough I do not think.1664    Baseline screening, like Prostate-Specific Antigen (PSA),1665colonoscopies earlier than age 40, those--cancer screening1666process, in addition to the traumatic brain injury and mental1667health, finding this--finding not just the treatment for their1668symptoms, but the root cause that can change their life to1669reverse the symptoms of their brain injury, whether it is HBOT,1670as Dr. Murphy said, we need to expand on that. This cohort1671specifically needs to be in a medical surveillance program that1672encompasses their entire care from traumatic brain injury to1673toxic exposure because I believe, as you do, that they are1674connected.1675    Ms. King-Hinds. I have 30 seconds and you have the rest.1676    Mr. Johnson. Sorry.1677    Ms. King-Hinds. My time--it is okay.1678    Mr. Miscusi. Thank you for the question. I would say if I1679had an ask for you today, from my evaluation, it seems like the1680question is what is the barrier? Is it money or is it1681institution? Are there institutional barriers within the VA1682that prevents them from making the programmatic changes that1683are needed to treat veterans and families with TBI? If there is1684an institutional barrier, well, then the BEACON Act solves1685that. If there is not, well then. I would ask you to evaluate1686what--so the question that--the thing that I would ask is how1687do you get--which program gets the care to the veterans fastest1688as they need it?1689    Then as far as a day in the life, I would say that I have1690five medical devices that have to shock some different part of1691my brain or my neck or something like that throughout the day1692so that I do not have those migraines and those episodes1693anymore. I would say that it is ongoing care throughout the1694day. Thanks.1695    Ms. King-Hinds. Thank you for that.1696    I am out of time. I yield back.1697    Ms. Miller-Meeks. Thank you.1698    The chair now recognizes Representative Cherfilus-McCormick1699for 5 minutes for any questions she may have.1700    Ms. Cherfilus-McCormick. Thank you so much. Thank you so1701much for your testimony.1702    Thank you, Mr. Johnson, for your recommendation because I1703think that is something that has been missed is looking at the1704root cause and testing for cancer. Thank you for bringing that.1705    Thank you also, Mr. Miscusi, for your statements because I1706think we have the same concern. What is the problem? Is it1707institutional? Who can get the services to our veterans faster?1708    That brings me to Dr. Gore. Thank you for your testimony,1709also. The concern really is if we are shifting money to outside1710organizations, you mentioned that 100, you said--I think you1711said 100 people are serviced with TBI within the VA. Is that1712what you said in your testimony earlier?1713    Dr. Gore. Yes, ma'am, within the intensive--the IETP1714program, that is the equivalent of what our programs are doing.1715    Ms. Cherfilus-McCormick. The concern is if we shift that1716money, then less than 100 people will be treated within that1717program. The question that I have is, is there any evidence to1718suggest that shifting those dollars would show that more people1719will be treated, that more veterans will have access? Is there1720any evidence for that?1721    Dr. Gore. I cannot speak to the shift in funding and how1722that may affect your decision-making and shifts--and decision-1723making from a legislative standpoint, but I can comment that1724absolutely, evidence is required for infrastructure to be in1725place to deliver care and for the finances to be in place to1726receive care.1727    Ms. Cherfilus-McCormick. Specifically, my question is, is1728there any evidence that these organizations would provide more1729care and better care to our veterans than if we have kept those1730funds within the VA? We already said the number in the VA is1731100. Do we have any tangible evidence to show that these1732outside organizations can do more and can do it better?1733    Dr. Gore. We do. We have evidence that the VA has collected1734that they see strong responses to treatment that is in line1735with evidence from multiple external organizations, including1736the National Intrepid Center of Excellence (NICoE) program in1737the Department of Defense. All of those programs have1738demonstrated that this treatment is effective.1739    A comparison between the VA and the civilian sector in this1740regard, I am not sure how really to answer that because what we1741are hoping to achieve is the research necessary to establish1742this as the standard of care. Once that is established as the1743standard of care, and that is what these resources would go1744toward, as well as other innovative treatments for TBI, I would1745suggest it is then the VA's responsibility to make a1746determination as to where to allocate funds so that they are1747taking care of veterans in the most optimal way.1748    These funds are not intended to just to treat veterans.1749These funds are intended for us to establish that this should1750be the standard of care and to look at more innovative models1751of treatment.1752    Ms. Cherfilus-McCormick. Well, before we shift those funds,1753I think we would want to know, like, with a substantial1754certainty that this would actually benefit our veterans versus,1755you know, shifting--leaving it where they are and actually1756growing it there. If there is any information that you can give1757to us that can help us come to that certainty, that would be1758extremely important.1759    My next question is your partner--your program partners1760with several academic and private institutions to deliver1761intensive short care treatment. You mentioned that. Can you1762walk us through the specific training and credentialing1763requirements for clinicians delivering TBI care in your program1764and how those standards compare to the interdisciplinary teams1765and clinical programs' practice guidelines used in the VA?1766    Dr. Gore. Within our programs, the credentialing of the1767physicians and rehabilitation specialists is very similar to1768the credentialing that would occur through the VA. To your1769questions, which I appreciated of Dr. Scholten earlier, we1770actually have a robust program that is focused on veteran and1771military competency across all of our providers. This is the1772same for also the Wounded Warrior Program treatment programs.1773    A vast majority of the clinicians have a connection to1774either the VA, to military service, whether it is their selves1775individually because they served or whether it may be a family1776member or previous experience practicing in the VA. The1777credentialing and the training process is very similar. We1778share a lot of the same talent within our programs as we see1779within the VA.1780    Ms. Cherfilus-McCormick. Do you have any specific programs1781for making sure that they have the cultural competency for1782military service or our veterans? Do you have anything specific1783that you guys are doing to make sure each and every1784practitioner is exposed to it?1785    Dr. Gore. We do. That programming actually for our network1786is seeded through my own program at the Shepherd Center in1787Atlanta because we have been doing this for so long and so we1788do have a training program that is geared toward cultural1789competency to make sure that individuals are aware of the1790unique needs of veterans and servicemembers.1791    Ms. Cherfilus-McCormick. While I have a few seconds, my1792last question is, do you believe that if it was mandatory for1793all outside organizations to have some kind of training, do you1794think that would be a benefit or do you think it would be a1795burden?1796    Dr. Gore. I think when you are looking at opportunities to1797provide care external to the VA, and there are numerous1798examples of this, not just in the TBI space, but also in the1799behavioral health space with programs specific for post-1800traumatic stress, that there is a massive benefit to ensuring1801that individuals are competent in that area. You know, whether1802that should be mandatory is a question maybe that I will leave1803up to you. I do not think that that would be a burden. I think1804that is important.1805    Ms. Cherfilus-McCormick. Thank you.1806    Ms. Miller-Meeks. The gentlewoman's time has expired. Thank1807you very much.1808    The chair now recognizes Dr. Murphy for 5 minutes for any1809questions he may have.1810    Mr. Murphy. Thank you, Madam Chair, and thank you all for1811coming today. For those of you guys that are dealing with the1812after effects of serving and sacrificing for my Nation, my1813heart goes out to my prayers with you. I pray that your journey1814and all this improves with each day. If you are having to have1815shocks with vagus nerve stimulators, I am guessing, I am1816assuming that is what it is, did you get that at the VA, may I1817ask?1818    Mr. Miscusi. Yes, sir, I did.1819    Mr. Murphy. Okay. Expediently done in a quick manner, good1820manner? Were you happy with the process?1821    Mr. Miscusi. It took a while to realize that that was the1822resource that was needed. Then once it was prescribed, I1823received it in a timely manner.1824    Mr. Murphy. Okay. How helpful is that to you? If you do1825not--I am sorry asking you personal questions.1826    Mr. Miscusi. I do not mind at all. It is the difference1827between me having an episode every day and being able to sit1828here and function. Maybe it occurs once a week.1829    Mr. Murphy. These are wonderful technological1830breakthroughs. We are on the cusp, especially with Artificial1831Intelligence (AI), of being able finally to, I think, crack the1832brain. It is the great frontier of the human body. We have a1833lot of work to do, but I pray that we can really crack the-on1834this stuff. Thank you for your service.1835    You know, I still, after being on this committee for years1836and years, do not understand the rationale of why we have to1837play us versus them as far--and with the veterans being bounced1838back between them, why it is VA versus outside institutions.1839Why can we just not care about the veteran first? Why is there1840this provinciality that we have to be so concerned about our1841own little world rather than what is best?1842    You know, Dr. Gore, I would love for you to just talk about1843your experience and whether you--you know, how you deal with1844these folks, what your protocol is, and how you deal with, you1845know, folks who come from the VA that may not have gotten the1846attention that they needed to and at what point do they show up1847on your door?1848    Dr. Gore. Thank you. I appreciate that question.1849    You know, I would start by saying that the Veterans1850Administration does a fantastic job managing a vast majority of1851the needs of our veterans. When these individuals come to my1852program, they have often cycled through a number of different1853treatment opportunities. There is some fracturing in the1854continuity of care, they are often left seeking care external1855to the VA. I think that that is natural.1856    I think if you are suffering and you are not finding the1857solutions that are addressing your suffering, it is normal and1858it is human. Honestly, you know, as a veteran myself, you know,1859we are individuals who want to get things done and we are going1860to find solutions. Folks are hungry to find opportunities and1861solutions to address their suffering.1862    When they come to us, I hear the full spectrum of stories.1863I hear about the positive experiences within the VA. I hear1864about the negative experiences. I hear about the negative and1865the positive experiences within the rest of the civilian1866healthcare system.1867    Mr. Murphy. Sure.1868    Dr. Gore. This issue is not unique to the VA. We have a1869very fractured TBI treatment system within the United States.1870When they come to us, we have an opportunity to really wrap our1871arms around them. What we hear consistently is, I have never1872had someone sit down and spend this much time with me. I have1873never been surrounded by a group of specialists all at the same1874time, all in the same room, all around the same table who are1875explaining to me the different deficits and how they are1876affecting my day-to-day life, and coming up with a plan. This1877is what interdisciplinary care is really all about.1878    One of the things I am really proud of is similar to the1879national statistics, only two-thirds of the veterans who come1880to us are connected to the VA. After we complete treatment, in1881their follow up phase after treatment, 90 percent are connected1882to the VA. We want them to utilize those resources smartly and1883we want to get them reconnected. The problem is that this1884treatment needs to be available and it is not currently within1885the VA in any meaningful way.1886    Mr. Murphy. Yes. You know, I think it has been the hallmark1887of, excuse me, medicine, at least in the last 20 years, that1888interdisciplinary study--interdisciplinary treatments is the1889way to go. We do it in oncology. We do it in other different1890fields. It is the best way to deal with all this.1891    You know, some people think just throwing money at a1892problem is the way to do it, and all you do is end up turning1893bureaucracy. You want a system that is efficient, that works,1894that gives you expected results, may not be able to deliver,1895you know, perfect outcomes every time, but if you are dealing1896with that type of efficient system, that understands that a1897blast is a blast and that you have to treat it from different1898angles, and also, just blasting out money is not the way you1899solve problems, this is the best mode of treatment that we1900can--or the best the best avenue of treatment that we can get1901for any patient, whether in their VA or not. I thank you guys1902for your service.1903    Lieutenant Colonel Johnson, it hurt me to hear that you1904feel that 50 percent of our folks consciously underreported.1905That is self--that is putting country before self. That hurts1906to hear. It is not unexpected because that is what our1907soldiers, airmen, Marines, et cetera, do, they put their1908country before for self. That is a lot of--it just hurts to1909hear that, but that is a reality.1910    Anyway, thank you all so much for your service. This is1911such a difficult, challenging problem, but thank you for1912working so hard.1913    Ms. Miller-Meeks. The gentleman's time has expired.1914    The chair now recognizes General Bergman for 5 minutes for1915any questions he may have.1916    Mr. Bergman. Thanks, Madam Chair. While I stepped out to1917take another meeting, I understand, you know, the committee1918process goes on, so I am going to just kind of lay out what the1919congressional Record was recorded as a few minutes. This is the1920quote, ``Congresswoman Brownley to Mr. Miscusi, quote, 'Do you1921think that diverting $60 million from existing VA programs as1922the BEACON Act requires helps or hinders VA in implementing1923intensive outpatient programs like the ones you have1924completed,' question mark, end quote?''1925    The BEACON Act does not, unless my team is mistaken, does1926not require the VA to divert $60 million. Instead, it allows1927the Department to use existing mental health funding and1928provides appropriators the option to allocate further funding1929specifically for the bill's purposes. I just want to make sure1930that the record stands straight that there is no diverting of1931$60 million here. Okay? I just wanted to inform my colleague1932that--of the mistake in her assumptions.1933    Having said that this is not personal. This is about facts.1934The panel's testimony makes clear that even when a TBI is1935labeled mild, the consequences for a veteran can be anything1936but. A significant number of veterans continue to live with1937persistent symptoms that affect daily function and community1938reintegration. That reality underscores why we must continue1939pursuing new treatments and innovative procedures to care for1940the veterans still living with these injuries.1941    With that as background, Dr. Gore, could you briefly1942explain the differences between a VA Polytrauma Rehabilitation1943Center and the other VA sites with TBI teams or polytrauma1944clinics?1945    Dr. Gore. Yes, thank you for that question. You know, I can1946certainly comment on my experience working with patients who1947have been in these--in the VA clinics, but I do not have1948personal experience working within the polytrauma center or one1949of the satellite community centers.1950    My experience talking with patients about this experience,1951their experience within the VA, the IETP programs are modeled1952after what we do. These are intensive programs with wraparound1953services, a therapy team that surround an individual for an1954intensive period of time. It is generally anywhere between 31955and 6 weeks of intensive treatment. That is only provided at1956the VA polytrauma centers.1957    The care that is provided in the general community is1958important screening care, potentially referrals to the1959polytrauma centers. Generally, individuals are given1960rehabilitation referrals that are to different locations around1961the community. The coordination of those referrals is very1962difficult. There is no communication or not a lot of1963communication between the providers providing that care, and1964that care occurs over an extended period of time. It is more1965the traditional model of rehabilitation that we see in this1966country. The fact that----1967    Mr. Bergman. I am going to--I know you could talk for a1968long time on this time, please. The point is, I would suggest1969that in any--we all use the term ``stovepipes.'' We know what a1970stovepipe is. You can have two stovepipes sitting next to one1971another, the Veterans Administration being one, a new, you1972know, polytrauma center, TBI teams, whatever, in another. If1973you are not communicating and sharing experiences of lessons1974learned, neither one of you are doing your job.1975    As we look at the Veterans Administration to get1976uncomfortable, in other words, get the hell out of your1977stovepipe and look at what you are proposing to do and see if1978you have got second and third order effects of what is working,1979what is not working, so that we expand on the quality of the1980care and the quality of the therapy and the quality of then,1981ultimately, outcomes when it comes to that. Because one thing,1982as we have talked about in all the committees I am on,1983especially Armed Services and Veterans' Affairs, is to break1984down the unnecessary stovepipes that have been allowed to grow1985over time and are beginning to look like weeds in a garden.1986When you got weeds in a garden, you do not get the beautiful1987flowers or the vegetables or whatever it is you are growing.1988Let us knock down the stovepipes.1989    With that, I yield back.1990    Ms. Miller-Meeks. Thank you, General Bergman.1991    The chair now recognizes Representative Stauber for 51992minutes for any questions he may have.1993    Mr. Stauber. Thank you, Madam Chair.1994    I want to begin by thanking Chairman Bost and you for1995allowing me to wave on to today's timely hearing. I also want1996to thank each of our witnesses for their service to our Nation,1997for sharing their experiences.1998    As the husband of an Iraq War veteran, I personally1999understand the burden our country puts on our military2000families. Behind every servicemember is a family who supports2001them. It is our duty as a Nation to help during and after2002service.2003    I want to take a moment to highlight my good friend Al2004Johnson, who is a constituent of mine in northern Minnesota.2005Mr. Johnson served with honor and distinction during his time2006in the Army and the Minnesota National Guard. I know it is his2007expert testimony that the Minnesota National Guard is the best2008in the Nation.2009    Mr. Johnson, I want to take--I want to ask you a quick2010question before I talk and not answer my 92-year-old father's2011phone call there. Mr. Johnson, I want to ask you about your2012experiences following the attack on Al-Asad. You note in your2013testimony that there is ample evidence that Iran used dirty2014warheads during this attack, correct?2015    Mr. Johnson. Thank you for your question, Congressman2016Stauber. I do not have the credentials to make that official2017call that it was a dirty warhead. I can tell you this, people2018are getting sick after this attack. In addition to when we were2019deployed there, we did not receive dosimeters to wear. After we2020left, they were issued dosimeters. There was some level of2021concern that occurred with the amount of radioactivity that was2022on the base post attack.2023    Mr. Stauber. Have Al-Asad veterans been able to easily2024access things like cancer screenings because of their presence2025during and after this attack?2026    Mr. Johnson. They have not. This is part of the problem2027where when these people separate, they spread all over the2028world or all over the United States. They become recluse. You2029lose contact with them. They are young. They do not know what2030to ask for because you do not know what you do not know. That2031is some of the gaps in not having a medical cohort surveillance2032program.2033    Mr. Stauber. You believe that because we do not have2034something like a medical surveillance program for Al-Asad2035veterans, they are----2036    Mr. Johnson. I think they are under-triaged, correct.2037    Mr. Stauber. In your testimony, you mentioned the tragic2038loss of SPC Jason Quitugua, who has become another victim in2039the veteran suicide epidemic plaguing our Nation. How many Al-2040Asad veterans like SPC Quitugua are slipping through the cracks2041because we do not have a medical surveillance program in place2042for the Al-Asad veterans?2043    Mr. Johnson. I do not know an exact number, but I know of a2044handful that nobody can get a hold of, and I do not know if2045they are suicidal, have addiction problems. That is concerning.2046    Mr. Stauber. Would it be your testimony that these veterans2047are not getting the care they need at the moment?2048    Mr. Johnson. That is correct.2049    Mr. Stauber. Do you believe having a medical surveillance2050program in place would help make sure those veterans get the2051support that they need?2052    Mr. Johnson. Yes, sir.2053    Mr. Stauber. You also raised an interesting point about2054accountability regarding SPC Quitugua's death. Did SPC Quitugua2055have TBI before the Al-Asad attack?2056    Mr. Johnson. Nothing was indicated in his record to say----2057    Mr. Stauber. Did SPC Quitugua have PTSD before the Al-Asad2058attack?2059    Mr. Johnson. Not that was indicated.2060    Mr. Stauber. Is SPC Quitugua dead because the terrorist2061regime in Tehran attacked Al-Assad?2062    Mr. Johnson. In my opinion and the opinion of experts that2063mTBI--all agree, yes.2064    Mr. Stauber. I just with the remaining time, Mr. Johnson, I2065want to give you the opportunity to highlight anything that you2066think was missed in today's hearing. The floor is yours.2067    Mr. Johnson. Well, first and foremost, I want to thank you2068and all of the panel for their commitment to the health and2069welfare of our veterans. We have made great strides in2070improving the lives of our warriors and families. We cannot2071leave the families out of this who deal with the consequences2072of war at home on a daily basis. There is always room for2073improvement.2074    Whether it is improving the equipment that protects us on2075the battlefield with the gear that we wear, passing legislation2076that holds terrorist countries accountable for what they do to2077innocent victims of, like in our case, blast injury, or funding2078for continued research to discover how to reduce or eliminate2079symptoms of TBI and PTSD, we rely on you, Congress. You are one2080of the conduits to solve these challenges.2081    The challenges of our servicemembers now that are facing in2082the Middle East, and this could not be more timely, this is not2083the last we are going to see about blast injuries and traumatic2084brain injuries continuing from the battlefield. It is just2085going to get worse. As we move into a more linear battlefield,2086these instances of recognizing TBI and appropriate care are2087going to be more prudent.2088    Mr. Stauber. Thank you very much, Madam Chair. I yield2089back.2090    Ms. Miller-Meeks. Thank you, Representative Stauber.2091    I now yield myself 5 minutes to ask any questions I may2092have.2093    All three of you are military veterans, correct? Sergeant2094Miscusi, Lieutenant Colonel Johnson, Colonel Gore, Dr. Gore?2095Let me ask you a question. The VA budget is just under, the VA2096healthcare budget, is just under half a trillion dollars. When2097we are talking about the BEACON Act, which is not diverting2098funds from any entity, it is $60 million for the BEACON Act. Do2099you know what percentage of the entire healthcare budget that2100is for the VA? Fifty percent, 10 percent? More like 1 percent2101of the entire VA healthcare budget.2102    I have heard--and so I am a 24-year military veteran. You2103all do not know me. I am a doctor. I was a nurse before. Left2104home at 16 to put myself through medical school. Let me ask2105you, all three of you are veterans. Sergeant Miscusi, when you2106went to Operation Mend, did you feel that they were culturally2107incompetent?2108    Mr. Miscusi. No, I did not.2109    Ms. Miller-Meeks. Lieutenant Colonel Johnson, as a PA or a2110medical flight, when you have received care outside the VA, did2111you feel that they were culturally incompetent?2112    Mr. Johnson. No, ma'am.2113    Ms. Miller-Meeks. Dr. Gore, having been both a veteran and2114providing services now not at a VA facility, do you feel and do2115the veterans feel that you are culturally incompetent?2116    Dr. Gore. I feel culturally competent, ma'am.2117    Ms. Miller-Meeks. Yes. Might you as veterans know if you2118are receiving culturally incompetent care? You might well--damn2119well know if you are receiving culturally incompetent care.2120    What I hear from veterans every single day, and as a2121veteran, married to a 30-year veteran, the daughter of a2122veteran, six of eight children having served in our military,2123veterans want choice. Veterans want care. They are fully2124capable of determining if they think care is culturally2125competent or if it is competent or if they have access to that2126care.2127    It is not really a question so much as it is that we are2128talking about getting care to veterans in a timely fashion to2129which they have access and to which they can determine if it2130meets their needs and if it allows them to be a functional2131human being, father, spouse, community member once again. That2132is why I support the BEACON Act, because to me, what is most2133important as the chair of this committee is that you receive2134the care that you need and that we expand services where we2135think there is unmet and undetected need.2136    Mr. Johnson, and I think you have answered this, how common2137is routine exposure to low level blast overpressure from2138breaching mortars? How is this different from regular infantry2139and special operations forces?2140    Mr. Johnson. It is more common than we recognize, these2141multiple sub-concussive events that happen daily over and over2142again in our line of work.2143    Ms. Miller-Meeks. Thank you. Dr. Gore, do you think that we2144currently are meeting the need that you have perceived through2145the VA system as it currently exists?2146    Dr. Gore. I think we could do much better.2147    Ms. Miller-Meeks. I think, Sergeant Miscusi, you would2148probably echo that sentiment?2149    Mr. Miscusi. Yes, ma'am.2150    Ms. Miller-Meeks. Yes. With that, I yield my time.2151    I think it is very profound, the testimony that we have2152heard today and the stories told by our guests. They bear2153witness to several things, especially with an ongoing conflict2154in the Middle East. They bear witness to the incredible2155strength and resilience of our American servicemember.2156Apologize for getting emotional on that, as well as the2157achievements of our VA healthcare system, which are incredible2158achievements, but also to the shortcomings of our system. It2159has been illuminating and an insightful hearing.2160    It is a moment in time when we are treating our veterans2161from the past two decades of warfare while catching a2162terrifying glimpse of what our future warfighters could face.2163It is imperative that Congress and the VA step up to the2164challenges of ensuring the health and safety of our future and2165our current veterans. Whether it is an institutional problem or2166whether it is a funding problem, both those things need to be2167addressed.2168    Representative Brownley, would you like to make any closing2169remarks?2170    Ms. Brownley. Thank you, Madam Chair. You know, all I am2171trying to say here is I, you know, certainly recognize and2172support the role that community partners and nonprofits play in2173getting needed care to veterans with TBI. In fact, many are2174already participating in VA's Community Care Network and2175academic affiliation. What I am just arguing for is we should2176be putting more money into the system to improve care to keep2177with the research that is out there to give optimal care to our2178veterans and not have the VA have to make choices between2179funding their existing services and supporting entities outside2180of the VA.2181    General, sitting over there, I am happy to work with you on2182this. I have great respect for you. We have served on the2183committee for a long, long time. We have had bills together. I2184would love to sit down and talk with you more about what our2185concerns are, what your concerns are, and see--and I know Ms.2186Elfreth as well. I have spoken with her this morning and would2187love to see if we can come to an agreement between us.2188    Mr. Bergman. This is bipartisan.2189    Ms. Brownley. Thank you. I yield back.2190    Ms. Miller-Meeks. Thank you, Ranking Member Brownley.2191    Again, just want to state that both as a physician and as a2192veteran, as a physician who has provided community care, I have2193always felt that my goal was to give excellent care, the2194highest quality of care, and in a culturally competent way,2195even if I was not trained by the VA in what some might consider2196culturally competent care. I appreciate our witnesses who have2197experienced both systems for letting us know where they think2198are the tremendous attributes of the VA as well as where the2199deficiencies are. It is through them that will prepare and2200extend a system that meets the needs of veterans.2201    I want to thank you for your participation in today's2202hearings and for the discussions that we have had on this very2203important topic. The complete written statements of today's2204witnesses will be extended--entered into the hearing record.2205    I ask unanimous consent that all members have 5 legislative2206days to revise and extend their remarks and include extraneous2207material. Hearing no objection, so ordered.2208    I thank the members and the witnesses for their attendance2209and their participation today. This hearing is now adjourned.2210    [Whereupon, at 12:14 p.m., the subcommittee was adjourned.]2211=======================================================================22122213                         A  P  P  E  N  D  I  X22142215=======================================================================22162217                    Prepared Statements of Witnesses22182219                              ----------22202221                  Prepared Statement of Rachel McArdle22222223    Chairwoman Miller-Meeks, Ranking Member Brownley, and Members of2224the Subcommittee: Thank you for the opportunity to testify on the2225Department of Veterans Affairs' (VA) efforts to support Veterans living2226with traumatic brain injury (TBI). Joining me today is Dr. Joel2227Scholten, Executive Director, Physical Medicine and Rehabilitation.2228Together, we will share how VA addresses the complex needs of Veterans2229with TBI through clinical care, research, and collaborations.22302231Understanding TBI22322233    TBI is defined as a disruption of normal brain function caused by2234an external force, such as a blow to the head, rapid acceleration or2235deceleration, or blast exposure.\1\ It can result in symptoms ranging2236from headaches and dizziness to memory problems, mood changes, and2237physical impairments. For Veterans, TBI is often associated with2238military service, particularly in combat environments, but it also2239occurs in training and civilian life.2240---------------------------------------------------------------------------2241    \1\  VA/DoD Clinical Practice Guideline for the Management and2242Rehabilitation of Post-Acute Mild Traumatic Brain Injury. The2243definition is on page 6. Available at: https://2244www.healthquality.va.gov/HEALTHQUALITY/guidelines/Rehab/mtbi/2245VADODmTBICPGFinal508.pdf2246---------------------------------------------------------------------------2247    TBI is considered a ``signature injury'' of recent conflicts, yet2248its impact extends across all eras of service. Importantly, TBI rarely2249occurs in isolation. Many Veterans experience co-occurring conditions2250such as posttraumatic stress disorder (PTSD), chronic pain, and sleep2251disturbances, which complicate diagnosis and treatment. Understanding2252this complexity is essential as we consider how to best support2253Veterans throughout their lives.2254    In addition to traumatic events that may cause a TBI, Service2255members may also have exposures labeled as Military Occupational Blast2256Exposure (MOBE). MOBE is caused by repeated exposure to jets on2257aircraft carriers, artillery fire, or blast during breaching2258operations. These exposures can cause symptoms similar to TBI and can2259accumulate over time leading to the development of persistent symptoms.2260MOBE is often overlooked, yet it may contribute to symptoms resulting2261in difficulties with employment, driving, and interpersonal2262relationships. As we recognize the scope of this issue, it will be2263important for VA to adapt how it structures its care systems to meet2264these needs.22652266VA's Care Systems22672268    VA has built a comprehensive care system to address TBI across the2269continuum of care. This includes screening, diagnosis, individualized2270treatment planning, and long-term support. At the heart of VA's2271approach is the Polytrauma System of Care, a nationwide network2272designed to provide specialized rehabilitation for Veterans with2273complex injuries, including TBI. This system includes five Polytrauma2274Rehabilitation Centers that deliver inpatient and outpatient,2275intensive, interdisciplinary care for Veterans with severe injuries.2276These centers work closely with Polytrauma Network Sites and Polytrauma2277Support Clinics to lead over 110 TBI teams across VA. Dedicated case2278managers coordinate services, facilitate transitions between settings,2279and support families throughout recovery.2280    VA screens all post-9/11 Veterans for TBI. Since 2007, VA has2281screened more than 1.8 million Veterans and connected Veterans with TBI2282specialists to complete an evaluation and develop a treatment plan. In2283Fiscal Year 2025 alone, VA treated over 160,000 Veterans with TBI-2284related conditions.2285    Every Veteran with TBI receives a personalized care plan tailored2286to his or her unique needs. These plans address physical, cognitive,2287and emotional symptoms, and often include therapies for co-occurring2288conditions, such as PTSD and chronic pain. VA emphasizes integrated2289care that combines rehabilitation with mental health services and whole2290health approaches. This comprehensive model helps Veterans manage2291symptoms, build resilience, and maintain gains achieved during2292rehabilitation. While clinical care is essential, VA also recognizes2293that research and innovation are critical to improving outcomes and2294shaping the future of TBI treatment.22952296Research and Innovation22972298    VA is committed to advancing knowledge and improving outcomes for2299Veterans with TBI through research and innovation. Our efforts focus on2300understanding long-term effects, developing precision diagnostics, and2301creating effective treatments. VA engages with leading academic2302institutions and the Department of War through initiatives such as the2303Long-Term Impact of Military-Relevant Brain Consortium, Chronic Effects2304of Neurotrauma Consortium, and the Translational Research Center for2305TBI and Stress Disorders. These programs study chronic effects of TBI,2306identify biomarkers, and develop interventions to improve brain health.2307    VA is also actively investigating the impact of repeated MOBE that2308occurs during military operations and training. These exposures may not2309cause immediate symptoms but can lead to cumulative effects over time.2310Research is underway to better document these exposures and understand2311their relationship to long-term health outcomes. In addition, VA has2312developed tools such as the Concussion Coach mobile application to help2313Veterans manage symptoms and access resources. Telehealth and virtual2314rehabilitation programs are expanding access to care, particularly for2315Veterans in rural and underserved areas. These research efforts and2316innovations are not isolated--they are integrated with VA's clinical2317programs and academic affiliations to ensure that discoveries translate2318into better care for Veterans.2319    The Brain Health Coordinating Center (BHCC) serves as VA's central2320resource for advancing brain health research and care. The Center2321integrates data from across VA medical facilities to identify risk2322factors, track treatment outcomes, and develop strategies that protect2323cognitive function in Veterans. The BHCC will also coordinate future2324brain and mental health clinical trials in diagnostics and2325therapeutics.2326    VA works closely with universities and TBI Model Systems, a2327multicenter longitudinal data base that captures rehabilitation and2328functional outcomes of individuals with TBI, to advance evidence-based2329care and train clinicians.\2\ These relationships allow VA to share2330best practices, conduct multi-site research, and accelerate the2331translation of findings into clinical care. By leveraging these2332connections, VA ensures that Veterans benefit from the latest2333scientific advances and that our workforce remains at the forefront of2334rehabilitation medicine. As we look to the future, these alliances will2335be essential in addressing remaining gaps and improving care for2336Veterans with TBI.2337---------------------------------------------------------------------------2338    \2\ The Traumatic Brain Injury Model Systems (TBIMS) National Data2339base is a prospective, multicenter data base and the largest2340longitudinal traumatic brain injury (TBI) data base in the world,2341funded by National Institute on Disability, Independent Living, and2342Rehabilitation Research (NIDILRR).23432344---------------------------------------------------------------------------2345Opportunities to Put Veterans First23462347    Despite progress, challenges remain. Currently, there is no single2348test to definitively distinguish symptoms caused by TBI from those2349related to mental health conditions. Veterans with mild or repeated2350TBIs may experience persistent symptoms that are difficult to treat. To2351advance the brain and mental health of Veterans, Total Brain2352Diagnostics is an ongoing precision, mental health research initiative2353to identify, validate, and integrate brain and mental health biomarkers2354among Veterans with specific consideration for depression, anxiety,2355PTSD, bipolar disorder, other mental health conditions, and TBI. The2356goal of this initiative is to assist clinicians in diagnosing complex2357brain and mental health conditions.2358    Looking ahead, VA will continue to improve documentation of blast2359and occupational exposures during military service, expand precision2360brain health approaches that tailor treatment to individual needs, and2361strengthen telehealth and intensive outpatient rehabilitation programs.2362We are committed to enhancing integration of mental health and whole2363health concepts into TBI care and deepening relationships with2364academia, Veterans Service Organizations, non-profits, and the2365Department of War to accelerate research and innovation. Finally, we2366aim to develop proactive case management strategies that engage2367Veterans with persistent symptoms and prevent functional decline.2368Through these efforts, we will continue to focus on putting Veterans2369first and advancing comprehensive care to Veterans with TBI.23702371Conclusion23722373    VA remains committed to delivering world-class care, advancing2374research, and supporting Veterans and families affected by TBI. Through2375our Polytrauma System of Care, research collaborations, and innovative2376programs, we strive to improve outcomes and quality of life for those2377who have sustained these injuries. Thank you for your leadership and2378continued support. We look forward to your questions.23792380                    Prepared Statement of Al Johnson2381[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]23822383                  Prepared Statement of Buster Miscusi23842385    Chairwoman Miller-Meeks, Ranking Member Brownley and Distinguished2386Members of the Committee, thank you for the opportunity to represent my2387fellow veterans who bear the invisible burden of traumatic brain2388injuries. I hope that my testimony today honors their service and2389experiences. While each of our journeys of injury and recovery are2390unique, rarely follow a straight path, and are unlikely to be repeated,2391they do tend to rhyme.2392    In 2001 I was in fourth grade on the Lower East Side of Manhattan2393on 9/11 when the United States was attacked. I remember being a 9-year-2394old kid reading the comics and sports pages on 9/10, and then sitting2395on those same playgrounds on 9/12 discussing international politics and2396the ethics of a military strike with my friends. It was then that my2397goal to serve in the U.S. military first materialized--a goal I would2398realize 9 years later when I enlisted in the Marine Corps infantry. I2399dreamt of a long career fighting in combat against the enemies of the2400United States, getting justice for the 2,977 victims of 9/11 and the2401countless other Americans whose lives were irreversibly changed that2402day.2403    Before my first deployment, that dream looked achievable. I was2404good at my job, getting meritoriously promoted twice within my first2405year. I could glance at a map, go on a 5-hour patrol, and know exactly2406where I was. I could expertly navigate the social world I lived in,2407understanding non-verbal communication, sarcasm, irony, and implied2408meaning to foster strong relationships with my unit, my newly wedded2409wife, and my family. I could tolerate change and new experiences,2410finding my way through chaotic environments. My future military2411career--and my life--looked bright.2412    When I came home from Afghanistan in 2012 I was diagnosed with2413PTSD. After a 3-week sequence of cognitive behavioral therapy I was2414well enough to get back in the fight.2415    Unfortunately, in 2015 I was diagnosed with Crohn's Disease and2416sent to Wounded Warrior Battalion East in Camp Lejuene, North Carolina2417to be medically retired. My dream of a long career in the Marine Corps2418had been shattered. Overnight I was no longer the mortar man, infantry2419squad leader, or martial arts instructor I had been for the past 52420years. Now I was a patient.2421    During the battery of appointments and evaluations for my medical2422board the providers diagnosed me with TBI on top of the Crohn's Disease2423and PTSD. From the outside looking in it looked like the wheels had2424come flying off the moment I slowed down. In reality, it was that by2425slowing down I realized that the wheels had fallen off a long time ago.2426What I was struggling with wasn't new, it had just built up so slowly2427over time that I had adapted little by little and barely noticed how2428far I had fallen.2429    During my time in the infantry I had fired thousands of rounds of2430mortars and detonated numerous explosives, but I never thought I had a2431TBI because I hadn't been exposed to an IED blast and I couldn't recall2432ever being knocked unconscious. Back then, the cumulative effects of2433repeated low blast exposures were not widely recognized, screened for,2434or understood within the military or clinical settings.2435    Additionally, because the majority of us in the infantry suffered2436from some type of headache, confusion, and anger problems we assumed it2437was normal. The effects of these repeated overpressure blasts were2438shared by all and treated with humor. Whether it was bloody noses,2439blood coming from our ears, or losing my hearing for 2 weeks--even2440while wearing ear protection--nothing was immune from an infantry2441marine's sense of humor. Somewhere there is a photo of me, flanked by a2442marine on either side, with two lit cigarettes dangling out of my ears2443in a poor man's attempt at ear candling after I had lost my hearing for24442 weeks. Back then, nothing couldn't be solved with a laugh, and a2445headache was no match for a sufficient amount of nicotine, caffeine, a2446change of socks, a drink of water, and some Advil. My headaches and2447vertigo were chalked up to dehydration, confusion was assumed to be2448caused by a character flaw, and inappropriate jokes, whether violent or2449sexual, were accepted as part of the military culture.2450    Now at Wounded Warrior Battalion, these experiences were seen as2451symptoms. I initially pushed back against the TBI diagnosis, confused2452since I had never been exposed to an IED. My providers explained that2453PTSD and TBI can share overlapping symptoms and that there were some2454ways that I was thinking and processing information that were uniquely2455related to TBI. The doctors explained that being exposed to repeated2456shock waves from firing weapons and detonating explosions in training2457could cause a TBI just as well as any explosion in combat.2458    What I had considered a ``painful headache that made things look2459funny'' was diagnosed as a complex migraine disorder with aura. The2460doctors rightly noticed that the confusion wasn't a character flaw, but2461by challenges with memory recall and information processing.2462Inappropriate jokes were recognized not as an infantry cultural norm2463that I couldn't let go of, but as a problem with my capacity to filter2464my thoughts and notice social and non-verbal cues. I was diagnosed with2465a traumatic brain injury caused by cumulative low-blast injuries. The2466doctors prescribed medications to help with my migraines, sent me to2467speech therapy for the memory challenges, and mental health for the2468problem with my filter. With a diagnosis and a treatment plan I was2469medically retired from the Marine Corps in 2018 and began going to2470college with dreams of becoming an astronomer.2471    Unfortunately, recovery is not linear and even if we stick to our2472treatment plan to the letter things can fall apart. A year after being2473medically retired from the Marine Corps I began having episodes where I2474would lose function in one side of my body, my face would sag and2475twitch, and my speech would slur and stutter. During an episode I2476couldn't walk, talk, or eat. My sense of touch deadened and I could no2477longer notice the difference between soft and sharp objects, or how2478hard I was holding something. The doctors at the VA ruled out a stroke2479saying that it felt like ``the engine still has power, the transmission2480just keeps slipping out of gear''.2481    While humorous in an infantry sort of way, these episodes were2482occurring nearly daily and would require a full day of rest to recover.2483It was no longer safe for me to drive and I had to leave school, unable2484to maintain the course of study. With my ability to function reduced2485such a significant extent, all of the symptoms that were previously2486managed became worse. The VA doctors did the best they could to manage2487these symptoms with the skills they had. They prescribed medications2488and medical devices, I tried acupuncture, massage, and hypnosis, but2489nothing seemed to help me return to a normal level of function. I began2490to fall into a depression, believing that I was a burden and that the2491meaning I had built my life around--service, responsibility, and2492usefulness--was lost.2493    Even in the midst of my despair, my wife held on to hope. Her hope2494inspired me to keep trying, to keep searching for anything that could2495help. I was at the end of my rope when I spoke to a nurse case manager2496from Semper Fi & America's Fund, who asked if I had ever heard of UCLA2497Operation Mend--an intensive outpatient program that partners with2498Wounded Warrior Project to help veterans with PTSD and TBI. I told her2499I hadn't, but that I would be willing to try anything once.2500    Operation Mend treated my brain injury differently. They didn't2501treat my injury as a problem to solve by trying to make it go away.2502During their intake they collected an entire picture of everything that2503was happening. Every single symptom that I was experiencing, even if it2504might have been associated with Crohn's Disease and not TBI, was2505considered. They took that information and, rather than trying to2506reduce my symptoms alone, they worked with me to identify the strengths2507I already had and the skills and resources needed to work around my2508limitations. They worked WITH me, not ON me.2509    More importantly, they included my wife in the process, working2510with her as well--recognizing that this injury does not affect one2511person alone, but impacts the entire family. It turns out that2512recovery, just like military operations, is a team sport. Operation2513Mend helped restore my belief that, while my brain injury was2514debilitating, painful, and difficult to understand, I could find a way2515to live a meaningful life of service if I learned to lean on my2516strengths and develop the skills and resources needed to support me and2517my family. Returning home with this new approach from Operation Mend I2518was able to get connected with a headache specialist who helped me2519understand that challenges I had been facing that I thought were part2520of Crohn's Disease, feeling like I was getting bitten by red ants,2521getting extremely weepy for no reason (don't play bag pipes around me2522unless you want to see me cry), and randomly getting voraciously hungry2523were all part of my migraine disorder too.2524    Operation Mend didn't make the migraines, the symptoms, or the TBI2525go away. I wasn't restored to my old level of functioning. But it did2526restore my sense of agency. Today, I still get migraines. I have a2527constant low-grade headache, my ears ring, and my head spins. I still2528break glass ware and I still get lost and need a GPS to get around. I2529struggle to understand sarcasm, irony, or implied meaning conveyed2530through non-verbal communication. I still cry when I hear bag pipes.2531Chaotic, cluttered, and crowded environments continue to confuse,2532disorient, and frustrate me. But now--thanks to Operation Mend, the VA,2533and my wife--these are challenges I have the skills and resources to2534face. I will likely face them for as long as I am alive, but they are2535no longer a sign of my failure. They are a sign of my survival. A2536survival that, while painful, is marked by humor, brotherhood, and2537purpose. While my future no longer looks the way it did when I first2538joined the Marine Corps, it is still full of hope.2539    By leveraging the skills and resources I have been given through2540Wounded Warrior Battalion, Operation Mend, Semper Fi & America's Fund,2541Wounded Warrior Project, and the VA, I now have the opportunity to2542discover new strengths and abilities within myself so that I can serve2543my family and my community with more compassion, patience, and wisdom2544than I was capable of before.2545    My story is not unique. The infantry is not the only military2546occupation exposed to environments with a risk of overpressure2547injuries. My struggle to describe my experience in a way that allowed2548me to access the right care is shared by many, especially those with2549brain injuries. Veterans, transitioning service members, and their2550families need to know that low blast exposure injuries can occur2551regardless of occupation, deployment history, or combat experience.2552Training must be developed so veterans, transitioning service members,2553and their families are given the language needed to explain their2554experiences and access appropriate care.2555    Programs like Operation Mend--where symptoms are treated as2556challenges to work with and through rather than obstacles to destroy or2557be destroyed by; where veterans are listened to for things they don't2558yet have words for; and where caregivers are honored as integral2559partners in the healing journey rather than a dispensable2560afterthought--should be the gold standard of care and emulated2561nationwide throughout the VA.2562    The capacity to provide this level of warrior-family-focused care2563already exists within the VA. The programs simply need to be organized,2564and veterans and caregivers need to be honored as key stakeholders in2565the design and implementation process. Developing these programs2566requires the collaboration of those who know what the problem is, those2567who know how to solve it, and those who have the platform to make it a2568reality. I know what this injury feels like, and I know what helped me.2569The VA knows how to solve it and has the platform to make it a reality.2570Now that this Committee understands it as well, the responsibility to2571act no longer rests with veterans alone.25722573                   Prepared Statement of Russell Gore2574[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]25752576                       Statements for the Record25772578                              ----------25792580   Prepared Statement of Association of VA Neurology Services (AVANS)25812582    Chairman, Ranking Member, and Members of the Committee:25832584    Thank you for the opportunity to discuss the care of Veterans with2585traumatic brain injury (TBI) and the role of the Neurology Centers of2586Excellence within the Veterans Health Administration (VHA). It is an2587honor to represent the clinicians, researchers, and staff who care for2588Veterans living with the enduring consequences of TBI.2589    After 35 years of Federal service, I retired from the Department of2590Veterans Affairs (VA) on September 30, 2025. At the time of retirement,2591I was the Executive Director of the national Neurology Clinical2592Programs and had supervisory responsibility for the 4 national networks2593of neurology Centers of Excellence (CoEs) and 3 national neurology2594tele-programs. My statement expresses my own opinions and is endorsed2595by the Board of Directors of AVANS.2596    Traumatic brain injury (TBI) remains one of the defining injuries2597of modern military service. While some injuries are immediately2598apparent, many TBIs--particularly mild TBIs and concussions--produce2599symptoms that may persist for months or years and are often invisible2600to others. Symptoms may begin months or even years following injury.2601Veterans with TBI frequently experience chronic headaches, seizures,2602cognitive changes, sleep disturbances, mood and behavioral symptoms,2603and, in some cases, increased long-term neurological risk. These2604effects can interfere with employment, relationships, and overall2605quality of life. For many Veterans, TBI is not a single episode of2606care; it is a chronic neurological condition requiring coordinated,2607longitudinal management.2608    The Neurology Centers of Excellence play a central role in meeting2609that need. TBI is neurologically complex and often intertwined with2610other conditions such as post-traumatic stress disorder (PTSD), chronic2611pain, substance use disorders, and orthopedic injuries. Accurate2612diagnosis and effective treatment require subspecialty expertise in2613areas such as epilepsy, headache medicine, and neurodegenerative2614disease. The Centers of Excellence ensure that this expertise is2615available across our national system and that Veterans receive care2616aligned with the best available evidence, regardless of geography.2617    For example, chronic headaches are the most common long-term2618sequela of TBI. The network of Headache CoE hubs and sites provide2619integrated, multidisciplinary care for refractory migraine and other2620headache disorders, often achieving significant improvements in2621function and quality of life that years of isolated care, whether in2622VHA or in the community, have failed to provide. The risk of epilepsy2623is increased both in the short-term and long-term following TBI. The2624VHA network of Epilepsy CoEs provide advanced diagnostic services such2625as inpatient video and electroencephalographic monitoring to confirm2626the diagnosis of epilepsy and determine the optimal medical, or in2627refractory cases surgical therapies. Veterans having episodic events2628may be found after diagnostic evaluation to have a functional disorder,2629paroxysmal nonepileptic seizures (PNES). More common in Veterans than2630in the general population, and often coexisting with PTSD, the VHA2631Epilepsy CoEs have pioneered the development and implementation of a2632network of clinicians trained in Neuro-Behavioral Therapy that2633effectively treats this disorder but is generally not available outside2634VHA. The incidence of neurodegenerative disorders such as Parkinson's2635disease and Alzheimer's disease is increased in Veterans with a history2636of TBI. To address the former, the VHA Parkinson's Disease Research,2637Education and Clinical Centers (PADRECCs) provide access to experts in2638Parkinson's Disease and other movement disorders for both diagnosis and2639management of therapies.2640    One of the most important contributions of the Neurology Centers of2641Excellence is the standardization of care across VHA. As the largest2642integrated healthcare system in the country, VHA serves Veterans in2643urban tertiary medical centers as well as in rural community clinics.2644Without systemwide coordination, practice patterns can vary. The2645Centers develop and disseminate evidence-based clinical pathways for2646the evaluation and management of post--traumatic headache, seizure2647disorders, cognitive impairment, and other neurological sequelae of2648TBI. They support clinical consultation networks and quality oversight2649processes that reduce unwarranted variation and promote consistent,2650high-quality care. A Veteran in a rural facility should receive the2651same standard of neurological assessment and management as a Veteran2652treated in one of our flagship medical centers. This may be achieved2653through virtual modes such as video telehealth and remote2654interpretation of studies such as electroencephalograms (EEGs), as well2655as through in-person care by interfacility referral. There is a2656national shortage of neurologists, especially in rural areas. The CoE2657networks allow Veterans anywhere to receive the benefits of neurology2658subspecialist care and oversight that is unavailable in rural areas,2659which often lack even general neurologists.2660    The Centers also operate in close partnership with VA's Polytrauma2661Rehabilitation System and rehabilitation medicine programs. Moderate2662and severe TBI frequently occurs in the context of polytrauma, and even2663mild TBI is often accompanied by comorbid psychiatric and physical2664conditions. Effective care demands coordination across neurology,2665mental health, physical medicine and rehabilitation, pain management,2666social work, and primary care. The Neurology Centers of Excellence2667strengthen these interdisciplinary connections and help ensure that2668Veterans receive comprehensive rather than fragmented care. This2669multidisciplinary coordinated care is generally unavailable within2670other health care systems, especially in rural or underserved areas of2671the country.2672    Access is another critical dimension of VHA care. Many Veterans2673live far from major medical centers. Through tele-neurology services,2674electronic consultation models, and remote interpretation of diagnostic2675studies such as electroencephalograms, the Centers extend subspecialty2676neurological expertise into rural and underserved areas. This model2677reduces travel burdens, shortens time to specialty input, and promotes2678equity in access to care.2679    Advanced diagnostic and therapeutic capabilities are also2680concentrated within the Centers of Excellence. Veterans with refractory2681post-traumatic epilepsy, chronic migraine and post--traumatic headache2682syndromes, functional neurological disorders, or complex cognitive2683impairment benefit from referral to clinicians with focused2684subspecialty training. The Centers serve as referral hubs for these2685complex cases while also supporting frontline clinicians managing less2686complicated presentations.2687    In addition to direct clinical care, the Neurology Centers of2688Excellence serve as engines of translation from research to practice.2689The VHA's integrated electronic health record and large Veteran2690population uniquely position it to conduct longitudinal research on TBI2691and its long-term neurological consequences. The Centers participate in2692and support VA-funded research efforts, evaluate emerging diagnostic2693tools and biomarkers, and integrate new evidence into clinical2694pathways. This research-to-practice cycle ensures that Veterans benefit2695from advances generated within the very system designed to serve them.2696    The Centers also contribute meaningfully to opioid stewardship.2697Chronic post-traumatic headache and pain are common following TBI. In2698the past, these conditions often led to significant opioid exposure.2699Neurology specialists within the Centers promote evidence-based,2700multimodal approaches to headache and pain management that reduce2701reliance on opioids and enhance patient safety. Close collaboration2702with mental health and addiction medicine services further strengthens2703the ability to mitigate risk while addressing suffering.2704    Workforce development is another essential function. The Centers2705provide education and training to neurologists, advanced practice2706providers, and primary care clinicians throughout the system. Through2707continuing education programs, case conferences, and clinical decision2708support tools, they build durable capacity across VHA rather than2709concentrating expertise in isolated locations. This investment in2710education ensures that expertise remains embedded within the broader2711system of care.2712    The impact of these efforts is seen in earlier identification of2713neurological complications, more precise diagnosis that distinguishes2714TBI-related symptoms from overlapping psychiatric and neurologic2715conditions, improved management of seizures and headaches, reduced2716avoidable emergency utilization, and better functional outcomes.2717Importantly, the Centers support long-term surveillance of Veterans2718with TBI who may face elevated risk for later neurological conditions,2719ensuring that care does not end once the acute injury has stabilized.2720    Given the central role of the neurology CoEs to the care of2721Veterans with TBI, as well as other neurological conditions, it is2722concerning that the Centers face several operational challenges.2723Budgets have generally increased in recent years, but often2724unpredictably. The neurology Centers are based within VA Medical2725Centers and their staff are hired locally. Even though CoE operations2726are supported through national specific purpose funds, individual2727medical centers may be reluctant to hire new staff if future funding2728may be cut or fail to provide for annual cost-of--living and other2729increases. Due to the recent focus on downsizing VHA staffing, a number2730of key positions are currently vacant due to clinical and2731administrative staff reassignment, resignation to accept positions2732outside VHA, or opting for early or standard retirement. Key vacancies2733include positions of national significance, such as regional CoE2734Directors and national CoE network administrators, as well as local CoE2735clinicians and other staff. In times of uncertainty concerning the2736stability and desirability of Federal employment, vacancies are proving2737hard to fill, and declinations of VHA job offers are now common. Even2738though full-time CoE hires are permitted under current policy,2739confusion remains regarding the rules and limits pertaining to CoE2740staffing. This can unintentionally place the Centers in competition2741with the host facilities for hiring.2742    The neurology Centers must retain large populations of Veterans to2743pursue their clinical, training and research missions. Recent trends to2744outsource Veteran care to the community threaten the ability to deliver2745on these missions. Further, measures that would use VA appropriations2746to fund extramural research related to TBI, such as the proposed BEACON2747Act, if passed, could drain vital resources from ongoing research,2748training and clinical programs, diverting funds to institutions with2749uncertain track records and limited experience working with the Veteran2750population.2751    A final concern, one not limited to the neurology CoEs but relevant2752to clinical care throughout VHA at the present time, is the changes in2753the workplace environment and culture in which VHA employees provide2754care. The VHA has long promoted the path to becoming a high reliability2755organization, with an obsessive attention to accuracy and avoidance of2756clinical errors, in a climate of psychological safety that encourages2757reporting of mistakes and ``near misses'' in a concerted effort to2758prevent patient harm. Unfortunately, these principles appear to be in2759abeyance at present. Clinicians are anxious about the security of their2760jobs due to real or threatened staffing reductions or reassignments,2761are stretched thin due to increased vacancies that go unfilled2762following staff departures, and in some cases are forced into cramped,2763inadequate space in overcrowded VA medical centers due to the return to2764office mandate. Restoration of psychological safety and a positive2765workplace culture and environment will ensure optimal safety for all2766Veterans cared for in VHA facilities.2767    In closing, the Neurology Centers of Excellence function as force2768multipliers within the Veterans Health Administration. They standardize2769care across a vast national system, extend subspecialty expertise to2770rural communities, translate research into clinical practice,2771strengthen patient safety, and support interdisciplinary, lifelong2772management of traumatic brain injury. TBI is not simply an acute event;2773for many Veterans, it is a lifelong condition. It is an obligation to2774provide coordinated, evidence-based neurological care that honors their2775service and addresses both immediate and long-term needs. The neurology2776Centers help Veterans with TBI on their journey from disability to2777fully functional, employed, and productive members of their2778communities. Adequate funding of the Centers, appropriate hiring2779authority for Center staff, and an improved work culture and2780environment generally, are required to allow the Centers to continue to2781provide optimal care to all Veterans in need of their expertise,2782including those with a history of TBI.2783    Thank you for your continued oversight and support of Veteran2784healthcare.27852786             Prepared Statement of Wounded Warrior Project27872788    Chairwoman Miller-Meeks, Ranking Member Brownley, and Members of2789the Subcommittee - thank you for inviting Wounded Warrior Project to2790share our perspective on Department of Veterans Affairs (VA) care for2791veterans with traumatic brain injury (TBI). Supporting veterans and2792Service members with invisible wounds like TBI and post-traumatic2793stress disorder (PTSD) has been central to our mission to honor wounded2794warriors, and our advocacy before Congress has been shaped by our2795experience delivering life-changing and life-saving care to this2796community.2797    Wounded Warrior Project (WWP) is built upon our promise to meet the2798needs of warriors and family support members no matter what. Since27992003, that promise has included programming designed to assist2800catastrophically disabled warriors with moderate and severe TBI. In2801Fiscal Year 2025, we delivered nearly 285,000 hours of in-home and2802local care through our Independence Program. This program provides2803personalized care and ongoing, innovative support to help these2804warriors remain at home and live more independent lives for as long as2805possible. Currently serving nearly 1,000 warriors, the Independence2806Program (IP) is a small but critical part of a larger ecosystem of care2807and support that spans a wide range of needs veterans have now and will2808have into the future.2809    Nearly one in five post-9/11 veterans sustained at least one TBI,2810and over 500,000 TBIs have been diagnosed in Department of Defense2811(DoD) personnel since 2000.\1\ Research indicates that this figure2812could be even higher due to undocumented injuries in Iraq and2813Afghanistan before improvements in documentation implemented in2814November 2006.\2\ Most of these individuals make a full recovery from2815their injuries, especially if they only had a single mild TBI, but some2816require lifelong care and support. At least one report has concluded2817that 1 in 4 veterans who have been hospitalized with TBI will develop2818long-term disability.\3\2819---------------------------------------------------------------------------2820    \1\ DEF. HEALTH AGENCY, U.S. DEP'T OF DEF., https://www.health.mil/2821Military-Health-Topics/Centers-of-Excellence/Traumatic-Brain-Injury-2822Center-of-Excellence/DOD-TBI-Worldwide-Numbers (last visited Jan. 9,28232026).2824    \2\ Rachel P. Chase & Remington L. Nevin, Population Estimates of2825Undocumented Incident Traumatic Brain Injuries Among Combat-Deployed US2826Military Personnel, 30 J. HEAD TRAUMA REHAB. E57 (2015) (available at2827https://journals.lww.com/headtraumarehab/Abstract/2015/01000/2828Population_Estimates_of_UndocumentedIncident.14.aspx).2829    \3\ Yll Agimi et al., Estimates of Long-Term Disability Among US2830Service Members With Traumatic Brain Injuries, 36 J. HEAD TRAUMA REHAB.28311 (2021) (available at https://pubmed.ncbi.nlm.nih.gov/32472830/).2832---------------------------------------------------------------------------2833    Injury data like the above is underscored by the fact that modern2834medicine and recent improvements to the delivery of in-theater care2835have saved more lives than ever before.\4\ Yet while many survived2836their wounds on the battlefield, recent scholarship has found excess2837mortality rates among post-9/11 veterans compared with the general U.S.2838population, particularly among veterans with TBI. Research funded by2839DoD and the Department of Veterans Affairs (VA) concluded that post-9/284011 veterans have higher death rates than expected, and those who had2841traumatic brain injuries had an even greater risk of dying. More2842specifically, ``[w]hile veterans exposed to moderate/severe TBI2843accounted for only 3 percent of the total post-9/11 Veteran population,2844they accounted for 34 percent of total excess deaths observed, which2845was 11-fold higher than would otherwise be expected.'' \5\ This study2846and others draw particularly close attention to the elevated risk of2847suicide that veterans face after TBI, particularly if those injuries2848are more severe.\6\2849---------------------------------------------------------------------------2850    \4\ Valecia Dunbar, Trauma Registry Yields Significant Increase in2851Traumatic Injury Survival Rates, U.S. ARMY (June 25, 2015), https://2852www.army.mil/article/150990/2853trauma_registry_yields_significant_increase_in_traumatic_injury_survival2854_rates.2855    \5\ Jeffrey Howard et al., Association of Traumatic Brain Injury2856With Mortality Among Military Veterans Serving After September 11,28572001, 5 JAMA NET. OPEN (2022) (available at https://doi.org/10.1001/2858jamanetworkopen.2021.48150).2859    \6\  Lisa Brenner et al., Associations of Military-related2860Traumatic Brain Injury with New-onset Mental Health Conditions and2861Suicide Risk, 6 JAMA Net. Open (2023) (available at https://2862jamanetwork.com/journals/jamanetworkopen/fullarticle/2807787); Jeffrey2863Howard et al., Suicide Rate Trends for Post-September 11, 2001, US2864Military Veterans, 8 JAMA NET. OPEN (2025) (available at https://2865jamanetwork.com/journals/jamanetworkopen/fullarticle/2838445); Kayla2866McIntire et al., Factors Increasing Risk of Suicide After Traumatic2867Brain Injury, 35 BRAIN INJ, 151-63 (2020) (available at https://2868doi.org/10.1080/02699052.2020.1861656).2869---------------------------------------------------------------------------2870    As these figures illustrate, we believe that TBI care must continue2871to be an area of critical focus for Congress, VA, and other community2872stakeholders. We are pleased to direct particular attention to several2873key areas where near-term action will create the long-term support and2874sustainability that so many need.28752876Care Journey Overview: The Phases of TBI Care28772878    The continuum of care for TBI spans acute care to long-term2879support. While TBIs are generally diagnosed along a spectrum of mild,2880moderate, and severe, this classification based on the severity of the2881injury does not necessarily correlate to the nature of symptoms or2882recovery prognosis. Each TBI patient's journey will have unique2883combinations of mental, physical, behavioral, and cognitive impacts2884alongside decisions about when, where, and how frequent health care2885interventions take place.2886    In ideal scenarios, veterans will have access to a continuum that2887integrates clinical treatments with supportive services, but veterans2888often experience regressions. Issues can arise due to improper2889diagnoses (perhaps due to a shortage of specialized TBI care2890providers), inconsistent follow-up care (routinely associated with a2891multi-disciplinary care approach versus more coordinated2892interdisciplinary care), delays in intervention, and general lack of2893knowledge of how and where to access the most appropriate level of care2894and resources. As observed by the National Academies, ``[f]or many2895people with TBI and their families, a `continuum of care' does not2896exist. Their journey is more aptly characterized as a fragmented series2897of silos (prehospital assessment, potential emergency department or2898hospital-based acute care, perhaps inpatient or outpatient2899rehabilitation, and possibly additional community or long-term services2900and supports) [...].'' \7\2901---------------------------------------------------------------------------2902    \7\  NAT'L ACADS. OF SCIENCES, ENG'G, AND MED., TRAUMATIC BRAIN2903INJURY: A ROADMAP FOR ACCELERATING PROGRESS 167 (2022).2904---------------------------------------------------------------------------2905    Despite this observation, an overview of stages in the TBI care2906continuum can help frame areas for congressional action:29072908      Acute Phase: The immediate care provided in trauma2909centers that focus on stabilization. Interventions like surgery and2910pain control are most often provided at military treatment facilities2911and the VA's network of Polytrauma Rehabilitation Centers.29122913      Post-Acute Rehabilitation Phase: After stabilization2914care, veterans and Service members may receive rehabilitation to2915restore function, addressing cognitive and behavioral deficits and2916comorbidities. This stage may last weeks, months, or even years,2917depending on the severity of the injury and incorporate elements of2918physical therapy, occupational, therapy, speech and language therapy,2919cognitive rehabilitation therapy, and psychological support. For2920veterans using VA, this care can take place in intensive inpatient and/2921or outpatient settings or Polytrauma Rehabilitation Centers.29222923      Long-Term Phase: During this segment, patients will focus2924on maintenance of therapies, as well as home and/or institutional2925support to regain or maintain independence and fulfill behavioral2926plans. This phase may involve VA home and community-based services2927including Home Based Primary Care, Adult Day Health Care, and Skilled2928Home Health Care, as well as VA-purchased care services like Homemaker/2929Home Health Aide, Veteran Directed Care, and Medical Foster Homes. For2930complex cases, residential-based care may be provided at VA Community2931Living Centers, Skilled Nursing Facilities, or at community-based2932nursing homes.29332934      Community Reintegration: As care becomes more familiar,2935veterans may move on to focus on independence, addressing isolation and2936other health issues, while incorporating active and ongoing case2937management. Aside from health care support, some veterans may benefit2938from VA services like the Veteran Readiness & Employment program to re-2939enter the workforce in a new capacity.29402941        While survival and early rehabilitation outcomes have improved,2942        the continuum of care has not evolved to address the lifelong2943        needs of this population. When long-term needs are not2944        addressed, predictable downstream impacts occur including:29452946      Functional regression and loss of independence resulting2947from discontinuation of ongoing rehabilitation and long-term supports;29482949      Higher long-term system costs driven by crisis-based2950care, emergency department utilization, and avoidable hospitalizations;29512952      Increased caregiver burden and burnout as veterans' needs2953increase and caregivers age alongside them, often impacting the entire2954family unit;29552956      Premature or inappropriate placement in institutional2957settings that are not designed to meet the clinical, behavioral, or2958rehabilitative needs of younger and mid-life veterans with TBI and lack2959proper government oversight and support personnel; and29602961      Increased social isolation and elevated suicide risk,2962with TBI recognized as an independent risk factor for mortality.29632964    Based on these assessments and considerations above, we offer2965several areas where congressional action can improve the TBI continuum2966of care.29672968Improving Case Management29692970    Service members and veterans living with severe injuries or2971multiple comorbid conditions often navigate some of the most fragmented2972care systems in the country. Many rely on multiple Federal and State2973programs at the same time, receiving care through Military Treatment2974Facilities (MTFs), TRICARE, VA, Medicare, Medicaid, private insurance,2975and local programs - each with its own eligibility requirements,2976coverage limits, and care-coordination processes. Without consistent,2977knowledgeable case management, transitions between these systems2978frequently lead to gaps in services, delayed treatment, and increased2979strain on caregivers. For veterans with TBI or complex neurological2980conditions, these disruptions can undermine health, independence, and2981long-term stability.2982    In a pair of 2007 memorandums of understanding, DoD and VA launched2983the Federal Recovery Coordination Program (FRCP) and designated Federal2984Recovery Coordinators as the ``ultimate resource'' for monitoring the2985implementation of services for wounded, ill, and injured Service2986members. At the time, these actions recognized that because of the2987dramatic changes in military battlefield medicine and rapid evacuation2988from the combat theatre, many returning Service members, and2989subsequently veterans, have multiple complex medical and mental health2990problems, including TBI, SCI, amputations, burns, and PTSD. Due to the2991complex nature of their benefits and health care needs, these warriors2992may receive care from many providers in multiple facilities, including2993MTFs, VA Medical Centers (VAMCs), private hospitals, rehabilitation2994facilities, or through home health agencies. Transitions among these2995facilities and providers, absent coordination, can result in care and2996benefits gaps.2997    The challenges that existed then persist to this day, and health2998systems must remain committed to uniform training for recovery2999coordinators and medical and non-medical care/case managers, efficient3000tracking systems, and commitments to comprehensive plans for the3001seriously injured. As time has passed however, the FRCP was3002consolidated into the Federal Recovery Consultant Office (FRCO) in3003February 2018 in response to the Presidential Executive Order,3004``Comprehensive Plan for Reorganizing the executive branch.'' While3005this shift may have created some efficiencies, WWP encourages a fresh3006assessment of whether the FRCO is sufficiently resourced to address the3007reforms that have not been fully realized. Additionally, we believe3008that similar efforts can be undertaken to support a broader population3009of veterans with complex needs and should include steps to ensure3010central oversight of policy implementation.3011    VA's Spinal Cord Injury/Disorder (SCI/D) System of Care offers a3012parallel approach that may be considered and illustrates an established3013example of how a condition-specific, lifelong care continuum can be3014structured within the Veterans Health Administration. The SCI/D model3015works through a hub-and-spokes network of 25 regional centers3016(``hubs'') supported by local VA facilities (``spokes''), allowing3017highly specialized, interdisciplinary care to be delivered close to3018where veterans live while maintaining access to expert clinical teams3019and necessary services.3020    These centers provide comprehensive, lifelong care spanning acute3021medical and surgical treatment, intensive rehabilitation, outpatient3022follow-up, home care programs, annual evaluations, and tailored long-3023term support aimed at maximizing independence and quality of life.3024    Care is coordinated across medical, psychosocial, vocational, and3025rehabilitation domains, with dedicated providers trained in the unique3026needs of spinal cord injury and disorder populations. Both primary and3027specialty care services remain integrated throughout the veteran's3028lifespan, with interdisciplinary teams actively managing and3029anticipating evolving needs over time. This structure not only supports3030continuity of care after initial injury but also promotes community3031reintegration, functional maintenance, and sustained caregiver support.3032A similar dedicated program for TBI could help address current3033fragmentation in care pathways, improve long term outcomes, and ensure3034that veterans with brain injury have access to care that is both3035specialized and continuous rather than episodic or plateau-driven3036within traditional silos.30373038Expanding Access to Assisted Living30393040    While many veterans and families prefer aging in place, home-based3041care is not safe or feasible for all individuals due to co-occurring3042behavioral and cognitive challenges, increasing medical complexity,3043aging caregivers, and limited natural support networks. When aging in3044place is no longer appropriate, families are often forced to make care3045decisions in crisis. In the absence of viable alternatives, families3046face an unacceptable binary choice: remain at home beyond what is safe3047or appropriate, or enter traditional geriatric nursing facilities that3048are ill-equipped to meet the clinical, behavioral, rehabilitative, and3049social needs of younger and mid-life veterans with TBI.3050    Wounded Warrior Project's current service to nearly 1,000 severely3051wounded veterans with moderate or severe TBI has shown us that phases3052of progressive independent living are missing as care options.3053Currently, slightly more than 7 percent of our Independence Program3054participants (average age 45.6) reside in nursing homes/institutions,3055highlighting the likelihood of an inappropriate placement due to age-3056generational gap, inability to find an age-suitable facility and/or3057inability of an institutional or non-institutional caregiving network3058to provide for the individuals in a safe or effective manner.3059Traditionally, VA provides clinical services to veterans who suffer the3060effects of TBI; however, many veterans with TBI may benefit from3061treatment in an intensive rehabilitation facility to assist with skills3062allowing for increased independence. Because the facilities are3063generally residential and the VA does not provide veterans with housing3064(with some exceptions), accessibility to such programs is limited or3065requires subsidized payment from other sources to cover the ``housing''3066expense.3067    The Assisted Living for Veterans with TBI (AL-TBI) pilot program,3068which ran from 2009 to 2018, provided some of these veterans with3069placement in private TBI rehabilitation facilities and assumed the3070living costs that may have otherwise put this treatment beyond their3071reach. After the program ended, an evaluation by VA concluded that3072participants had experienced improvements in physical and emotional3073health, TBI symptoms, and other outcomes. In its place, VA now offers a3074TBI-Residential Rehabilitation Program, but enrollees must pay for3075their own room and board, something many veterans cannot afford.3076    Solutions to remove this financial barrier - and to improve the3077associated care coordination that can span several systems - are sorely3078needed. TBI rehabilitation facilities provide a variety of services,3079primarily therapy in individual and group settings. At the same time,3080the facilities vary widely in other offerings and lack standardization3081because individual injuries and the effectiveness of each treatment can3082vary so significantly.\8\ The tools used to measure progress as well as3083the methods by which therapy is provided or defined may also contain3084nuance and disparity between facilities.\9\ These nuances induce3085``difficulties [with] outcome analysis related to the blurring of3086program labels, categories, and definitions'' while limited uniform3087populations make randomized trials and studies nearly impossible.\10\3088Studies indicate that treatment standardization and standard3089measurements of progress would assist in formalized rehabilitation3090programs with improved overall treatment.\11\ Further, anecdotal3091feedback suggests that veterans are most likely to benefit from3092particular facilities that can accommodate the difficulties associated3093with behavioral problems (often rooted in physical injury to the brain)3094in addition to other TBI symptoms. Such facilities are very limited but3095are best positioned to support veterans' needs.3096---------------------------------------------------------------------------3097    \8\ See, e.g., Tina Trudel, et al., Brain Injury Treatment Models3098and Challenges for Civilian, Military and Veteran Populations, 44 J.3099REHAB. RESEARCH & DEV. 1007 (2007) (available at https://3100www.brainline.org/article/brain-injury-treatment-models-and-challenges-3101civilian-military-and-veteran-populations).3102    \9\ Id.3103    \10\ Id.3104    \11\ Id.3105---------------------------------------------------------------------------3106    In sum, the AL-TBI pilot program provided a beneficial service to3107warriors and caregivers during its tenure but has left a gap to be3108filled by families, private and other non-VA care, often putting the3109financial burden on the warrior and/or caregiver. Additional urgency is3110created by the fact that many of these caregivers are aging beyond3111their ability to provide the necessary support at home. These3112challenges continue to highlight the need for durable, well-3113coordinated, and adequately resourced programs capable of supporting3114veterans with lifelong injuries, not only for months or years, but over3115a full lifespan.31163117Increasing Special Monthly Compensation31183119    The Sharri Briley and Eric Edmundson Veterans Benefits Expansion3120Act represents one of the most meaningful opportunities in decades to3121strengthen financial security for the Nation's most severely disabled3122veterans. A key provision of this legislation would increase the amount3123of Special Monthly Compensation (SMC) by $10,000 annually for the most3124severely disabled veterans - those who depend on regular aid and3125attendance of another, including for residuals of TBI. SMC is arguably3126the most important ancillary benefit for veterans with severe, service-3127connected disabilities. SMC-T in particular, which is provided to3128veterans with TBI, can help offset caregiver burden and the increasing3129costs of high-quality care - both of which can keep veterans at home3130and of institutional living.3131    Wounded Warrior Project supports this legislation because it3132reflects the core principle that those who sacrificed the most deserve3133the strongest safety net. Far too many families shoulder around-the-3134clock caregiving responsibilities with inadequate financial support,3135particularly families like the Edmundsons, whose daily lives revolve3136around complex medical needs following devastating combat injuries.31373138Coordinating Action on Blast Overpressure31393140    Military service often exposes Service members to blast3141overpressure, a rapid increase in air pressure generated by explosions3142or blast waves that exceed normal atmospheric conditions. Both high-3143intensity and/or repeated exposures are increasingly associated with3144cumulative neurological effects, including neuroinflammation, cognitive3145decline, elevated risk of traumatic brain injury, and co-occurring3146mental health conditions.\12\ Those at highest risk include armorers,3147artillery and gunnery personnel, combat engineers, explosive ordnance3148disposal specialists, special operations forces, and medical personnel3149assigned to expeditionary units - as well as individuals working with3150shoulder-mounted weapons, .50 caliber systems, and indirect fire3151platforms. While the DoD has taken important steps to reduce blast3152exposure during training through increased standoff distances, limits3153on live-fire events, and protective equipment, these measures largely3154focus on prevention for active-duty personnel, and do not address the3155long-term health consequences for Service members and veterans already3156affected.3157---------------------------------------------------------------------------3158    \12\ See, e.g., Andrea Diociasi et al., Distinct Functional MRI3159Connectivity Patterns and Cortical Volume Variations Associated with3160Repetitive Blast Exposure in Special Operations Forces Members, 3153161Radiology (2025) (available at https://pubmed.ncbi.nlm.nih.gov/316240167438/); Kyle Bourassa et al., Traumatic Brain Injury and3163Accelerated Epigenetic Aging Among Post-9/11 Members, J. HEAD TRAUMA3164REHAB. (2025) (available at https://pubmed.ncbi.nlm.nih.gov/40828005/).3165---------------------------------------------------------------------------3166    The Blast Overpressure Research and Mitigation Task Force Act (H.R.31676444) would strengthen coordination between the DoD and VA through a3168Joint Executive Committee (JEC) task force. By mandating annual3169reports, cross-agency coordination, and integration of mobile,3170longitudinal diagnostics, the bill would create the infrastructure3171needed to translate emerging evidence into standardized screening,3172targeted mitigation strategies, and benefits adjudication for blast-3173exposed veterans. Further, the inclusion of Task Force recommendations3174related to VA claims processing and disability evaluations hold the3175promise of ensuring that veterans affected by blast overpressure3176injuries are connected to the care and support they have earned through3177their service.31783179Increasing Commitment to TBI Research31803181    The congressionally Directed Medical Research Programs (CDMRP)3182represent a proven and accountable model for investing Federal research3183dollars to achieve high-impact outcomes. Through its unique,3184coordinated approach, CDMRP has accelerated advances in patient care,3185driven breakthrough technologies, and delivered tangible results in3186areas of critical need - particularly with diseases and conditions that3187have historically received limited research attention. Congress'3188sustained investment of more than $2.5 billion in the Traumatic Brain3189Injury and Psychological Health Research Program, led by the Military3190Health System\13\, has resulted in the award of over 297 research3191studies for nearly 500,000 Service members diagnosed with traumatic3192brain injury.\14\ These efforts have strengthened DoD's ability to3193prevent, detect, treat, and rehabilitate TBI, while improving3194psychological health outcomes essential to force readiness and long-3195term veteran well-being. Continued congressional support for CDMRP is3196essential to maintain momentum, protect prior investments, and ensure3197that the DoD can meet its obligations to Service members and their3198families through evidence-based solutions to TBI and psychological3199health challenges.3200---------------------------------------------------------------------------3201    \13\ Cong. Directed Res. Prog., Traumatic Brain Injury and3202Psychological Health Research Program, U.S. DEP'T OF DEF. (2025),3203https://cdmrp.health.mil/tbiphrp/pbks/TBIPHRP %20Summary3204%20Sheet_22July25.pdf.3205    \14\ Cong. Directed Res. Prog., Traumatic Brain Injury and3206Psychological Health, U.S. DEP'T OF DEF. (2025), https://3207cdmrp.health.mil/tbiphrp/default.32083209---------------------------------------------------------------------------3210Precision Medicine for TBI Care32113212    Despite increased awareness, substantial gaps remain in3213understanding the long-term effects of repetitive low-level blast3214exposure and chronic mild TBI. Emerging evidence links these exposures3215to measurable brain changes, impairments in balance and gait, and3216increased risk of suicide among veterans. Individuals diagnosed with3217TBI may continue to suffer from lasting effects that overlap with3218mental health conditions, substance use disorders, and chronic physical3219symptoms. These complex and interconnected challenges demand a more3220precise, data-driven approach to care.3221    Precision medicine tailors healthcare treatments and interventions3222to each patient's unique characteristics, including their genetic3223makeup, lifestyle, and environment. Instead of a one-size-fits-all3224model, precision medicine uses advanced diagnostic tools - such as3225genetic testing, biomarker analysis, and imaging techniques - to3226identify the most effective therapies for individuals. In brain health,3227this approach takes a specialized form, focusing on neurological and3228psychiatric conditions. Clinicians analyze a patient's brain structure,3229function, genetic profile, and cognitive patterns to create targeted3230treatment plans for conditions like Alzheimer's disease, Parkinson's3231disease, depression, and TBI. This personalized strategy enhances3232therapeutic outcomes, reduces side effects, and ensures lasting3233benefits. Specifically for veterans, this approach can help identify3234those at higher risk for long-term neurological or psychological3235effects, such as chronic traumatic encephalopathy (CTE), PTSD, and3236cognitive decline. The Precision Brain Health Research Act (S. 800)3237would advance a more systematic and longitudinal approach by directing3238VA to implement a coordinated 10-year research strategy and establish a3239structured data sharing partnership with the DoD. This framework3240utilizes the promise of precision medicine and would improve tracking3241of exposure history, support identification of biomarkers associated3242with brain and mental health conditions, and strengthen VA's ability to3243deliver earlier, more accurate diagnoses.32443245Concluding Remarks32463247    Wounded Warrior Project extends our gratitude to the Committee for3248its sustained focus on TBI research, treatment, and long-term support.3249A TBI is not an isolated event, it is a chronic condition that requires3250lifelong management. journey that requires a coordinated continuum of3251care, strong case management, appropriate residential and community-3252based options, meaningful financial support for families, and continued3253investment in cutting-edge research. From strengthening recovery3254coordination and restoring viable assisted living pathways, to3255advancing Special Monthly Compensation and deepening our understanding3256of blast overpressure and precision brain health, your leadership3257shapes whether veterans with TBI experience fragmented systems or3258integrated, life-sustaining care. We are particularly encouraged by3259congressional efforts to modernize research through precision medicine3260and cross-agency collaboration, ensuring that emerging science3261translates into earlier diagnoses, targeted interventions, and improved3262long-term outcomes.3263    The men and women who have sustained these invisible wounds in3264service to our Nation deserve nothing less than a system built for3265durability, dignity, and lifelong support. We stand ready to work3266alongside you to ensure that policies enacted today create a3267sustainable, evidence-based framework of care that honors their3268sacrifice not only in the immediate aftermath of injury, but across the3269full span of their lives. Thank you for your continued commitment to3270these warriors and the families who remain steadfast beside them.32713272          Document for the Record Submitted by Julia Brownley3273[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]32743275          Prepared Statement of American Academy of Neurology3276[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]32773278            Document for the Record Submitted by Greg Murphy3279[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]32803281                                 [all]