Hidden Wounds: Effectively Supporting Veterans with TBI

...VA's funding to private companies. Not only is this wasteful and duplicative, but it could lead to a further fracturing of continuity of care for veterans. On that note, I ask unanimous consent to enter into the hearing record this article from the American Prospect that expands on many of the concerns I have just raised.

No objection.

As our understanding of TBI's diagnosis and how to treat it evolves, I'm confident that VA's TBI model of care will evolve with it. In fact, I believe that many colleagues on this committee will continue to provide robust oversight and direction to ensure that it does. What VA does need is the resources and support to continue to build on its existing system of care. Legislation like the BEACON Act will only run counter to those efforts. This hearing is an excellent opportunity to hear directly from veterans with TBI about their experiences and where VA's care can improve. I look forward to hearing from the witnesses on panel two about how we can achieve our shared goal of improving TBI care at VA, and I hope we will all keep in mind the investment we need to make in VA's existing care model to achieve that goal. With that, Madam Chair, I yield back.

Thank you, Ranking Member Brownley. I would now like to introduce the first panel. Testifying before us on behalf of the VA, we have Ms. Rachel McArdle, Deputy Executive Director of Rehabilitation and Prosthetic Services at the VA. She's accompanied by Dr. Joel Scholten, Executive Director of Physical Medicine and Rehabilitation Services at the VA. Dr. McArdle, you're now recognized for five minutes to present your testimony.

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

Thank you very much. As is my typical practice, I'll reserve my time until all other members have had a chance to ask their questions. I now recognize Ranking Member Brownley for five minutes for any questions she may have.

Thank you, Madam Chair. And thank you for your testimony this morning. Dr. McArdle, what are some examples of things VA would be able to do with an additional... Pardon me? I want to recognize your member. Oh, go right ahead. It's already done. Oh, okay. I'll start from the top. So, what are some examples of things VA would be able to do with an additional $60 million in funding to advance the care provided to veterans with TBIs?

Thank you for the question, Ranking Member Brownley. It sounds like you may be referring to the pending legislation that VA testified on in January. As to how would VA spend an additional $60 million, we're grateful for the support of this committee. I will take that question back for the record in order to conduct a full and appropriate review of our programs for you.

Would you say that VA needs $60 million additionally to properly serve our veterans?

I appreciate the question. My focus today is to share with you what we are doing in TBI and I will follow up with your office.

Okay. All right. Dr. Scholten, can you expand on VA's integrated approach to treat both TBI and co-occurring conditions including PTSD? How does this affect veterans' outcomes, and I want, and this is the important part of the question, especially compared to individuals who may be navigating care outside of the VA?

Thank you for that question, Ranking Member Brownley. As you point out, TBI and PTSD commonly co-occur in veterans, and so VA research has shown that veterans who participate in evidence-based therapies for PTSD also show improved cognitive functioning, both for in regards to their PTSD and or TBI symptoms. This highlights the importance of our approach of developing an individualized plan of care for every veteran with traumatic brain injury, as each veteran has a unique presentation, therefore their plan of care should be individually developed. Any efforts we can do to better integrate care delivery will likely result in greater impact on symptom reduction and or treatment reduction. I'd also like to point out that it's incredibly important to engage with the veteran family and their caregiver. Integrated care relies on keeping the veteran informed and at the center of the care plan with input and assistance from their caregivers and family. That care is obviously easier to provide when it is provided within the VA healthcare system as we're focused on providing wrap-around services for veterans with traumatic brain injury.

Thank you. And can you describe VA's approach to addressing the differences in TBI symptoms and experiences between men and women veterans?

Thank you for that question. Yes, we have a very large research program as was mentioned earlier. VA allocates over $50 million to research in FY 25 to 175 research programs. A specific example that we've learned from our VA research includes understanding the unique effects that women might experience compared to their male counterparts. One significant difference is the cumulative trauma exposure. We've found that female veterans have a much higher trauma burden disproportionately affected by military sexual trauma and intimate partner violence. Therefore we need to screen for military sexual trauma as well as IPV and better incorporate mental health treatments into the individualized care plan. In addition, the LIMBIC study, which was mentioned earlier in the opening statements, has shown that female veterans with a history of at least one TBI present with worse psychological health outcomes in the areas of PTSD, depression, TBI symptoms, and quality of life, again highlighting the importance of an individualized care plan that addresses the unique needs of that veteran.

Thank you for that, and I yield back.

Thank you, Ranking Member Brownley. The chair now recognizes Representative King-Hinds for five minutes for any questions she may have.

Thank you, Chair, and thank you to you, Dr. McArdle and Dr. Scholten, for being here and hopefully have a conversation about the future of some of these research programs that are underway. I had prepared remarks, but as I was coming here, this very decorated war hero from the Northern Marianas came to mind. He's actually a good friend, he's my neighbor, and he's suffering from TBI. But he's having a challenge connecting the TBI to his service. He served in the Iraq War and he was exposed to a lot of toxins, which he believes has contributed to some of his injuries. The last time I saw him, you know, he was sharing that if you were to describe his pain level one to 10, it's a 12, and you know, the solution that is given to him is just more pain meds, right? So I kind of want, because we're talking about advancing research, I kind of wanted to hear a little bit more from you whether you're considering whether traumatic brain injury linked to toxic exposure should be evaluated for presumptive service connection, and if not, what specific evidentiary threshold is preventing that? Because he's been going through this process and every time he files a claim, it seems like he's run out of options, and I just want to find a way to help him out.

Thank you for that question and thank you for sharing that story. First I would like to point out that I can talk about the clinical presentation of the individual that mentioned that you mentioned. I'm unable to comment on the presumptive ratings as VA has a process that they work through in studying the research evidence to determine those. I will say that veterans, VA screens all post-9/11 veterans for a possible traumatic brain injury. Those individuals with a positive screen are referred to a TBI specialist to complete a thorough clinical history and physical examination to document or come up with a diagnosis. As part of the healthcare system and as part of that evaluation an individual plan of care is developed. But hopefully that individual will also have completed the toxic exposure screening that VA offers for every veteran and repeats every five years. We know that each individual veteran has a unique presentation. Toxic exposures and other traumas that veterans may experience during their military service can affect the trajectory of their clinical recovery as well as their symptom presentation. So helping to devise a comprehensive evaluation and then coming up with a plan that will work for that individual veteran is essential.

Okay, so can I just ask a more directed question? Is there research currently underway examining whether toxic exposures including burn pits can contribute to a worsening brain injury, to a worse brain injury?

I can't, yes, there are certainly a number of research projects that are ongoing about long-term effects of toxic exposures. We can work with our colleagues back at VHA to provide you a complete list.

Okay, that'd be great. And just for my, just for my personal clarity, at what point in the primary care process is a veteran referred to a specific TBI treatment?

That would occur on the veteran's first entrance into VHA for healthcare. The TBI screen would be completed and then that would trigger the evaluation or referral to a TBI specialist.

Okay. And just one last question, how could we better support your efforts to be able to better screen and provide the services that our vets need?

I would say that this hearing is a perfect example, raising awareness of TBI in veterans, also acknowledging that as was mentioned March is TBI Awareness Month. And we would appreciate your assistance in encouraging all veterans to enroll in VHA for healthcare. We know that not all veterans do take advantage of that opportunity but we would encourage you to help us spread that message to choose VA for healthcare.

Thank you for your time. I yield back.

Thank you Representative King-Hinds. The chair now recognizes Dr. Conaway for five minutes for any questions he may have.

Thank you. Thank you Chairman Miller-Meeks and Ranking Member Brownley for gathering us here today to discuss the treatment of traumatic brain injuries. As traumatic brain injuries become more common in the veteran population due to more exposure to service-related risk factors like blast injuries, it is crucial that we discuss how to advance TBI treatment at the VA. The VA has a long history of medical breakthroughs and innovation. VA in fact ranks as a top research institution and for the last 20 years has conducted significant research relating to TBIs. Additionally through its polytrauma system of care, VA can provide integrated care to address TBI as well as co-occurring injuries and conditions including mental health conditions. Dr. McArdle, can you explain how the VA's tiered polytrauma system of care is well suited to address the healthcare needs of veterans with TBI, even in areas that don't have a polytrauma rehabilitation center in the immediate area?

Thank you for the question. VA polytrauma system of care has been in existence for over 20 years and was designed to ensure all veterans who are enrolled in VA healthcare have access to TBI experts. This system of care has over 110 TBI clinical teams across VHA providing individualized care for veterans with TBI. For veterans who are in more rural or highly rural areas, we also utilize virtual care to expand the availability of services through the lifetime of a veteran who is dealing with the chronic symptoms associated with TBI. Our primary focus is on making sure veterans get the care they need, whether that care is direct care or care provided by the community.

Thank you. And can you elaborate on some of the advances, again, large research institution with a huge patient population and big data that can be brought to bear, but you can talk about how the standard of care for diagnosis and treating traumatic brain injuries has resulted from the VA's own research?

I'll let Dr. Scholten who oversees the polytrauma TBI system of care and is a practicing TBI physician provide you more information.

Thank you. Doc.

Thank you for that question and again I would like to recognize the incredible research infrastructure that VA does possess. A number of findings have emerged over the course of the last 20 years of the VA's research portfolio. We've identified a number of areas to improve veteran access for care. One of the things we in research findings and knowing the high prevalence of TBI exposure for veterans returning from the post-9/11 conflicts, VA implemented the TBI screen and evaluation process to make sure that any veteran who served after September 11, 2001 was actually screened for possible TBI and then evaluated by a specialist to ensure that their medical record was documented with a specific diagnosis and that individualized treatment plan. We've leveraged emerging findings showing that we do know veterans with TBI compared to their civilian counterparts have a higher comorbidity of mental health conditions. And so that has led our efforts to beef up our mental health integration within our TBI and polytrauma teams and we're really trying to in that effort normalize or destigmatize the fact that mental healthcare is required for physical rehabilitation. We've also found with the heavy symptom burden particularly for some of our special operators who experience rapid deployments in complex combat operations that they require intensive evaluation and treatment. VA stood up with a combination of those research findings the intensive evaluation and treatment programs at our five polytrauma rehab centers and we've expanded that over the past five years to improve access to those intensive programming for veterans and service members who need it.

Thank you for that. I will have to run to another hearing but I did want to just raise some issues about how certain programs are funded. The Beacon Act which will be discussed by our second panel, unfortunately I might not be here for all of it, one of the grant programs would award eligible grantees $5 million per year to conduct research for TBI veterans. The second grant program would require the VA to enter into an agreement with a further third-party organization to administer a grant program to study and implement treatments of TBI veterans. The program would be funded by diverting existing VA clinical care funds. And we know that the VA's already undertaken clinical trials and research into new TBI treatments. When considered, I'll ask and get to it and that is the diversion of funds within the VA to other programs does concern us. Do you have a concern that these diversions would interfere with the work that the VA is doing? That is, I'd rather see you get the additional funds rather than diverting funds from other VA programs. Any thoughts on that?

We appreciate the question Congressman. We will have to take that for the record.

Thank you. I yield back.

Thank you very much Dr. Conaway. The chair now recognizes Dr. Murphy for five minutes for any questions he may have.

Thank you Madam Chairman. Got a lot to cover real quick. Dr. Scholten, do you, you said you practice, correct?

Yes I do.

What do you do for TBI and PTSD patients who have basically failed your cut and cookie cutter approach to just TBI? What do you do when people come to the end?

Well I personally in my clinical practice, again as was mentioned earlier, do a thorough history and evaluation, come up with a definitive diagnosis and then develop an individualized treatment plan. That plan considers what interventions, first it considers which symptoms are most problematic for the individual veteran based on their functional ability, their ability to work and access the community. And then we discuss what interventions have been tried and what other opportunities...

What, let me just get to the chase. What therapies do you offer these people that basic therapies do not work?

Well the therapies that are most commonly offered are the standard rehabilitation therapies of physical therapy, occupational therapy and speech therapy. It's critical to encourage or to evaluate the impact of mental health conditions and then offer appropriate evidence-based therapies to help with any diagnoses such as PTSD.

All right, so let me just get to the chase. At an end we get to the point where there's not really much that we offer to patients and sadly enough this is the part where suicide, this is the part where tragedy occurs with family and I think this is where personally I think the VA is failing to come out of to come into the 21st century and understand that there are modalities of treatment. Are you by any chance familiar with the work of Dr. Shai Efrati in Israel with HBOT and PTSD? The voluminous work that he has with trauma with PTSD using hyperbaric oxygen.

Yes I've read some of those articles.

And your opinion?

My opinion along with that of VA and Department of the Department of War is the after thorough review of evidence on hyperbaric oxygen therapy, while there are a number of studies that have happened, the guidelines, current clinical guidelines don't find sufficient evidence to offer HBOT for use of TBI.

Are you familiar by any chance with the work of Dr. Joseph Maroon at the University of Pittsburgh who does the same work?

I'm not familiar with his work.

All right, please if you will for professional education please familiarize yourself with his work. I'd like to submit for a record a meta-analysis done in the Frontiers of Neuroscience in October of 2023 talking about the multiple, multiple studies that show hyperbaric oxygen for veterans for PTSD shows an improvement not only in clinical data and clinical wellness but in physiological achievements.

No objection.

You know, the American Academy of Pediatrics in my opinion was negligent in the fact that they created an institution a generation of children now adults who are allergic to peanuts because they refused through their hubris through their arrogance to go back and see data was wrong. They for 20 years did not go back and do this. Same thing with NIH with the fact that we deprived women of getting Premarin and estrogen replacement increasing cardiovascular disease, bone loss and so many of these other things. I believe the VA is being absolutely negligent and still living in 1950s and 1960s and 1970s science in not looking at real data in an era where we are failing our veterans that are in my opinion conducive presenting conducive environments and allowing our veterans in an environment that it creates for suicide because we are stuck back in saying that we're not right now. The VA may have had data back years ago, but look, I want you personally to read this paper. We are being the VA is being negligent in not allowing veterans access to this treatment. In North Carolina, there's an institution called HBOT for Heroes. They've treated over 250 veterans with, in my opinion, my clinical objective opinion, because I have scrubbed this data, because as a surgeon I am a skeptic first. That they have helped a tremendous number of our veterans where nothing else worked. So I'm tired of the cubicle captains at the VA still repeating the same rows over and over and over again of saying this doesn't work when clinical data shows otherwise. You guys have a duty to our veterans to stop this massive suicide rate when we can intervene. That I'll yield back.

Thank you, Dr. Murphy. The chair now recognizes Dr. Morrison for five minutes for any questions she may have.

Thank you, Madam Chair, and thank you, Ranking Member Brownley. And thanks to our witnesses for being here today and for the work that you do on behalf of our veterans living with traumatic brain injury. Dr. Scholten, you understand well that traumatic brain injury rarely exists as a single diagnosis. In practice, what we see are veterans who are navigating a variety of challenges: cognitive symptoms, headaches, sleep disruption, chronic pain, depression, PTSD, and difficulties with memory, concentration, and executive function. A trend we've observed across patients is increasing medical complexity. Veterans understand from their own lived experience that conditions often overlap and reinforce each other and evolve over time. Treating one in isolation can fall short of truly addressing their needs. That's why the model of care is so critical. One of VA's strengths is that it was built to address complex service-oriented conditions across a veteran's lifetime. When we talk about TBI care at VA, we're not just talking about a neurology visit or a rehabilitation consult. We're talking about a system that integrates rehabilitation, medicine, neurology, behavioral health, pain management, and social support. That integrated approach is especially important when we think about the kinds of injuries prevalent in modern military service. Many vets are exposed to blast injuries, repeated concussive events, and operational stressors that non-VA health systems don't have the expertise to anticipate or to understand. Understanding how the various exposures interact with mental health and other service-connected conditions is essential to provide effective care. The VA has built a system specifically designed for that challenge. Through the polytrauma system of care, veterans with complex injuries can access specialized rehabilitation centers, network sites, and support clinics that work together across disciplines. From a clinical standpoint, that kind of coordination is rare and incredibly valuable. Those who have spent time navigating our health system know exactly how difficult it can be for patients to navigate fragmented systems where different specialties are all operating in silos. For veterans with TBI, fragmentation and a lack of military-informed treatment can mean delayed diagnosis, incomplete treatment, or symptoms that fall through the cracks entirely. Another important part of this conversation is identification and long-term management. Over the past two decades, VA has screened large numbers of post-9/11 veterans for traumatic brain injury and continues to treat a significant population of veterans living with TBI-related conditions. Many vets experience symptoms that fluctuate or become more apparent years after the original injury. This makes continuity of care and longitudinal follow-up critically important, and it also highlights why military-informed care is so essential. Providers need to understand the exposures veterans experienced in training and combat, the cultural context of military service, and the ways those factors influence both diagnosis and recovery. So, Dr. Scholten, how important is it that traumatic brain injury care be integrated with treatment for other common co-occurring conditions?

Thank you for the question. It is incredibly important that all of the factors, all the diagnoses, all the trauma and the exposures that that individual veteran brings to the table that may affect their traumatic brain injury. One thing I didn't mention on the earlier question with research findings is that TBI is viewed now as a chronic condition, thanks in a large part to the ongoing research efforts through VA. And so what that means is that a TBI is not just a point in time. Veterans don't just come to a TBI rehabilitation clinic and have a silo of care and then move on and live the rest of their life. Instead, that intensive evaluation and skilled treatment is focused on improving the veteran's symptoms, improving their functional ability and their ability to participate in community activities. And then when that's ended, we help transition veterans toward wellness activities because we know very well that long-term brain health is affected by a number of factors. And so in mitigating the chronic effects of a traumatic brain injury, it's essential to transition into a long-term brain health wellness plan or a brain health prescription, which we have recently developed and deployed through the VA.

Thank you for that answer. Dr. McArdle, in your testimony, you described VA's polytrauma system of care. What advantages does that model provide for veterans with complex injuries compared to more fragmented systems of care?

Thank you for the question. VA's polytrauma system of care, the way it was established to provide the individualized team-based care in the case management that comes with that. So we utilize the wrap-around care, the primary care, the mental health care, other specialties to optimize their entire care in order to optimize the outcomes that also are associated with TBI. The VA is uniquely set up to be able to do all of this in a single system.

Really quickly if you can. Oh, I'm past. Thank you both for your service to our veterans and thank you, Madam Chair. I yield back.

Thank you very much. I now yield myself five minutes for any questions that I might have. Dr. Scholten, how long does a typical TBI screening take?

Thank you for the question, Chairwoman. The TBI screen takes possibly 30 to 60 seconds to complete.

Okay. And is this the TBI screening that is done at the VA, is that similar to what you would do at active duty? And is it similar to what is done in the civilian workplace? As we know, TBI can occur from a variety of occurrences, not just those that are acquired in the military.

Yes, our screen we use in VA is similar to the screen used at the Department of War. It is different compared to the community because our patient population has typically sustained their traumatic event months to years previous. In the community, most TBI care is delivered acutely following a concussion or an accident. So the screen is different.

And since I'm not on HASC, is active duty military Department of War, are they now given the knowledge we have about TBI, which was not the same when I was a nurse on a neurosurgical floor or even when I was Director of Public Health in Iowa. The knowledge base has certainly changed. And so with that, is the Department of War, are they screening for TBIs for those individuals that would be at risk or were in theaters where they would put at risk so that they have a seamless referral into the VA system?

I know Department of War has an entire brain health program, however I can't answer for that agency.

Okay. It gives me another mission to take on here. What does the TBI treatment look like for future veterans, which was the genesis of this question, as the landscape and methods of war constantly changing?

Again, that would depend on the individual veteran, their presenting characteristics and presenting symptoms, as well as their cumulative trauma exposure as well as other exposures. So the key is really taking that individualized history, looking at all the available documentation, coming up with a diagnosis, and then again that individualized treatment plan that's shaped in collaboration both with the veteran and their caregiver.

And what treatment protocol have you found to be the most promising in treating the whole neuropsychological syndrome of TBI?

In my experience and what the scientific literature would support is integrated holistic care that's providing that wrap-around services. So giving team-based care where the team actually has a chance to meet and discuss along with the veteran progress, prioritizing goals. And then the other important piece of that is ensuring that mental health experts are participating in that plan and supporting the veteran.

And if a veteran is remotely located from so the polytrauma centers are all at major I'm going to say academic VA medical centers. So if a veteran is remote, i.e. in Iowa could be two hours away or three hours away or four hours away if they're in Northwest Iowa, would this team approach be done virtually?

Yes, it certainly can. In our polytrauma system of care, we see a little over 50,000 veterans in our TBI-specific clinics every year. 54 percent of those veterans in fiscal year 25 had some type of virtual care offered to them throughout the year.

And to follow up on that, considering TBI to include mTBI that may be more widespread given now screening more widespread than previously understood, does VHA have the capacity to treat our current and future veterans with the highest impact treatment protocol?

Thank you for that question. As we mentioned, VA has over 110 specialized teams in the polytrauma system of care that are expert in assessing, diagnosing, and then treating those veterans. With those care plans that are developed, any care that's not able to be offered to that veteran in a timely manner can be utilized through our community care partners, and then we will take that information, integrate it back into the care plan to ensure a seamless care delivery.

Thank you for acknowledging that. And my time is about to expire, but can you estimate the proportion of the veteran population that likely has TBI but has not been evaluated by the VA for TBI?

I don't have a good answer for that. I can tell you that in the TBI screening and evaluation process, about 20 percent of veterans have a positive screen that then are referred on for a comprehensive evaluation.

Thank you very much. I yield back my time. The chair now recognizes General Bergman for five minutes for any questions he may have.

Thank you, Madam Chair, and my apologies for being late. I was on the floor doing a memorial speech for a leader in my district who passed and who also happened to be my first cousin. And so if I sound a little I don't have an emotional bone in my body, so I've been told, but I do have a lot of passion. So the passion is running hot right now, especially as I was coming up here and finding out that some of my colleagues were attacking the BEACON Act. And so I'm, you know, in God's grace and forgiveness, I won't talk about either a person's inability to comprehend what we're trying to do or a bias to prevent good things from happening. That'll sort itself out in life, and we all know who if you spoke the words, you spoke the words. They're recorded. But I think about 20-plus years ago when we had four polytrauma centers: Palo Alto, Minneapolis, Richmond, Tampa, the original four. And when I was in uniform, I traveled to all of them because some of my Marines were in there for treatment during the time. And when we think about here we are 20-plus years later, still trying having made some advancements, but not nearly enough for the need and what the Veterans Administration is trying to do and what the BEACON Act does to help the Veterans Administration in a very positive way. And anybody who uses the word privatize obviously has either no creative thought, no historical knowledge, or no vision of the future when it comes to treatment for veterans or the population in general because of the factor that if we're going to solve and I don't know if solve is the right word if we're going to diagnose and treat and the future treatments going forward for traumatic brain injury, we need to have all hands on deck. So anybody who uses the word privatize obviously either doesn't care or has an alternative agenda. And as my mother would say, shame on them. Now, enough of that because I was always taught to be positive. So let me ask you a question. I thanks to our doctors for being here. Dr. McArdle, you describe the five polytrauma rehabilitation centers and also a broader network: polytrauma network sites, support clinics, and over 110 TBI teams. What's the real difference in care a veteran gets at a polytrauma rehabilitation center versus those other sites?

Thank you for the question. I'm going to defer it to Dr. Scholten who oversees the polytrauma network.

Okay.

So the difference in the care provision at some of our larger centers is the there are more rehabilitation and TBI related assets, more intensive programming. Most of our intensive inpatient treatment programs are located at those five centers and that allows us to leverage the huge amount of expertise in clinical care, not only for TBI, but also in expertise in other other clinical areas to include neurosurgery, internal medicine, orthopedic surgery, and mental health to provide that intensive and expert level of care. Once if a veteran is not from that area and accesses one of those polytrauma rehab centers, once they transition back to their home area, the system of care is set up to have to remain connected to that veteran so that they can return to their home area, access primary care and other specialty...

So not to put words in your mouth, this is truly developing a network, a broad based network of care. When you think about before the early 1980s, surgery centers didn't exist pretty much. If you wanted any type of surgery, no matter how minor, you had to go to a hospital pretty much because surgery centers that now do everything from lower back surgery to cataract surgery to all of those different things and have brought the care to the community in such a way that the patient result is better, the accumulation of knowledge in the providers is better. It's a success story and anybody who opposes the BEACON Act in this case is seeking to, whether it's intentionally or accidentally, prevent better care for veterans. With that I yield back.

Thank you, General Bergman. The chair now recognizes Representative Cherfilus-McCormick for five minutes for any questions she may have.

Thank you so much, Madam Chairwoman. Thank you so much for being here. This is like one of the main issues we've been having in my VA. We had several suicides and making sure our veterans can actually get the care they need is so important to us. But we also have some concerns also when it comes to making sure the cultural competence that comes to the our soldiers and our veterans are there and they're being provided. So my question for you as we're looking at that, do you have any concerns and how would you address those concerns to make sure that every practitioner can actually be aware and to recognize certain things that are specific to our veterans?

Thank you for that question. Cultural competency when it comes to healthcare delivery is critical. We know that in VA we have we feel we have better veteran awareness or better awareness of military specific issues and our system of care is developed so that it provides these wrap around services that can address those military and veteran specific issues. As you know, suicide is suicide prevention is one of the is our highest clinical priority within VA and our Office of Suicide Prevention as well as our Office of Research and Development has focused their efforts in better understanding suicide risk as well as better understanding interventions to decrease or to promote suicide prevention efforts. So in our integrated system we can we can enhance as well as deliver that enhanced screening and treatment for trying to minimize and minimize the suicide risk for our veterans.

Well, that's also my question when it comes to the screening process. It seems like the screening tools lack reliability and biomarkers. What is the VA doing to improve diagnostic accuracy so veterans aren't misdiagnosed or missed entirely and whereas veterans still are falling through the cracks?

So as we mentioned earlier, VA's Office of Research and Development allocated 50 million in direct research funding for FY 25 research projects for traumatic brain injury. Part of those efforts are aimed at developing better biomarkers not only for traumatic brain injury, but also other co-occurring mental health diagnoses. And so as we work to better understand and better identify biomarkers not only for TBI, but also looking at those associated or affiliated risk factors that can enhance suicide risk, we'll better be able to care for veterans as we take that information and turn it back into our healthcare system.

My next question is that the BEACON Act would establish new grant programs that shift funding to non-VA entities for TBI research and treatment. Why should Congress divert resources outside the VA instead of strengthening the VA's existing research infrastructure and how could outsourcing care impact continuity and suicide prevention efforts? While also taking into context that cultural competence for our community care providers.

Thank you for that question. VA does its best to provide that integrated care. However, there are times when the the expertise doesn't exist in the VA or can't be provided in a timely manner. It's important then that we do where it's time sensitive, where we do work with our community partners to get veterans in the community care network to get that piece of their care provided in the community, but we need to integrate those results back into their treatment plan.

Now, do you believe that there's an advantage to having services done at the VA and that there's a way we can actually harmonize the two? Because the expertise I guess the concern is that the expertise of the VA might be lost when our soldiers go or our veterans go into the community. Do you believe there's a way we can harmonize the two so we're not losing any expertise?

As a 28 year employee of the Department of Veterans Affairs as a healthcare provider, I think we're well positioned to very well positioned to provide that wrap around care and leverage that military and veteran competency to maximize the results.

Now, are there any steps specific steps you'd like to see Congress take to make sure that exists in all situations?

As I mentioned earlier, we appreciate the ability to testify here today on VA's TBI programs. We appreciate the fact that this is helping to spread awareness about TBI and veteran specific injuries, especially since March is TBI awareness month. And we appreciate your help in encouraging veterans to enroll for VA in VHA for care to ensure or to choose VHA for their healthcare.

Thank you, I yield back.

Thank you, Representative Cherfilus-McCormick. On behalf of the subcommittee, I want to thank you all for your testimony and for joining us here today. You're now excused and we'll wait for a moment as the second panel comes to the witness table. Welcome to all of our witnesses and thank you for your participation today testifying on such an important matter. In accordance with committee rule 5E, I ask unanimous consent that Representative Stauber, who is not here yet, from Minnesota be permitted to participate in today's committee subcommittee hearing. Without objection, so ordered. On our second panel, we have Mr. Al Johnson, retired U.S. Army Lieutenant Colonel and a flight surgeon who was present when the Iranians attacked Al-Asad Airbase in retaliation to neutralizing the IRGC terrorist Soleimani. Mr. Buster Miscusi, former U.S. Marine Corps Sergeant and graduate of Operation Mend, and Dr. Rusty Gore, chief medical officer at Avalon Action Alliance. Once again, thank you all for your participation in today's hearing. Mr. Johnson, you are now recognized for five minutes to present your testimony.

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

Thank you, Mr. Johnson. Mr. Miscusi, you are now recognized for five minutes to present your testimony.

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

Thank you very much, Mr. Miscusi. Dr. Gore, you're now recognized for five minutes to present your testimony.

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

Thank you, Dr. Gore, and I thank all of our witnesses for appearing here today. As is my typical practice, I'll reserve my time until all other members have had a chance to ask their questions. I now recognize Ranking Member Brownley for five minutes for any questions she may have.

Thank you, and thank you to all the witnesses for being here and your testimony as well. Mr. Miscusi, in your testimony you say that VA has the capacity and the platform to provide the type of care you received at Operation Mend. What from your point of view is holding VA back? Do you think that diverting $60 million from existing VA programs as the BEACON Act requires helps or hinders VA in implementing intensive outpatient programs like the one you've completed? And I'm grateful that you've had the treatment that you need.

Thank you, Ranking Member Brownley. I can't answer to how the money could be used, but I can answer to whether or not why I think that those resources are available. I'm not engaged with the Veterans Health Administration on the level of understanding how things are organized, but I do engage directly with their practitioners and I receive care from them. And so I know that they care deeply. And that's ultimately what is needed is people who care deeply, and the thing that's missing is organization, I think. If these pieces could be organized together, I think that it could be effective. Operation Mend is a model of how that organization could occur. Where the money goes ultimately, I want it to serve veterans. That's what matters most. Thank you.

Well, and I appreciate that, and I think your point about in the VA they care is one of the primary reasons why veterans, if they have a choice, would prefer to go to the VA other than community care outlets. So I don't have any data to support that on the TBI issue necessarily, but generally that's what veterans tell me every single day is they would prefer to be in the VA and under VA care. So I appreciate that. So you never attempted to try to get care in the VA with regards to your situation?

I did receive care. And I continue to receive care at the VA for the TBI.

Okay. Okay, very good. Dr. Gore, in your testimony, you also claim that the BEACON Act was written to supplement, not supplant, VA's existing clinical care and research. But the bill is pretty clear to me as written that it would divert $60 million from the VA National Center for PTSD and mental health services. So I'm trying to understand how that's not supplanting, but it's supplementing.

Thank you for that question. I see this as an opportunity for building partnerships, building capacity, and for establishing the evidence necessary to shift what we consider to be the standard of care for traumatic brain injury. This is a national problem. The VA and the work that we're doing with veterans is an opportunity to leverage the volume of individuals with traumatic brain injury and the resources available so that we can demonstrate that the standard of care needs to shift. All of the downstream opportunities for folks to receive care and access to care are dependent on establishing a standard of care. And the current standard of care for traumatic brain injury in this country, in particular mild to moderate injury, is to do nothing. And that's scary. Folks in this room, your friends, your loved ones are affected by this every single day. They get no care when they have these injuries and are released from the emergency room. So all of us are doing an amazing job just because we care and we're providing intervention, but we need to establish a standard of care which is going to improve both VA care and care external to the VA.

And what does that look like?

What that looks like for me is that veterans have an option to seek care in a place that they choose. In my experience, veterans are frustrated with the VA care that they receive. They receive multiple referrals from very well-meaning providers, and those referrals are at different locations throughout their community, they're poorly coordinated, it's very difficult to execute on those plans. This intensive program brings all of those resources under one roof and provides care over 100 visits for care over a three to four week period. And it's been shown to work. The VA has actually modeled their IETP program after programs like mine at the Shepherd Center. We started doing this in 2006. So what we've seen is that this seems to work. The problem is the VA is treating fewer than 100 veterans per year in the IETP program. I heard 50,000 veterans a year being treated in the VA for TBI. So just my basic math, 80 percent are mild and 50 percent of those have chronic needs, that's 20,000 a year that should have access to this care, but it's less than 100. Because most of the folks receiving that care are actually active duty service members and mostly special operators. So I see providing access to this life-saving care as my personal priority and I hope that you'll appreciate that.

Thank you, I yield back.

Thank you very much. The chair now recognizes Representative King-Hinds for five minutes for any questions she may have.

I want to start off by saying thank you to Mr. Miscusi and Mr. Johnson for your testimony today. I think when folks talk about traumatic brain injury, they don't really have a full idea of the lived experience. And I want to be able to give you the opportunity to, one, share your thoughts as to if you had just one ask that Congress could do to make your life better as somebody who has TBI, share that thought and give us a day in the life of what it looks like to live with this type of injury. And I'll start with you, Mr. Johnson, and then we can go to Mr. Miscusi after.

Thank you for your question and your comments, Representative King-Hinds. The comments you made earlier about the toxic exposure interests me more than you could imagine because that's our cohort. Personally, my experience in dealing with my traumatic brain injury is I've been working in emergency medicine for in some capacity for 37 years. About 18 of that or 15 of that was as a sole provider in a rural community, which is a lot like tailgate medicine that you find on the battlefield. After my traumatic brain injury, however, I had to bench myself from being the only provider with two nurses in a rural setting because of my difficulties in navigating complex medical disease pathways and things like that. So that's how it's affected me personally. I can't do what I love to do anymore. If I had my one ask to Congress, and believe me, it's taken me six years of dead-end attempts to finally get in front of an audience that can maybe help the folks that were on Al-Asad that day. The toxic exposure has created a unique opportunity along with a traumatic brain injury cohort. So you've got 147, 150 soldiers that were in one place at one time that all experienced the same exposure, blast exposure and toxic environment exposure. You talk about a control for a research program, you can't ask for anything better than that. The care that they need, here's the problem. When you have a 22-year-old now separated soldier from the service because they were medically retired, that goes to their primary or their VA CBOC and says, hey, I think I was exposed, I'm not really sure what I was exposed to, what do I need to do about it? A lot of times it's nothing. These individuals should be getting baseline screening for cancers. They should be getting thyroid ultrasounds, advanced brain imaging as needed, including MR venograms to I've had a couple of patients me personally in the ER that have had traumatic brain injuries, I end up doing an MRV which I know none of my partners would do, and sure enough, venous sinus thromboses, which are causing their symptoms. So I know the research on that is like 4 percent of traumatic brain injuries have that, but it could be higher. We just don't search for it enough, I think. Baseline screening like PSAs, colonoscopies earlier than age 40. Those cancer screening process in addition to the traumatic brain injury and mental health, finding not just the treatment for their symptoms, but the root cause that can change their life to reverse the symptoms of their brain injury, whether it's HBOT as Dr. Murphy has said. We need to expand on that. But this cohort specifically needs to be in a medical surveillance program that encompasses their entire care from traumatic brain injury to toxic exposure. Because I believe as you do that they are connected.

I have 30 seconds and you have the rest of my time. It's okay.

Thank you for the question. I would say if I had an ask for you today, from my evaluation, it seems like the question is what's the barrier? Is it money or is it institution? Are there institutional barriers within the VA that prevents them from making the programmatic changes that are needed to treat veterans and families with TBI? If there is an institutional barrier, well then the BEACON Act solves that. If there is not, well then so I would ask you to evaluate what so the question that the thing that I would ask is how do you get which program gets the care to the veterans fastest as they need it? And then as far as a day in the life, I would say that I have five medical devices that have to shock some different part of my brain or my neck or something like that throughout the day so that I don't have those migraines and those episodes anymore. So I would say that it's ongoing care throughout the day. Thank you.

Thank you for that. I'm out of time. I yield back.

Thank you. The chair now recognizes Representative Cherfilus-McCormick for five minutes for any questions she may have.

Thank you so much, and thank you so much for your testimony. And thank you, Mr. Johnson, for your recommendation because I think that is something that has been missed is looking at the root cause and testing for cancer. So thank you for bringing that. And thank you also, Mr. Miscusi, for your statements because I think we have the same concern. What is the problem? Is it institutional or who can get the services to our veterans faster? And that brings me to Dr. Gore. Thank you for your testimony also. The concern really is if we're shifting money to outside organizations, you mentioned that 100 you said I think you said 100 people are serviced with TBI within the VA. Is that what you said in your testimony earlier?

Yes, ma'am, within the intensive the IETP program that is the equivalent of what our programs are doing.

So the concern is if we shift that money, then less than 100 people will be treated within that program. So the question that I have is, is there any evidence to suggest that shifting those dollars would show that more people would be treated, that more of our veterans will have access? Is there any evidence for that?

I can't speak to the shift in funding and how that may affect your decision-making and shifts and decision-making from a legislative standpoint, but I can comment that absolutely evidence is required for infrastructure to be in place to deliver care and for the finances to be in place to receive care.

Specifically my question is, is there any evidence that these organizations would provide more care and better care to our veterans than if we have kept those funds within the VA? And we already said the number in the VA is 100, so do we have any tangible evidence to show that these outside organizations can do more and can do it better?

We do. We have evidence that the VA has collected that they see strong responses to treatment that is in line with evidence from multiple external organizations, including the NICoE program in the Department of Defense. All of those programs have demonstrated that this treatment is effective. A comparison between the VA and the civilian sector in this regard, I'm not sure how to really answer that because what we're hoping to achieve is the research necessary to establish this as the standard of care. Once that's established as the standard of care, and that's what these resources would go towards as well as other innovative treatments for TBI, I would suggest it's then the VA's responsibility to make a determination as to where to allocate funds so that they're taking care of veterans in the most optimal way. So these funds are not intended to just to treat veterans, these funds are intended for us to establish that this should be the standard of care and to look at more innovative models of treatment.

Well, before we shift those funds, I think we would want to know with a substantial certainty that this would actually benefit our veterans versus shifting, leaving it where they are and actually growing it there. And so if there's any information that you can give to us that can help us come to that certainty, that would be extremely important. My next question is, your program partners with several academic and private institutions to deliver intensive short-care treatment. You mentioned that. Can you walk us through the specific training and credentialing requirements for clinicians delivering TBI care in your program and how those standards compare to the interdisciplinary teams and clinical programs practice guidelines used in the VA?

Within our programs, the credentialing of the physicians and rehabilitation specialist is very similar to the credentialing that would occur through the VA. To your questions which I appreciated of Dr. Scholten earlier, we actually have a robust program that's focused on veteran and military competency across all of our providers. This is the same for also the Wounded Warrior Program treatment programs. A vast majority of the clinicians have a connection to either the VA to military service, whether it's themselves individually because they served or whether it may be a family member or previous experience practicing in the VA. So the credentialing and the training process is very similar and we share a lot of the same talent within our programs as we see within the VA.

Do you have any specific programs for making sure that they have the cultural competency for military service or our veterans? Do you have anything specific that you guys are doing to make sure each and every practitioner is exposed to it?

We do. That programming actually for our network is seated through my own program at the Shepherd Center in Atlanta because we've been doing this for so long. And so we do have a training program that's geared towards cultural competence to make sure that individuals are aware of the unique needs of veterans and service members.

And while I have a few seconds, my last question is, do you believe that if it was mandatory for all outside organizations to have some kind of training, do you think that would be a benefit or do you think it would be a burden?

I think when you're looking at opportunities to provide care external to the VA and there are numerous examples of this, not just in the TBI space but also in the behavioral health space with programs specific for post-traumatic stress, that there's a massive benefit to ensuring that individuals are competent in that area. Whether that should be mandatory is a question maybe that I'll leave up to you. I don't think that that would be a burden. I think that's important.

Thank you. The gentlewoman's time has expired. Thank you very much. The chair now recognizes Dr. Murphy for five minutes for any questions he may have.

Thank you, Madam Chair, and thank you all for coming today. And for those of you guys that are dealing with the aftereffects of serving and sacrificing for my nation, my heart goes out to my prayers with you and I pray that your journey in all this improves with each day. If you're having to have shocks with vagus nerve stimulators, I'm guessing I'm assuming that's what it is. Did you get that at the VA, may I ask?

Yes, sir, I did.

Okay. Expediently, done in a quick manner, good manner? Were you happy with the process?

It took a while to realize that that was the resource that was needed, but then once it was prescribed, I received it in a timely manner.

Okay. And how helpful is that to you? If you don't I'm sorry I'm asking you personal questions.

I don't mind at all. It's the difference between me having an episode every day and being able to sit here and function and maybe it occurs once a week.

These are wonderful technological breakthroughs. We are on the cusp, especially with AI, of being able finally to I think crack the brain. It's the great frontier of the human body. We have a lot of work to do, but I pray that we can really crack the nut on this stuff. So thank you for your service. You know, I still after being on this committee for years and years don't understand the rationale of why we have to play us versus them as far and with the veterans being bounced back between them. Why it is VA versus outside institutions. Why can't we just care about the veteran first? Why is there this provinciality that we have to be so concerned about our own little world rather than what's best? You know, Dr. Gore, I'd love for you to just talk about your experience of whether you, you know, how you deal with these folks, what your protocol is, and how you deal with, you know, folks who come from the VA that may not have gotten the attention that they needed to and at what point do they show up on your door?

Thank you, I appreciate that question. You know, I would start by saying that the Veterans Administration does a fantastic job managing a vast majority of the needs of our veterans. When these individuals come to my program, they've often cycled through a number of different treatment opportunities. And because there's some fracturing in the continuity of care, they are often left seeking care external to the VA. And I think that that's natural. I think if you're suffering and you're not finding the solutions that are addressing your suffering, it's normal and it's human and honestly, you know, as a veteran myself, you know, we're individuals who want to get things done and we're going to find solutions. So folks are hungry to find opportunities and solutions to address their suffering. When they come to us, I hear the full spectrum of stories. I hear about the positive experiences within the VA, I hear about the negative experiences. I hear about the negative and the positive experiences within the rest of the civilian healthcare system. Sure. This issue isn't unique to the VA, this we have a very fractured TBI treatment system within the United States. So but when they come to us, we have an opportunity to really wrap our arms around them and what we hear consistently is I've never had someone sit down and spend this much time with me. I've never been surrounded by a group of specialists all at the same time, all in the same room, all around the same table who are explaining to me the different deficits and how they're affecting my day-to-day life and coming up with a plan. And this is what interdisciplinary care is really all about. And one of the things I'm really proud of is similar to the national statistics, only two-thirds of the veterans who come to us are connected to the VA. After we complete treatment, in their follow-up phase after treatment, 90 percent are connected to the VA. We want them to utilize those resources smartly and we want to get them reconnected. The problem is that this treatment needs to be available and it's not currently within the VA in any meaningful way.

Yeah, you know, I think it's been the hallmark in medicine at least in the last 20 years that interdisciplinary study, interdisciplinary treatments is the way to go. We do it in oncology, we do it in other different fields, it's the best way to deal with all this. And you know, some people think just throwing money at a problem is the way to do it. And all you do is end up turning bureaucracy. You want a system that is efficient, that works, that is gives you expected results, may not be able to deliver perfect outcomes every time, but if you're dealing with that type of efficient system that understands that a blast is a blast and that you have to treat it from different angles and also just blasting out money is not the way you solve problems. This is the best mode of treatment that we can or the best avenue of treatment that we can get for any patient, whether in their in the VA or not. And so I thank you guys for your service. Lieutenant Colonel Johnson, it hurt me to hear that you feel that 50 percent of our folks consciously underreported. That's self-that's putting country before self, that hurts to hear. It's not unexpected because that's what our soldiers, airmen, marines, etc. do, they put their country before self. That's a lot of it just hurts to hear that, but that's a reality. Anyway, thank you all so much for your service. This is such a difficult challenging problem, but I thank you for working so hard.

The gentleman's time has expired. The chair now recognizes General Bergman for five minutes for any questions he may have.

Actually, Madam Chair, while I stepped out to take another meeting, I understand, you know, the committee process goes on. So I'm going to just kind of lay out what the congressional record was recorded as a few minutes ago. This is the quote, Congresswoman Brownley to Mr. Miscusi. Quote, do you think that diverting $60 million from existing VA programs as the BEACON Act requires helps or hinders VA in implementing intensive outpatient programs like the ones you've completed? Question mark, end quote. The BEACON Act does not, unless my team is mistaken, does not require the VA to divert $60 million. Instead, it allows the department to use existing mental health funding and provides appropriators the option to allocate further funding specifically for the bill's purposes. So I just want to make sure that the record stands straight that there's no diverting of $60 million here, okay? So I just wanted to inform my colleague that of the mistake in her assumptions. So having said that, this is not personal, this is about facts. The panel's testimony makes clear that even when a TBI is labeled mild, the consequences for a veteran can be anything but. A significant number of veterans continue to live with persistent symptoms that affect daily function and community reintegration. That reality underscores why we must continue pursuing new treatments and innovative procedures to care for the veterans still living with these injuries. So with that as background, Dr. Gore, could you briefly explain the differences between a VA polytrauma rehabilitation center and the other VA sites with TBI teams or polytrauma clinics?

Yes, thank you for that question. You know, I I can certainly comment on my experience working with patients who have been in these in in the VA clinics, but I don't have personal experience working within the polytrauma center or one of the satellite community centers. My my experience talking with patients about this experience, their experience within the VA, the IETP programs are modeled after what we do. So these are intensive programs with wrap-around services, a therapy team that surrounded individual for an intensive period of time. It's generally anywhere between three and six weeks of intensive treatment. That is only provided at the VA polytrauma centers. The care that's provided in the general community is important screening care, potentially referrals to the polytrauma centers, but generally individuals are given rehabilitation referrals that are to different locations around the community and the coordination of those referrals is very difficult and there's no communication or not a lot of communication between the providers providing that care and that care occurs over an extended period of time. It's more the the traditional model of rehabilitation that we see in this country. The fact...

And I'm going to I know you could talk for a long time on this, but time fleets. So the point is, I would suggest that in any we all use the term stovepipes, we know what a stovepipe is, and you can have two stovepipes sitting next to one another, the Veterans Administration being one, a new the new, you know, polytrauma center, TBI teams, whatever, in another, and if you're not communicating and sharing experiences of lessons learned, neither one of you are doing your job. So as we look at the Veterans Administration to get uncomfortable, in other words, get the hell out of your stovepipe and look at what you're proposing to do and see if you've got second and third order effects of what's working, what's not working, so that we expand on the quality of the care and the quality of the therapy and the quality of then ultimately outcomes when it comes to that. Because one thing as we've talked about in all the committees I'm on, especially Armed Services and Veterans Affairs, is to break down the unnecessary stovepipes that have been allowed to grow over time and are beginning to look like weeds in a garden. And when you've got weeds in a garden, you don't get the beautiful flowers or the vegetables or whatever it is you're growing. So let's knock down the stovepipes and with that I yield back.

Thank you General Bergman, the chair now recognizes... Thank you, General Bergman. The chair now recognizes Representative Stauber for five minutes for any questions he may have.

Thank you, Madam Chair. I want to begin by thanking Chairman Bost and you for allowing me to waive on to today's timely hearing. I also want to thank each of our witnesses for their service to our nation and for sharing their experiences. As the husband of an Iraq War veteran, I personally understand the burden our country puts on our military families. Behind every service member is a family who supports them, and it is our duty as a nation to help during and after service. I want to take a moment to highlight my good friend Al Johnson, who is a constituent of mine in northern Minnesota. Mr. Johnson served with honor and distinction during his time in the Army and the Minnesota National Guard, and I know it is his expert testimony that the Minnesota National Guard is the best in the nation. Mr. Johnson, I want to ask you a quick question before I talk and not answer my 92-year-old father's phone call there. Mr. Johnson, I want to ask you about your experiences following the attack on Al-Asad. You note in your testimony that there is ample evidence that Iran used dirty warheads during this attack, correct?

Thank you for your question, Congressman Stauber. I don't have the credentials to make that official call that it was a dirty warhead, but I can tell you this. People are getting sick after this attack and in addition to, when we were deployed there, we did not receive dosimeters to wear. After we left, they were issued dosimeters. So there was some level of concern that occurred with the amount of radioactivity that was on the base post-attack.

Have Al-Asad veterans been able to easily access things like cancer screenings because of their presence during and after this attack?

They have not. And this is part of the problem where when these people separate, they spread all over the world or all over the United States, they become recluse, you lose contact with them, they're young, they don't know what to ask for because you don't know what you don't know, and that's some of the gaps in not having a medical cohort surveillance program.

So you believe that because we do not have something like a medical surveillance program for Al-Asad veterans, they're...

I think they're under-triaged, correct.

In your testimony, you mentioned the tragic loss of SPC Jason Quatacker, who has become another victim in the veteran suicide epidemic plaguing our nation. How many Al-Asad veterans like SPC Quatacker are slipping through the cracks because we don't have a medical surveillance program in place for the Al-Asad veterans?

I don't know an exact number, but I know of a handful that nobody can get a hold of, and I don't know if they're suicidal, have addiction problems, that's concerning.

Would it be your testimony that these veterans are not getting the care they need at the moment?

That's correct.

Do you believe having a medical surveillance program in place would help make sure those veterans get the support that they need?

Yes, sir.

You also raised an interesting point about accountability regarding SPC Quatacker's death. Did SPC Quatacker have TBI before the Al-Asad attack?

Nothing was indicated in his record to say.

Did SPC Quatacker have PTSD before the Al-Asad attack?

Not that was indicated.

Is SPC Quatacker dead because the terrorist regime in Tehran attacked Al-Asad?

In my opinion and the opinion of experts in TBI, all agree yes.

I just, with the remaining time, Mr. Johnson, I want to give you the opportunity to highlight anything that you think was missed in today's hearing and the floor is yours.

Well, first and foremost, I want to thank you and all of the panel for their commitment to the health and welfare of our veterans. We have made great strides in improving the lives of our warriors and families, we can't leave the families out of this, who deal with the consequences of war at home on a daily basis, but there's always room for improvement. Whether it's improving the equipment that protects us on the battlefield with the gear that we wear, passing legislation that holds terrorist countries accountable for what they do to innocent victims of, like in our case, blast injury, or funding for continued research to discover how to reduce or eliminate symptoms of TBI and PTSD, we rely on you, Congress. You're one of the conduits to solve these challenges. The challenges our service members now that are facing in the Middle East, and this couldn't be more timely. This isn't the last we're going to see about blast injuries and traumatic brain injuries continuing from the battlefield. It's just going to get worse. As we move into a more linear battlefield, these instances of recognizing TBI and appropriate care are going to be more prudent.

Thank you very much, Madam Chair, yield back.

Thank you, Representative Stauber. I now yield myself five minutes to ask any questions I may have. All three of you are military veterans, correct? Sergeant Miscusi, Lieutenant Colonel Johnson, Colonel Gore, Dr. Gore? So let me ask you a question. The VA budget is just under, the VA healthcare budget is just under half a trillion dollars. And when we're talking about the BEACON Act, which is not diverting funds from any entity, it's $60 million for the BEACON Act. Do you know what percentage of the entire healthcare budget that is for the VA? 50 percent? 10 percent? More like one percent of the entire VA healthcare budget. And I've heard a lot, and so I'm a 24-year military veteran, you all don't know me. I'm a doctor, I was a nurse before, left home at 16 to put myself through medical school. So let me ask you, all three of you are veterans. Sergeant Miscusi, when you went to Operation Mend, did you feel that they were culturally incompetent?

No, I did not.

And Lieutenant Colonel Johnson, as a PA, aeromedical flight, when you've received care outside the VA, did you feel that they were culturally incompetent?

No, ma'am.

And Dr. Gore, having been both a veteran and providing services now not at a VA facility, do you feel and do the veterans feel that you're culturally incompetent?

I feel culturally competent, ma'am.

Yeah. And might you as veterans know if you're receiving culturally incompetent care? You might well damn well know if you're receiving culturally incompetent care. What I hear from veterans every single day, and as a veteran, married to a 30-year veteran, the daughter of a veteran, six of eight children having served in our military, veterans want choice. Veterans want care. They're fully capable of determining if they think care is culturally competent or if it's competent or if they have access to that care. So it's not really a question so much as it is that we're talking about getting care to veterans in a timely fashion to which they have access and to which they can determine if it meets their needs and if it allows them to be a functional human being, father, spouse, community member once again. That's why I support the BEACON Act. Because to me what's most important as the chair of this committee is that you receive the care that you need and that we expand services where we think there is unmet and undetected need. Mr. Johnson, and I think you've answered this, how common is routine exposure to low-level blast overpressure from breaching mortars and how is this different from regular infantry and special operations forces?

It's more common than we recognize, the multiple sub-concussive events that happen daily over and over again in our line of work.

Thank you. And Dr. Gore, do you think that we currently are meeting the need that you have perceived through the VA system as it currently exists?

I think we could do much better.

And I think Sergeant Miscusi, you would probably echo that sentiment?

Yes, ma'am.

Yeah. With that I yield my time. I think it's very profound the testimony that we've heard today and the stories told by our guest and they bear witness to several things, especially with an ongoing conflict in the Middle East. They bear witness to the incredible strength and resilience of our American service member, apologize for getting emotional on that, and as well as the achievements of our VA healthcare system, which are incredible achievements, but also to the shortcomings of our system. And it's been an illuminating and an insightful hearing. It's a moment in time when we are treating our veterans from the past two decades of warfare while catching a terrifying glimpse of what our future warfighters could face. And it is imperative that Congress and the VA step up to the challenges of ensuring the health and safety of our future and our current veterans, whether it is an institutional problem or whether it is a funding problem, both those things need to be addressed. Representative Brownley, would you like to make any closing remarks?

Thank you, Madam Chair. You know, all I'm trying to say here is I, you know, certainly recognize and support the role that community partners and nonprofits play in getting needed care to veterans with TBI. In fact, many are already participating in VA's community care network and academic affiliation. What I'm just arguing for is we should be putting more money into the system to improve care, to keep up with the research that is out there to give optimal care to our veterans and not have the VA have to make choices between funding their existing services and supporting entities outside of the VA. And General sitting over there, I'm happy to work with you on this. I have great respect for you. We've served on the committee for a long, long time. We've had bills together. And I would love to sit down and talk with you more about what our concerns are, what your concerns are and see, and I know Ms. Elrath as well, I've spoken with her this morning, and would love to see if we can come to an agreement between between us. Thank you, I yield back.

Thank you, Ranking Member Brownley. Again, just want to state that both as a physician and as a veteran, as a physician who has provided community care, I've always felt that my goal was to give excellent care, the highest quality of care, and in a culturally competent way, even if I wasn't trained by the VA in what some might consider culturally competent care. I appreciate our witnesses who have experienced both systems for letting us know where they think are the tremendous attributes of the VA as well as where the deficiencies are, because it's through them that we'll prepare and extend a system that meets the needs of veterans. I want to thank you for your participation in today's hearings and for the discussions that we've had on this very important topic. The complete written statements of today's witnesses will be entered into the hearing record. I ask unanimous consent that all members have five legislative days to revise and extend their remarks and include extraneous material. Hearing no objection, so ordered. I thank the members and the witnesses for their attendance and their participation today. This hearing is now adjourned.