▶ 0:09:26This is an audio check. Mic check. This is a mic check. 1 2 3 4 5 6 7 8 9 10. Veterans Affairs 360. This is an audio check for captions. Mic check.
▶ 0:50:02Subcommittee on Health will now come to order. Without objection, the chair may declare recess at any time. Before we begin, please uh join me in keeping the service members deployed to the Middle East and in harm's way in our thoughts, as well as the families of the courageous service members who recently gave their lives to keep them in our thoughts and our prayers. Uh, two of those individuals are uh from Iowa and deployed with the 103rd uh sustainment command out of De Moines.
▶ 0:50:30I'd like to welcome all members and witnesses to today's hearing. March is brain injury awareness month. So, this is very timely and it's why I'm also proud to be leading this hearing on how the VA can continue to lead the way in the care for traumatic brain injury or TBI. In a budget briefing last summer, the VA shared that TBI is the top clinical, legislative, and agency priority. I look forward to hearing how the VA has prioritized TBI so far and what we can expect for the rest of the year.
▶ 0:50:59I'm confident that the VA has all the data, legal authority, and funding it needs to effectively treat TBI. Right now, I believe the VA's main objective should be to build on the quality of data and the quality of care for the veteran. Here's what the VA does best. specialized treatment, rehabilitation, and research. After enrollment in VA healthcare, veterans are assigned to a primary care team. These primary care staff are trained on the issues unique to post-deployed veterans, and that includes TBI.
▶ 0:51:30I'm pleased that TBI and other issues unique to veterans are part of the primary care experience at the VA, not a specialty that requires extra steps. VA poly trauma centers are a key resource for veterans with TBI. At these centers, the VA is not just treating but leading in outpatient and inpatient care for veterans with TBI. And in fact, their treatment model will probably become state-of-the-art across the United States.
▶ 0:51:56The centers in Richmond, Tampa, Minneapolis, Palo Alto, and San Antonio are knowledge hubs for other facilities treating poly trauma nationwide. This is important infrastructure to treat veterans diagnosed with complex multi-trauma injuries, including TBI. The VA's research enterprise is also unmatched. One longitudinal research program, LIIB, examines the effects of and treatment for service connected TBI with the focus on the long-term effects of mild TBI.
▶ 0:52:24The limbic goals are one, to learn more about how concussion affects the brain. Two, find out effects of concussion later in life, such as risk for dementia. Three, see if some service members and veterans are more likely to be um affected or have a predelection for. And four, identify the best treatments for concussion.
▶ 0:52:46VA researchers at this center have documented links between chron combat concussions and dementia, Parkinson's disease, chronic pain, opioid use, and suicide risk. They have also developed specialized diagnostic tests using questionnaires, physical exams, brain imaging, fluid biomarkers, and electrphysiology to probe how the brain recovers from injury.
▶ 0:53:08With these systems in place, as a physician, I believe the VA can evaluate veterans with TBI and can uh enact intervention earlier. I've heard many veterans share their positive experiences with the VA. Indeed, a report by the VA Office of Inspector General about TBI treatment at one facility revealed that the facility was provided needed care for veterans with TBI. Unfortunately, I've also heard from veterans that that has not been their experience at the VA.
▶ 0:53:37Here's where I've seen the VA needs improvement. Consistent quality in patient care and data. In January, the VA released a report about a patient who died by suicide after receiving mental health care at a VA facility. Among the reviewed concerns, the VA found that the VA facility did not provide adequate follow-up for the patients TBI.
▶ 0:54:03This veteran was a middle-aged male with a history of mental illness, migraines, chronic pain, and gate disturbances with documented falls. In other words, his was the classic clinical picture of an individual with TBI. Yet somehow, the patient didn't receive follow-up specific to TBI, and his mental health only declined until the end. Fortunately, the facility in question now requires annual training on TBI screening and care consultations.
▶ 0:54:31I wish this had been the case sooner, but at least it's the case now. At another facility, the OIG found that a veteran who had screened positive for TBI and died by suicide failed to receive adequate care at the VA. Among other issues, faculty staff did not submit a consultation for a TBI evaluation following the veterans positive TBI screen even though a consult is This is not acceptable.
▶ 0:54:58These veterans earned TBI care at the VA and their service demands better from all of us. Their service demands consistency in quality care. They deserve to know that the VA has their back. While quality and patient care is the most urgent need, while quality and patient care is the most urgent need, quality and data is also necessary. In the past, annual congressional reports have reflected outdated information and the number of inpatient beds dedicated to TBI.
▶ 0:55:29Reports have also omitted key spending information and the number of veterans with TBI treated annually. Some might say, "Does it matter?" Well, these numbers show the VA's capacity to provide care. These numbers should reveal the needs of the patient population and how a medical center is able to meet those needs. And Congress needs this information to know what resources to allocate to the VA for TBI care. And the VA also needs to get these numbers to determine the resources a hospital should get.
▶ 0:55:59I know the VA has the capability to report this kind of data. Like I said, VA has all the data it needs. It must capture that data consistently and then be able to translate that information into clinical practice. Otherwise, wrong data takes resources away from areas of need. And I look forward to hearing from the VA about how they're going to put this into practice. Under my leadership, veterans health has always been this subcommittee's priority. We must eliminate preventable errors.
▶ 0:56:27As a practitioner and a 24 uh year Army veteran, I know excellence is possible and it's imperative. The one who bears the cost of shortfalls is always always the veteran. This also means positioning the VA to support the veteran of contemporary and future warfare. This is where I see opportunities for the VA.
▶ 0:56:49We may not know the landscape of tomorrow's battlefield, but with the right systems and the right people in place, the VA can navigate and pivot to whatever lies ahead. Finally, while we may not discuss it extensively today, I want to recognize the veterans who use residential rehabilitation for TBI. This population is small, but it is far from invisible. I appreciate efforts by the VA's geriatrics and extended care program to address the needs of these veterans.
▶ 0:57:17And I'll take the opportunity I can to ensure that these veterans get the care they deserve from the VA. Under the leadership of Chairman Bost, President Trump, and Secretary Collins, I'm confident that the VA's role as a premium care provider for veterans with TBI. While the VA is on mission, it is the best in the business for veterans with chronic and sometimes catastrophic injuries, visible and hidden. I now yield to Ranking Member Brownley for any opening remarks she may have.
▶ 0:57:45Thank you, Madam Chair, and uh thank you for your uh words with regards to our six service members who who who died proudly serving our country. I appreciate it very very much. Traumatic brain injuries are one of the most common service related injuries facing veterans today. Even mild TBIs can lead to lifelong complications and challenges for veterans who have sustained them.
▶ 0:58:12As our understanding of TBIs and their risk and our ability to diagnose them, we must ensure that VA is equipped to treat and care for veterans with TBIs at all points of their recovery journey. I'm looking forward to hearing more from our VA witnesses about the current approach to care and a treatment as well as future developments the VA is working towards.
▶ 0:58:36TBI is not an illness that goes away with medicine, nor is it an injury that heals with bandages. It is a long-term chronic condition for which many veterans need ongoing integrated and well-coordinated care to manage symptoms and make strides towards recovery. That is why as the largest integrated health care system in the United States, VA is well suited to provide the level of care that veterans with TBI need.
▶ 0:59:06Through its polytrauma system of care, veterans receive specialized interdisciplinary customized care for any and all injuries and conditions related to their service, including TBI and any co-occurring conditions. With its tiered hub and spoke model, the system is designed to provide care to veterans wherever they are and whatever level of care is appropriate for them.
▶ 0:59:33I expect we will hear from some witnesses today that legislation like the Beacon Act is necessary to fill gaps in VA's care. I do not disagree that veterans may need support from several different avenues to support their recovery journeys and I don't discount the role that nonprofits and academic affiliates play in facilitating and supporting that care.
▶ 0:59:57However, I need to draw the line at legislation that will take money from existing VA programs and redirect it to outside organizations and providers to do essentially the very same thing VA is already doing, but with fewer guard rails and fewer requirements to ensure quality of care. The Beacon Act contains several concerning provisions.
▶ 1:00:20First, the bill would divert funding from both VA general mental health care programs and the National Center for PTSD to establish grant programs for outside entities. This funding is in intended for both the provision of mental health care and to advance the study and treatment of PTSD.
▶ 1:00:42Although many veterans with TBI also suffer from associated mental health conditions or PTSD, it is simply not appropriate to fund outside ent entities to provide care using these sources. It's very difficult to understand this funding structure as anything other than a a drain on the resources that VA can use to provide direct care to veterans who need it.
▶ 1:01:06One of the grant programs even requires VA to contract with a third-party entity modeled after its own National Center for PTSD to administer the grants. If we are serious about expanding TBI treatment funding and research for veterans, why are we asking a third-party entity to copy what VA is already doing instead of giving VA the resources it needs to do this itself?
▶ 1:01:34Second, eligible entities are expected to use the funding under these grant programs to conduct clinical trials related to TBI. However, the bill does not establish sufficient uses of funds or require sufficient scientific rigor to ensure the outcomes of the clinical trials are usable. Further, not only all of the eligible entities are equipped or have the necessary experience to conduct robust clinical trials.
▶ 1:02:04VA's existing research infrastructure is better suited to conduct these trials and already does. And there's nothing stopping academic institutions and community providers who wish to treat veterans from working with VA through its academic affiliate network or the community care program.
▶ 1:02:25Taken together, these concerning provisions of the Beacon Act represent an effort to diminish VA's direct direct care program and research enterprise and create no strings attached handouts of VA's funding to to private companies. Not only is this wasteful and dup duplicative, but it could lead to a further fracturing of continuity of care for veterans.
▶ 1:02:50On 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.
▶ 1:03:02No objection.
▶ 1:03:05As 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 pro 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.
▶ 1:03:31Legislation 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.
▶ 1:03:46I look forward to hearing from the witness on panel 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. Uh thank you uh ranking member Brownley. I would now like to introduce the first uh panel testifying before us on behalf of the VA.
▶ 1:04:12We have um Miss Rachel Mardle, deputy executive director of rehabilitation and prosthetic services at the VA. She's accompanied by Dr. Joel uh Skolton, executive director of physical medicine and rehabilitation services at the VA. Dr. McCardle, 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.
▶ 1:04:43I am joined today by Dr. Joel Scolton, 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, de acceleration, or blast exposure, and its effects vary widely from headaches and dizziness to memory problems, mood changes, and physical impairments.
▶ 1:05:12TBI 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 MOI repeated exposure to jets, artillery fire or breaching operations.
▶ 1:05:38While these exposures may 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 MOI, 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.
▶ 1:06:03At the center of the effort is the Poly Trauma 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 911 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.
▶ 1:06:34Every 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 teleaalth 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.
▶ 1:07:00Research and innovation remains 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.
▶ 1:07:29It 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 in 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.
▶ 1:08:00And many veterans with mild or repeated TBIs continue to exper 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.
▶ 1:08:18Looking ahead, VA will continue to enhance blast exposure documentation, expand brain health approaches, strengthen teleaalth and intensive outpatient rehabilitation programs, and deepen relationships with 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.
▶ 1:08:42In 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 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. Uh thank you, Madam Chair.
▶ 1:09:12Uh and thank you uh for your testimony this morning. Uh Dr. Mardle, what are some examples um I of things VA would be able to do with an unart pardon me.
▶ 1:09:24I want to recognize your member.
▶ 1:09:27Oh, go right ahead.
▶ 1:09:30It's already done.
▶ 1:09:31Oh, okay. I'll start from the top. So, um, 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?
▶ 1:09:45Thank you for the question, Rank 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.
▶ 1:10:07Would you um say that uh VA needs $60 million additionally to properly serve our veterans?
▶ 1:10:21I 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.
▶ 1:10:28Okay. All right. uh, Dr. Schultton, can you expand on VA's, uh, integrated approach to treat both TBI and co-occurring conditions, including PD PTSD? How does this affect veterans outcomes? And I want, and this is the important part of the question, especially compared to indivi individuals who may be navigating care outside of the VA.
▶ 1:10:55Thank you for that question, uh, ranking member Brownley. Um, as you point out, TBI and TBI and PTSD commonly co-occur in veterans. And so, um, VA research has shown that veterans who participate in evidence-based therapies for PTSD also show improved cognitive functioning, uh, both for, uh, in regards to their PTSD and/or TBI symptoms.
▶ 1:11:19This 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 uh developed. Any efforts we can do to better integrate care delivery will likely um result in greater impact on symptom reduction and or and treatment reduction.
▶ 1:11:44I'd also like to point out that it's incred incredibly important to engage with a veteran family and their caregiver. Um, integrated care relies on keeping the veteran informed and at the center of the care plan with input and assistance from their caregivers and families. That care is obviously easier to provide when it is integr when it is provided within the VA health care system as we're focused on providing wraparound services for veterans with traumatic brain
▶ 1:12:13Thank you. and can you describe VA's approach to addressing the differences in TBI symptoms and experiences between men and women veterans?
▶ 1:12:24Thank you for that question. Yes. Um we have uh a a very large research program. As was mentioned earlier, VA um allocates over $50 million uh to research in FY25 to research programs. Um, a specific example that we've learned from our VA research includes understanding uh the unique effects that women might experience compared to ma their male counterparts.
▶ 1:12:54One significant difference is the cumulative trauma exposure. We've found that female veterans have a much higher um trauma burden uh 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.
▶ 1:13:19In addition, the limbic study, which was mentioned earlier in the um 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 a of an individualized care plan that um addresses the unique needs of that Thank you for that and I yield back.
▶ 1:13:48Thank you, Minky Member Brownley. The chair now recognizes Representative King Hines for five minutes for any questions she may have.
▶ 1:13:56Uh thank you, Chair, and thank you to uh you Dr. Mardo and Dr. children for being here and um hopefully have a conversation about the future of um some of these research programs uh that are on the way. I had prepared remarks, but as I was coming here um this very decorated war hero from the Northern Marianas came to mind. He's actually a good friend. He's my neighbor.
▶ 1:14:23uh and he's suffering from from TBI, but he's having a challenge connecting the TBI to his service. Uh he served in in the Iraq war and he was exposed to a lot of toxins which he believes uh has contributed to some of his injuries.
▶ 1:14:43Um the last time I saw him, you know, he was sharing that uh if you were to describe his pain level 1 to 10, it's it's a 12 and um you know the solution uh that is given to him is just more pain meds, right?
▶ 1:15:03So, I kind of wanted because we we're talking about advancing research, um I kind of wanted to hear a little bit more from you, uh whether um you're considering whether traumatic uh brain injury linked to toxic exposure should be evaluated for presumptive service connection and if not, what specific evidentiary threshold is preventing that?
▶ 1:15:30because he's been going through this process and 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
▶ 1:15:44Thank you for that question and thank you for sharing that uh story. Uh first I would like to um uh 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 a process that um they work through in studying the research evidence to determine those. Um I will will say that uh veterans VA screens all vet post 911 veterans for possible traumatic brain injury.
▶ 1:16:14Those individuals with a positive screen are referred to a TBI specialist to to complete a thorough uh clinical history and physical examination to document or come up with a diagnosis. As part of the health care system and as part of that evaluation, an individual plan of care is is developed.
▶ 1:16:35But 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 Toxic exposures and other traumas that uh veterans may experience during their military service can affect the trajectory of their um of their clinical recovery as well as their symptom So helping to
▶ 1:17:05devise a comprehensive evaluation and then coming up with a 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 uh can contribute to a worsening brain injury to a worse brain injury? Um, I can't. Uh, yes, there are certainly uh a number of research projects that are ongoing about long-term effects of toxic exposures.
▶ 1:17:35We can uh work with our colleagues back at VHA to to provide you a complete list.
▶ 1:17:41Okay, that'd be great. And and just for I just for my personal clarity, at what point in the primary care process is a is a veteran referred to a specific TBI that would occur um on the veteran's first entrance into VHA for health care. The TBI screen would be completed and then that would trigger the evaluation or referral to a TBI specialist.
▶ 1:18:07Okay. And just one last question, how could we better support your efforts to be able to better screen and provide uh the services that our vets need?
▶ 1:18:19I would say that this hearing is a perfect example raising awareness of TBI and veterans. Um, also acknowledging that as was mentioned, March is TBI awareness month and we would encou we would appreciate your assistance in encouraging all veterans to enroll in VHA for healthcare. We know that that not all veterans do take advantage of that uh opportunity, but we would encourage you to help us spread that message to choose VA for healthcare.
▶ 1:18:45Thank you for your time. I yield back.
▶ 1:18:48Thank you, Representative King Hines. The chair now recognizes Dr. Conway for five minutes for any questions you may Uh thank you. Thank you um 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.
▶ 1:19:19VAA in fact ranks as a top research institution and for the last 20 years has conducted significant research relating to TBIs. Additionally, through its poly trauma system of care, VA can provide integrated care to address TBI as well as co-occurring injuries and conditions including mental health conditions. Dr.
▶ 1:19:37Ricardo, can you explain how the VA's tiered poly trauma system of care is well suited to address the health care needs of veterans with TBI, even in areas that don't have a poly trauma rehabilitation center in the immediate area? Thank you for the question. VA Poly Trauma system of care has been in existence for over 20 years and was designed to ensure all veterans for who are enrolled in VA healthcare have access to TBI experts.
▶ 1:20:04This 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.
▶ 1:20:27our primary focus is on making sure veterans get the care they need whether that care is direct care or care provided by the community.
▶ 1:20:35Uh thank you and um can you elaborate uh on some of the advances again a large research institution with a huge patient population and big data that can be brought to bear but you can talk about um how the standard of care for diagnosis and treating traumatic brain uh injuries has resulted from the VA's own research. I'll let Dr. Scolton who oversees the Polytrauma TBI system of care and is a practicing TBI physician provide you more information.
▶ 1:21:03Thank you.
▶ 1:21:05Uh thank you for that question. Um and again I would like to recognize the incredible uh research infrastructure that VA does possess. Um a number of findings have emerged over uh the course of the last 20 years of the VA's research portfolio. We've um identified a number of areas to improve veteran access for care.
▶ 1:21:26Uh, one of the things, um, we wi in research findings and knowing the the high prevalence of TBI exposure for veterans returning from the post 911 conflicts, VA implemented the TBI screen and evaluation process to make sure that any veteran who served after uh, September 11th, 2001 was actually screened for possible TBI and then in order to and then uh, evaluated by a specialist to ensure that their medical
▶ 1:21:57record was documented with a specific diagnosis and that individualized treatment plan. We've leveraged emerging findings showing that uh we we do know veterans with TBI compared to their their civilian counterparts have a higher comorbidity of mental health conditions. And so that has led our efforts to um beef up our um mental health integration within our TBI and poly trauma teams.
▶ 1:22:25And we're really trying to in that effort normalize or the fact that mental health care is required for physical rehabilitation. Uh we've also uh found with the heavy symptom burden particular particularly for some of our um special operators who experience rapid deployments in uh complex combat operations that they require intensive evaluation and treatment.
▶ 1:22:53VA stood up uh with a combination of th those research findings the intensive evaluation and treatment programs at our five polytrauma rehab centers. We've expanded that over the past five years to ensure or to improve access to those u that intensive programming for veterans and service members who need it. Thank you for that.
▶ 1:23:13I I will have to run to uh another hearing, but I did want to just raise um uh some issues about how uh certain programs are funded. The Beacon Act uh 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.
▶ 1:23:36The second grant program would require the VA to enter into an agreement with a further thirdparty organization to administer a grant program to study and implement treatments of TBI veterans. Uh the program would be funded by advert diverting existence existing VA clinical care funds. Um and we know um that VA's already undertaken clinical trials and research into new TBI treatments.
▶ 1:24:00when considered uh I I'll ask uh and get to it and that is uh the diversion of funds within the VA to other programs does does concern us. Do you have a concern uh that these diversions uh would interfere with um the work that the VA is doing? That is I'd rather see you get the additional funds rather than diverting funds from other VI programs. Any thoughts on that?
▶ 1:24:25We appreciate the question, Congressman.
▶ 1:24:28We will have to take that for the Uh, thank you very much, uh, Dr. Conway. Um, the chair now recognizes Dr. Murphy for five minutes for any questions you may have.
▶ 1:24:39Thank you, Madam Chairman. Got a lot to cover. Real quick, Dr. Schultton, do you you said you practice, correct?
▶ 1:24:45Yes, I do.
▶ 1:24:46What do you do for TBI um, and PS 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 uh come up with a definitive diagnosis and then develop an individualized treatment plan.
▶ 1:25:11That 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. Um and then we discuss what interventions have been tried and what uh other uh opport what what therapies do you offer these people that basic therapies do not work?
▶ 1:25:38Uh well the the therapies that are most commonly offered are the standard uh rehabilitation therapies of physical therapy, occupational therapy and speech therapy. It's critical to en encourage or to evaluate the impact of med mental health conditions and then offer appropriate evidence-based therapies to help with uh any u uh any diagnoses such as PTSD.
▶ 1:26:04All right, so let 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 is failing uh to come out of to come into the 21st century and understand that there are modalities of treatment. Are you are you by any chance familiar with the uh work of Dr.
▶ 1:26:29Shia in Israel with HBOT and PTSD the voluminous work that he has with trauma with PTSD using hyperbaric Uh yes, I've read some of those articles
▶ 1:26:43and your your opinion
▶ 1:26:45um my opinion along with that of VA and department of department of war is the after thorough review of um 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 we can we are
▶ 1:27:06you familiar by any chance with the work of Dr. Joseph Marone at the University of Pittsburgh who does the same work.
▶ 1:27:12I'm not familiar with this.
▶ 1:27:13All right. Please, if you will, for professional education, please familiarize yourself with his work. I'd like to submit for a record um a uh metaanalysis done in the frontiers of neuroscience in October of 2023 talking about the multiple multiple studies that show hyperbaric oxygen um for veterans for PTSD shows an improvement not only in uh clinical data and clinical wellness but in physiological achievements.
▶ 1:27:44No 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 were 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 primmerin um and estrogen replacement, increasing cardiovascular disease, bone loss, and so many of these other things.
▶ 1:28:14I 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 that are in my opinion uh presenting conducive environments and and uh allowing our veterans in an environment that they that creates for suicide because we are stuck back in saying
▶ 1:28:44that 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 to this treatment. In North Carolina, there's an institution called HBOT for Heroes.
▶ 1:29:06They'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 over and over and over again saying this doesn't work when clinical data shows otherwise.
▶ 1:29:34You guys have a duty to our veterans to stop this massive suicide rate when we can intervene. That I'll yield back.
▶ 1:29:44Thank you, Dr. Murphy. The chair now recognizes Dr. Morrison for five minutes for any questions you may have.
▶ 1:29:49Thank 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. Scolton, you understand well that traumatic brain injury rarely exists as a single diagnosis. In practice, we see 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.
▶ 1:30:17A 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 serviceoriented conditions across a veteran's lifetime.
▶ 1:30:42When 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. We think about the kinds of injuries prevalent in modern military service. Many vets are exposed to blast injuries, repeated concussive events, and operational stressors. The nonVA health systems don't have the expertise to anticipate or to understand.
▶ 1:31:13Understanding how the various exposures interact with mental health and other serviceoriented service connected conditions is essential to providing effective care. The VA has built a system specifically designed for that challenge. Through the Polytrauma system of care, veterans with complex injuries can access specialized rehabilitation centers, network sites, and support clinics that work together across disciplines. From a clinical standpoint, that kind of coordination is rare and incredibly valuable.
▶ 1:31:41Those 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 militaryinformed treatment can mean delayed diagnosis, incomplete treatment, or symptoms that fall through the cracks entirely. Another important important part of this conversation is identification and long-term management.
▶ 1:32:06Over the past two decades, VA has screened large numbers of post 911 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 followup critically important and and it also highlights why militaryinformed care is so essential.
▶ 1:32:32Providers 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, Drs. Golden, how important is it that traumatic brain injury care be integrated with treatment for other common co-occurring Thank you for the question.
▶ 1:32:54Um, it is incredibly important that all of the factors uh all the diagnoses, all the trauma and the exposures that that individual veteran brings to the table that that may affect their traumatic brain injury. Um, one thing I didn't mention on the earlier question with research findings is that uh, TBI is viewed now as a chronic condition. Thanks in in a large part to the ongoing research efforts through VA.
▶ 1:33:21And so what that means is that a TBI is not just a a 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.
▶ 1:33:36instead that that intensive evaluation and um skilled treatment is focused on improving the veteran's symptoms um improving their functional ability and their comm their ability to um communicate or participate in community activities. And then when that's ended, we help transition veterans toward wellness activities uh because we know very well that long-term brain health is affected by a number of factors.
▶ 1:34:04And so in mitigating the chronic effects of a traumatic brain injury, it's it's in it's it's essential to transition into a long-term brain health wellness plan or a brain health prescription which we have uh recently developed and deployed through the VA.
▶ 1:34:20Thank you for that answer. Um Dr. Mardo, in your testimony, you describe VA's polytrauma system of care. What advantages does that model provide for veterans with complex injuries compared to more fragmented systems of care?
▶ 1:34:35Thank you for the question. VA's polytrauma system of care, the way it was established to provide the team-based care and the case management that comes with that. So we utilize the wraparound 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 uh in a single system.
▶ 1:35:06Thank you. Really quickly, if you can Oh, I'm passing.
▶ 1:35:09Your time is
▶ 1:35:10Thank you both for your service to our veterans and thank you, Madam Chair. I yield back.
▶ 1:35:15Thank you very much. I now yield myself five minutes for any questions that I might have. Um, Dr. Scolton, how long does a typical TBI screening take? Uh, thank you for the question, uh, Chairwoman. Um, the TBI screen takes 30 to 60 seconds to complete.
▶ 1:35:37Okay. And is this the TBI screening that is done at the VA, is that similar to what you would do active duty? uh and is it similar to what is done in the civilian workplace as we know TBI can occur from a variety of in occurrences not just those that are uh acquired in the military.
▶ 1:35:58Uh yes our screen we use in in VA is similar to the screen used at the department of war. It is different compared to the community because um our patient population has typically sustained their traumatic event months to years previous. In the community, most TBI care is delivered acutely, you know, following a concussion or an accident. So, the the screen is different.
▶ 1:36:22And since I'm not on Hask is 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, um or even when I was director of public health in Iowa, the knowledge base has certainly changed.
▶ 1:36:40And so with that is the uh 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.
▶ 1:36:54I know Department of War has an entire brain health program. However, I can't answer for that agency.
▶ 1:37:01Okay. It gives me another mission to take on here. Um what does the TBI treatment look like for future veterans? uh which was the genesis of this question. As the landscape and methods of war constantly changing,
▶ 1:37:14um again that would depend on the individual veteran, their um presenting characteristics and presenting symptoms as well as their um ex cumulative trauma exposure as well as other exposures.
▶ 1:37:28Uh so the the key is really taking that individualized history um looking at all the available documentation coming up with a diagnosis and then again that individualized treatment plan that's that's shaped in uh collaboration both with the veteran and their
▶ 1:37:47and what pre treatment protocol have you found to be the most promising in treating the whole neurosychological syndrome of TBI? Um in my experience and what the scientific literature would support is integrated holistic care that's providing that wraparound services.
▶ 1:38:06So giving team- based care where the team actually has a chance to meet and discuss along with the veteran progress uh prioritizing goals and then uh the other important piece of that is uh ensuring that mental health uh uh experts are participating in that plan and uh supporting the veteran
▶ 1:38:27and if a veteran is remotely located from so the the poly trauma centers are all at major uh I would I'm going to academic uh VA medical centers. So if the if a veteran is remote, i.e. in Iowa, it could be two hours away or three hours away or four hours away if they're in northwest Iowa. Uh would this team approach be done virtually?
▶ 1:38:49Yes, it certainly can. Um in our poly trauma system of care, we've we see a little over 50,000 veterans in our TBI specific clinics every year. uh 54% of those veterans in fiscal year 25 had some type of virtual care offered to them throughout their throughout the
▶ 1:39:08And to follow up on that, considering TVI to include MTVI, it may be more widespread given now screening uh more widespread than previously understood. Does VHA have the capacity to treat our current and future veterans uh with the highest uh impact treatment protocol? Uh thank you for that question.
▶ 1:39:30As we mentioned, VA has over 110 specialized teams in the poly trauma system of care that are expert in assessing and assessing, diagnosing, and then treating those veterans. Um we um with those care plans that are developed, any care that's not be 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
▶ 1:40:01Uh, thank you for acknowledging that. And, uh, I'm 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?
▶ 1:40:14I don't have a good answer for that. I can tell you that in the TBI screening and evaluation process about 20% of veterans have a positive screen that then are referred on for a comprehensive
▶ 1:40:26Thank you very much. I yield back my time. Uh the chair now recognizes General Bergman uh for five minutes for any questions you may have.
▶ 1:40:35Thank you, Madam Chair. And uh uh my my apologies for for being late. I was on the floor doing a a memorial speech for a leader in my district who passed and who also happened to be my first cousin. And um 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.
▶ 1:40:59So the the passion is running hot right now, especially as I was coming up here finding out that some of my colleagues were attacking the Beacon Act. And uh so I'm, you know, in in in God's grace and 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.
▶ 1:41:29They're recorded. But I think about 20 plus years ago when we had four uh poly trauma centers, PaloAlto, Minneapolis, Richmond, Tampa, the original four. And uh when I was in uniform, I traveled to all of them because some of my Marines were in there for treatment during the time.
▶ 1:41:50And 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 uh in a very positive way.
▶ 1:42:12And 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 a is 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
▶ 1:42:42hands on deck. So, anybody who uses the 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. Okay. I thanks to uh our doctors for being here. Um Dr.
▶ 1:43:09Mardle, you describe the five poly trauma rehabilitation centers and also a broader network poly poly trauma network sites, support clinics and over 110 TBI teams. What's the real difference in care a veteran gets at a poly trauma rehabilitation center versus those other
▶ 1:43:33Thank you for the question. I'm going to defer it to Dr. Schultton who oversees the poly trauma network. Okay.
▶ 1:43:39So, the difference in the the care provision at some of our larger centers is the there there are more rehabilitation and TBI related assets. Um more intensive programming. Um most of our intensive uh inpatient treatment programs are located at those five centers and that allows us to um leverage the the um huge amount of expertise in clinical care.
▶ 1:44:07um not only for TBI but also in uh expertise in other uh um other clinical areas to include neurosurgery, internal medicine, orthopedic surgery um and mental health to provide uh that that uh intensive and expert level of care.
▶ 1:44:28Uh once if a veteran is not from that area and accesses one of those poly trauma rehab centers once they transition back to their home area, the the system of care is set up to have um to remain connected to that veteran so that they can uh return to their home area, access primary care and other special.
▶ 1:44:49So 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.
▶ 1:45:03If 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.
▶ 1:45:28It'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.
▶ 1:45:42Thank you, uh, General Bergman. The chair now recognizes Representative Sherless McCormack for five minutes for any questions she may have. Thank you so much, Madam Chairwoman. Um, thank you so much for being here. This is like one of the main issues we've been having. In my um, VA, we had several suicides and um, making sure our veterans can actually get the care they need is so important to us.
▶ 1:46:05But we also have some concerns also when it comes to making sure the cultural competency that comes to the um, 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?
▶ 1:46:30Thank you for that question. Um cultural competency when it comes to healthc care delivery is critical. Um we know that in VA we have um uh we we feel we have better veteran awareness or better awareness of military specific issues and our system of care is developed so that uh it provides these wraparound services that can address those military and veteran specific issues.
▶ 1:46:58Um as um 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 uh focused their efforts in better understanding suicide risk as well as better understanding interventions to decrease um or to promote suicide prevention efforts.
▶ 1:47:27So in our integrated system, we can um we can enhance as well as deliver that enhanced screening and treatment for um trying to minimize and uh minimize the the suicide risk for our
▶ 1:47:41Well, that's also my question. When it comes to the screening process, um it seems like the screening tool is the lack reliability and biomakers. What is the VA doing to improve diagnostic accuracy? So veterans are aren't misdiagnosed or missed entirely. and whereas veterans still are falling through the cracks.
▶ 1:48:00So, as we mentioned earlier, VA's Office of Research and Development uh allocated 50 million in direct research funding for FY25 research projects for traumatic brain injury. U part of those efforts are aimed at developing better biomarkers not only for uh traumatic brain injury but also other co-occurring mental health diagnoses.
▶ 1:48:21And 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 we'll better be able to care for veterans. Um as we uh as we take that information and turn it back into our health care system.
▶ 1:48:44Um, my next question is that the Beacon Act would establish new grant programs that shift funding to nonVA 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 while also taking into context that um cultural competency for our community care providers?
▶ 1:49:14Thank you for that question. Um VA does its uh 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 timesensitive where we do work with our community partners to get veterans uh in the community care network to get that that piece of their care uh uh provided in the community.
▶ 1:49:41but we need um to integrate those results back into their treatment plan.
▶ 1:49:46Now, 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 the concern is that the expertise of the VA might be lost when our soldiers go, our veterans go into the community. Do you believe there's a way we can harmonize the two so we're not losing any expertise?
▶ 1:50:06As a 28-year employee of the Department of Veterans Affairs, as a health care uh provider, I think we're well positioned to pro um very well positioned to provide that wraparound care and leverage that military and veteran competency to maximize the results.
▶ 1:50:22Now, are there any steps, specific steps you would like to see Congress take to make sure that exists in all situations? Um, as I mentioned earlier, uh, we appreciate the ability to testify here today on VA's TBI programs. U, we, um, appreciate the the fact that this is helping to spread awareness about TBI and veteran specific injuries.
▶ 1:50:44Uh, especially since March is TBI awareness month and we appreciate your help in encouraging veterans to enroll for VA in VHA for care uh, to enu or to choose VHA for their healthcare. Thank you. I yield
▶ 1:50:59Thank you, Representative Sheriff Mormack. 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.
▶ 1:52:10Welcome 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 Stabber, who is not here yet, uh from Minnesota be permitted to participate in today's uh committee subcommittee hearing without objection. So ordered. On our second panel, we have Mr.
▶ 1:52:34Al Johnson, retired US Army Lieutenant Colonel and a flight surgeon who was present when the Iranians attacked Al-Assad Air Base in retaliation to neutralizing the IRGC terrorist Solomaini. Mr. Buster Mccusei, former US Marine Corps sergeant and graduate of Operation Mind, and Dr. Rusty Gore, chief medical officer at Avalon Action Alliance. Once again, thank you all for your participation in the today's hearing. Mr.
▶ 1:53:01Johnson, you are now recognized for five minutes to present your testimony.
▶ 1:53:07Thank you, Chairwoman Miller Meeks, indis distinguished members of the Thank you for inviting me to testify today. My name is Al Johnson. I'm a retired lieutenant colonel uh 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.
▶ 1:53:28Uh I speak both as a military medical provider and as a patient that suffered TBI uh someone whose life was permanently changed by a traumatic brain injury. In fact, on January 8th, 2020, while deployed to Al-Assad Air Base in Iraq, I was injured in one of the largest ballistic missile attacks on US forces in the history of of war. Uh Iran fired 15 medium-range ballistic missiles at our base, each weighing roughly 1,500 pounds.
▶ 1:53:55I was sheltered in an indirect fire shelter which was not adequate for uh ballistic missiles. It was more designed for rockets and mortars. I have no memory of the first three impacts because I was knocked out uh at impact number three. I came to uh just as uh impacts number four, five and six uh were hitting the base. Um all of these were in very close proximity to my position with number six being 60 feet away from my position.
▶ 1:54:23Uh that massive percussion uh wave knocked me unconscious for the second time that day. Uh the missiles struck occupied operational areas resulting in damage to critical infrastructure and barracks. Uh environmental testing after the attack detected radioactive isotopes, heavy metals, and toxic chemicals at the site.
▶ 1:54:43Uh as a result result of the missile attack, I've been diagnosed with a TBI, PTSD, cranial nerve damage causing double vision, uh insomnia, tenidis, neck pain, everything that you can imagine that would come with a blast injury. Uh I struggle emotionally with hypervigilance, depression, a sense of distance from the people I love and my friends. Uh I'm also in a thyroid surveillance program due to multiple thyroid nodules that have developed since the attack.
▶ 1:55:12Um after the attack and despite our own injuries, uh myself and my two medics immediately began treating other service members. Many who now live with injuries similar or worse than mine. Uh one soldier, specifically Specialist Jason Quitqua, suffered a uh TBI that resulted in headaches, insomnia, PTSD, and severe depression. Sadly, he died by suicide on October 7th, 2021.
▶ 1:55:38Uh the injuries he sustained during the attack ultimately cost him his life. Uh another was chief warrant officer Thomas Codill. Uh I diagnosed his TBI using the MACE 2 screening tool available to us on the on the base uh and arranged for his medical evacuation. He was subsequently evacuated, had uh a CT of the brain performed which was unremarkable and returned to duty literally the same day back into theater.
▶ 1:56:07Um, many soldiers passed the largely self-reporting screening and remained in mission essential roles due to conscientious under reporting. Uh, they immediately began to assist in cleanup. Many other service members now experienced chronic medical and med and mental health conditions including thyroid disease.
▶ 1:56:27Uh, I've co-auth co-authored uh two different peer-reviewed studies uh on the service members who were Uh, one showed that out of 583 exposed personnel, over 80% reported blast exposure and nearly half were still symptomatic a month later. Another identified 20% more TBI diagnosis a month after the attack than what were initially thought.
▶ 1:56:54Uh, people passed early screening because these tools often missed or delayed cumulative blast injuries. Um, another soldier, Patrick Ben, was uh assisting in cleanup, ultimately diagnosed with uh thyroid thyroid toxicosis and underwent thyroidctomy after being exposed to the toxic chemicals. Uh, I'm aware of multiple similar other cases in that cohort of of soldiers that were on on the base that uh during that attack.
▶ 1:57:23While improvements have been made uh since al-Assad, 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 uh to address those concerns accordingly. Um early identification is not only a medical issue, it's a compensation and access to care issue.
▶ 1:57:46Service members injured in terrorist attacks depend on documentation uh to qualify for VA care and benefits as uh 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. Uh 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.
▶ 1:58:18Thank you, Mr. Johnson. Mr. Makuzi, um you are now recognized for five minutes to pro 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.
▶ 1:58:37They 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 Before my injury, I could tolerate chaos, process information quickly, and stay oriented to my environment and to the people around me.
▶ 1:59:04These 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.
▶ 1:59:34At 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 over pressure 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.
▶ 2:00:04We 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.
▶ 2:00:33It 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.
▶ 2:01:04The 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.
▶ 2:01:32But 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.
▶ 2:01:58Previously, 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.
▶ 2:02:18I still live with migraines, stroke-like episodes, ringing ears, cognitive overload, and emotional 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.
▶ 2:02:42Many veterans and families are struggling to find the resources to develop the skills to learn to work as a 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.
▶ 2:03:07What 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
▶ 2:03:30Thank you very much, Mr. Ms. Kusie, Dr. Gore, you're now recognized for five minutes to present your testimony.
▶ 2:03:37Chairwoman 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 co-occurring disorders we've discussed today. These are complicated, persistent.
▶ 2:04:08These result in life impairments that are associated um 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.
▶ 2:04:35These 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.
▶ 2:05:02Veterans 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. Mardle 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.
▶ 2:05:29Many veteran many injuries go unreported and this number does not account for injuries due to repetitive exposure to blasts. US milit 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% may experience chronic symptoms.
▶ 2:05:58The VA has made meaning has made meaningful progress addressing veteran TBI with some of the current initiatives also outlined by Dr. Schultton and Dr. McCardle earlier. I'm privileged to serve on the vet the federal advisory committee overseeing VA neurot trauma. So I've experienced firsthand the compassion and tireless effort of VA clinicians managing this epidemic of TBI. Enhanced screening efforts in the poly trauma system of care have certainly helped many veterans. Despite this progress, the VA cares for only twothirds of veterans.
▶ 2:06:26And among veterans completing suicide, fewer than 40% were seen in the VA the the 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.
▶ 2:06:50Veterans with persistent symptoms need an integrated pathway, comprehensive evaluation, individualized rehabilitation, and reliable follow-up. I see firsthand at the Shepard 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 neuro rehabilitation. This includes the VA's five poly trauma centers, the Avalon Action Alliance, and the Warrior Care Network.
▶ 2:07:18These 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 lifesaving care. Care that helps them return to family roles, school and work, care that restores function, care that restores dignity.
▶ 2:07:43The 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. Um the VE the Beacon Act will help us to identify what works, scale it, and make it available to more veterans.
▶ 2:08:03This 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. Approve approval of the Beacon Act to establish the efficacy of the intensive neuro rehabilitation treatment model. Expand partnerships to increase VA capacity. Scale access to this treatment through reimbursement from government and private payers.
▶ 2:08:32established this treatment as the standard of care for any American suffering from chronic mild TBI. Members of this committee 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.
▶ 2:08:59Thank 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
▶ 2:09:12Thank you and thank you to all the witnesses for being here and your testimony as well. Um, Mr. Msuzi, in your testimony, you say that VA has the capacity uh and the platform to provide the type of care you received at uh Operation Mend. What from your point of view is holding VA back?
▶ 2:09:31Do you think that diverting 6 $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 I'm grateful that you've had the treatment that you need.
▶ 2:09:50Thank you, Ranking Me Ranking Member Brownley. I um I I can't answer to how how the money could be used, but I can answer to uh whether or not how why I think that those resources are available. Um I'm I'm not engaged with the veteran with the veterans health administration on the level of understanding how things are organized, but 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.
▶ 2:10:19And the thing that's missing is organization, I think. Um, if these if these pieces could be organized together, I think that it could be effective. Uh, Operation Mend is a model of how that organization could occur. Where the money goes ultimately, I I want it to serve veterans. That's what matters most. Thank you.
▶ 2:10:36Well, and I appreciate that. And I think your point about um in the VA they care um is one of the primary reasons why veterans, if they have a choice, would prefer to go to the VA other than uh community care. uh outlets. So, um you know, I 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.
▶ 2:11:07Um so, um I appreciate that. And so, you've you never attempted to try to get care in the VA with regards to your situation? I I did receive care and I continue to receive care at the VA for for the TBI.
▶ 2:11:24Okay. Okay. Very good. Um Dr. Gore, in your testimony, um you also uh well, you you claim that the Beacon Act, it was written to supplement, not supplant, uh VA's existing clinical care and research. But the bill is pretty clear to me as written that it would divert $60 million um from the VA National Center for PE for PTSD and mental health services.
▶ 2:11:51So I'm trying to understand how that's not um uh supplanting or but it's supplementing.
▶ 2:12:01Thank you for that question. Um, I see this as an opportunity for building partnerships, building capacity, and for establishing the evidence necessary to shift what it what we consider to be the standard of care for traumatic brain injury. This is a national problem. The VA is the VA and the work that we're doing with veterans is an opportunity um 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.
▶ 2:12:32Um, 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 and that's scary. Folks in this room, um, 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.
▶ 2:12:56So 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.
▶ 2:13:09And what does that look like?
▶ 2:13:11Um what that looks like for me is that veterans have an option to to seek care in a place that they that they that they choose. Um 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. Um they're poorly coordinated. Um it's very difficult to execute on those plans.
▶ 2:13:36Um this intensive program brings all of those resources under one roof and provides care over 100 visits for care over a 3 to four week period. And it's been shown to work. The VA is has actually modeled their IETP program after programs like mine at the Shepard Center. We started doing this in 20 2006. So, um, what we've seen is that this seems to work. The problem is the VA is treating fewer than a 100 veterans per year in the IEP program.
▶ 2:14:05I heard 50,000 veterans a year are being treated in the VA for TBI. So, just my basic math, 80% are mild and 50% of those have chronic needs. That's 20,000 a year that should have access to this care. Um, but it's it's less than a hundred because most of the folks receiving that care are um actually active duty service members and mostly special operators. So, I I I see providing access to this life-saving care as as as my personal priority and I hope that uh that you'll appreciate
▶ 2:14:34Thank you. I yield back.
▶ 2:14:36Thank you very much. The chair now recognizes Representative King Hines for five minutes for any questions you may Um, I want to start off by saying thank you to Mr. Mscoozie and Mr. Johnson for your testimony today. Um, I think when when folks talk about traumatic brain injury, uh, they don't really have a full idea of the lived experience.
▶ 2:15:00And 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 share share that thought and um you know give us a day in the life of 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. for Msusi after.
▶ 2:15:31Thank you for your question and your comments. Uh, Representative King Hines, uh, the comments you made earlier about the toxic exposure um, interests me more than you can imagine because that's our cohort. Personally, my experience uh, in dealing with my traumatic brain injury is I've been working in emergency medicine for, you know, in some capacity for 37 years.
▶ 2:15:59about 18 of that or 15 of that was as a sole provider in a rural community which is a lot like tailgate medicine that you find on the battlefield. After my traumatic brain injury however I had to bench myself from being the only provider with two nurses in a rural setting because of my difficulties in complex n you know navigating complex medical uh disease pathways and things like that. Um, so that's how it's affected me personally.
▶ 2:16:29Um, I can't do what I love to do anymore. Uh, if I had my one ask to Congress, and believe me, it's taken me six years of dead-end uh, attempts to finally get in front of an audience that can maybe help the folks that were on Al-Assad that day.
▶ 2:16:48Um the toxic exposure has has um created an a unique opportunity along with a traumatic brain injury uh cohort. So you've got 147 150 soldiers that are where were in one place at one time that all experienced the same exposure, blast exposure and toxic environment exposure.
▶ 2:17:17You talk about a control for a research program, you can't ask for anything better than that. The care that they need. Um, here's the problem. When you have a 22-year-old now separated, uh, soldier from the service because they were medically retired that goes to their primary or or their VA seabbach and and says, "Hey, I would I think I was exposed. I'm not really sure what I was exposed to.
▶ 2:17:47Uh what do I need to do about it? A lot of times it's nothing. Um these individuals should be getting baseline screening for cancers. They should be getting thyroid ultrasounds. Uh advanced brain imaging as needed, including uh MRNOGS to uh 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 one none of my partners would do.
▶ 2:18:14And sure enough, venus sinus thrombosis which are causing their symptoms. So I know the research on that is like 4% of traumatic brain injuries have that but it could be higher. We just don't search for it enough I don't think. U baseline screening like PSAs, colonoscopies earlier than age 40.
▶ 2:18:33those cancer screening uh um process in addition to the traumatic brain injury and mental health finding the finding not just the treatment for their symptoms but the root cause uh that can change their life to reverse the symptoms of their brain injure whether it's HBOT as Dr.
▶ 2:18:55Murphy said, um, we need to expand on that, but this cohort specifically needs to be in a medical surveillance program that encompasses their entire care, uh, from traumatic brain injury to toxic exposure because I believe, as you do, that they are connected.
▶ 2:19:14I have 30 seconds and you have the rest of my time. It's okay.
▶ 2:19:19Thank you for the question. Um, I would say if I had an ask for you today, uh, from my evaluation, it seems like the question is, um, 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 uh, veterans and families with with TBI? If there is an institutional barrier, well, then the Beacon Act solves that.
▶ 2:19:46If there's not well then so I would 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. Um and then as far as a day in the life I would say that I have uh five medical devices that have to shock some different part of my brain or my neck or something like that uh throughout the day so that I don't have those migraines and those episodes anymore.
▶ 2:20:14So, I would say that it's a ongoing care um through throughout the day. Thanks.
▶ 2:20:19Thank you for that. I'm out of time. I yield back.
▶ 2:20:22Thank you. The chair now recognizes Representative Sherful McCormack for five minutes for any questions you may
▶ 2:20:28Thank you so much. And thank you so much for your testimony. Um 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. Mitusi, 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.
▶ 2:20:51Also, the concern really is if we're shifting money to um outside organizations, you mentioned that 100, you said I think you said 100 people or service with TBI within the VA. Is that what you said in your testimony earlier?
▶ 2:21:06Yes, ma'am. within the intensive um the IETP program that is the the equivalent of what our programs are doing.
▶ 2:21:14So 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 um show that more people would be treated that more of our veterans will have access. Is there any evidence for that?
▶ 2:21:34I I can't speak to the shift in funding and how that may affect um affect your decision- making and shifts and and decision-m uh from a legislative standpoint, but I can uh comment that um absolutely evidence is required for um infrastructure to be in place to deliver care and for the finances to be in place to receive care.
▶ 2:21:58Specifically, 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?
▶ 2:22:18We we do. Um, 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 NIKO program in the Department of Defense. Um, all of those programs have demonstrated that this uh treatment is effective. um a comparison between the VA and the civilian sector.
▶ 2:22:42Um in this regard, I I'm not sure how really to to 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, um, and that's what these resources would go towards, as well as other innovative treatments for TBI, I would suggest it's then the TBI, the the vet, the the VA's responsibility to make a determination as to where to allocate funds um, so that they're they're taking care of veterans in the most optimal way.
▶ 2:23:12So, 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 um, and to look at more innovative models of treatment. Well, before we shift those funds, I think we would want to know like with a substantial certainty that this would actually benefit our veterans versus, you know, shifting leaving it where they are and actually growing it there. 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.
▶ 2:23:39My next question is, um, your partner, your program partners with several academic and private institutions to deliver intensive short care treatment. You mentioned that. Can you can you walk us through the specific training and credentiing 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
▶ 2:24:04Um within our programs the credentiing uh of the physicians and rehabilitation specialists is very similar to the credentiing that would occur through the VA. Um to to your questions which I appreciated of Dr. Sculton earlier. Um we actually have a robust program that's focused on um on veteran and military competency across all of our all of our providers. Um this is the same for also the wounded warrior program treatment programs.
▶ 2:24:31Um a vast majority of the clinicians have a connection to either the VA to military service whether it's theirelves individually because they served or whether it may be a family member or previous experience practicing in the VA. So the credentiing and the training process is very similar and we share a lot of the same talent um within our programs as we see within the VA.
▶ 2:24:54Do you have any specific programs for u making sure that they have the cultural competency for military service or um our veterans? Do you have anything specific that you guys are doing to make sure each and every practitioner is exposed to it? Um we do um that that programming actually for our network is seated through um my my own program at the Shepard Center in Atlanta because we've been doing this for so long.
▶ 2:25:16And so we do have a a training program that's geared towards cultural competency to make sure um 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 um outside organizations to have some kind of training, do you think that would be a benefit or do you think it would be a
▶ 2:25:38I I I think when you're looking at uh opportunities to provide care external to the VA, and there are numerous examples of this, not just in the TBI space, but also in um the the behavioral health space with programs specific for post-traumatic stress. um that there's a a massive benefit to ensuring that individuals are competent in that area. You know, whether that should be mandatory is a question maybe that I'll leave up to you. I don't think that that would be a burden. I think that's
▶ 2:26:05Thank you.
▶ 2:26:05Gentleoman's time has expired. Thank you very much. The chair now recognizes Dr. Murphy for five minutes for any questions you may have.
▶ 2:26:12Thank you, Madam Chair, and thank you all for coming today. And for those of you guys that are um dealing with the after effects of serving and sacrificing for my nation, my heart goes out to my prayers with you and I pray that uh your journey in all this improves with each day. Um if you're having to have shocks and with Vegas nerves stimulators, I'm guessing I'm assuming that's what it is. Um did you get that at the VA? May I
▶ 2:26:37Yes, sir. I did.
▶ 2:26:38Okay. Um 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 was received it in a timely manner.
▶ 2:26:49Okay. And how helpful is that to you? If you don't I'm sorry asking you personal
▶ 2:26:53I don't mind at all. Uh it's the difference between uh me having a an episode every day and being able to sit here and function and maybe it occurs once a week.
▶ 2:27:01These 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 of the human body. Um we have a lot a lot of work to do. Um, but I pray that we can really crack the nut on this on this stuff. So, um, thank you uh for your service. You know, I I 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.
▶ 2:27:30Why it's why it is VA versus outside um institutions. Why can we just not care about the veteran first? Is there this provinciality that we have to be so concerned about um our own little world rather than what's best? You know, Dr. Gore, I'd love for you to just talk about your experience and whether you u you how you deal with these folks, what your protocol is, and how you deal with uh you know, folks who come from the VA that may not have gotten the attention that they needed to and what at what point do they show up on your door?
▶ 2:28:02Thank you. I appreciate that question. Um, you know, I would I would start by saying that the Veterans Administration does a fant fantastic job managing 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. Um, and because there's some fracturing in the continuity of care, um, they are often left seeking care external to the VA. Um, and I think that that's natural.
▶ 2:28:30I I think if if you're suffering and you're not um finding the solutions that that are addressing your suffering, it's it's normal and it's human. And honestly, you know, as a veteran myself, you know, we're 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. Um when they come to us, um I hear I hear the the full spectrum of stories. I hear about the positive experiences within the V. I hear about the negative experiences.
▶ 2:28:59I hear about the negative and the positive experiences within the rest of the civilian health care system. Sure. Um this issue isn't unique to the VA. This we have a very fractured TBI um treatment um system within the United States. So, but when they come to us, we have an opportunity to really wrap our our arms around them. And what we hear consistently is, I've never had someone sit down and spend this much time with me.
▶ 2:29:23I'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 and 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 twothirds of the veterans who come to us are connected to the VA.
▶ 2:29:48after we complete treatment in their follow-up phase after treatment 90% are connected to the VA. We want them to utilize those resources smartly and we want to get them reconnected. The problem is that that this treatment needs to be available and it's not currently within the VA in any meaningful way.
▶ 2:30:05Yeah. You you know I think it's been the hallmark of excuse me in medicine at least in the last 20 years that interdisciplinary study u interdis interdisciplinary treatments is the way to go. We do it in oncology. We do it in other different fields. It's the best way um to deal with all this. And you know, some people think just throwing money at a problem is the way to do it. Um and all you do is end up turning bureaucracy.
▶ 2:30:27You want a system that is efficient, that works, that is uh gives you expected results, may not be able to deliver, you know, 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.
▶ 2:30:50This is the best mode of treatment that we can or the best uh the best avenue of treatment that we can get for any patient whether in their in their VA or not. And so um I thank you guys for your service. It Lieutenant Colonel Johnson it it hurt me to hear that you feel that 50% of our uh folks consciously under reportported. Um that's self uh that's putting country before self. That that hurts to hear. Um it's not unexpected because that's what our our soldiers, airmen, marines, etc. do. they put their country before self.
▶ 2:31:21Um that's a lot of uh it just hurts to hear that but uh that's a reality. So anyway, thank you all so much for your service. This is such a difficult challenging problem, but thank you for working so hard.
▶ 2:31:31The gentleman's time's expired. The chair now recognizes General Bergman for five minutes for any questions you may
▶ 2:31:41Thanks, Madam Chair. Uh well, I stepped out um take another meeting. I I understand you know the the committee process goes on. Um so I'm going to just kind of lay out what the congressional record was recorded as a few minutes. This is the quote Congresswoman Brownley to Mr. Mscus.
▶ 2:32:00Quote, "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 End quote. The Beacon Act does not, unless my team is mistaken, does not require the VA to divert $60 million.
▶ 2:32:26Instead, 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, uh I just wanted to inform my colleague that uh of the mistake in in her um assumptions.
▶ 2:32:57So, 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 s symptoms that affect daily function and community reintegration.
▶ 2:33:24That 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.
▶ 2:33:37Gore, could you briefly explain the differences between a VA poly trauma rehabilitation center and the other VA sites with TBI teams or poly trauma Yes, thank you for that question.
▶ 2:33:55Um, you know, I 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 poly trauma center or one of the satellite um community centers. um my my experience talking with patients about this experience um their experience within the the VA. The IETP programs are modeled after what we do.
▶ 2:34:22So these are intensive programs with wraparound services, a therapy team that surround an individual for an intensive period of time. It's generally anywhere between three and six weeks of of intensive treatment. That is only provided at the VA poly trauma centers.
▶ 2:34:39Um the care that's provided in the general community is important screening care, potentially referrals to the poly trauma centers, but generally individuals are given um rehabilitation referrals that are to different locations around the community. Um 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.
▶ 2:35:06It's more the more the traditional model of rehabilitation that we see in this country. Um the fact
▶ 2:35:11and I'm gonna I know you could talk for a long time on this. The time fleet. So the point is I would suggest that in any um we all use the term stove pipes. We know what a stove pipe is and you can have two stove pipes sitting next to one another. The Veterans Administration being one, a new a new, you know, poly trauma 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.
▶ 2:35:39So, as we look at the Veterans Administration to get uncomfortable, in other words, get the hell out of your stove pipe 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.
▶ 2:36:09when 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 stove pipes that have been allowed to grow over time and are beginning to look like weeds in a garden. And when you 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 stove pipes. With that, I yield back.
▶ 2:36:39Thank you, General Bergman. The chair now recognizes Representative Stabber for five minutes for any questions he may have.
▶ 2:36:44Thank you, Madam Chair. I want I want to begin by thanking Chairman Bost and you uh for allowing me to wave on to today's timely hearing. I also want to thank each of our witnesses for their service uh 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.
▶ 2:37:12I 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 take uh I want to ask you a quick question uh before I talk not answer my 92-year-old father's phone call there. Uh Mr.
▶ 2:37:40Johnson, I want to ask you about your experiences following the attack on al-Assad. Uh you note in your testimony that there is ample evidence that Iran used dirty warheads during this attack. Correct.
▶ 2:37:52Thank you for your question. Uh, Congressman Stabber, um, I don't have the credentials to make that official call that it was a a dirty warhead, but I can tell you this. Um, people are getting sick after this attack. And in addition to when we were deployed there, we did not receive domters to wear. After we left, they were issued domters.
▶ 2:38:15So there was some level of concern that occurred um with the amount of radioactivity that was on the base post uh attack.
▶ 2:38:25Have a al-Assad veterans been able to easily access things like cancer screenings because of their presence during and after this attack?
▶ 2:38:32They have not. And and this is part of the problem where when these people separate, they spread all over the world or out of all over the United States. They become recluse. Uh 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 in not having a medical cohort surveillance program.
▶ 2:38:53So you you believe that uh because we do not have something like a medical surveillance program for al-Assad veterans, uh they're
▶ 2:38:59I think they're under they're under triaged. Correct.
▶ 2:39:02In your testimony, you mentioned the tragic loss of SPC Jason Quaka, who uh has become another victim in the veteran suicide epidemic plaguing our nation. How many al-Assad veterans like SBC Quetica are slipping through the cracks because we don't have a medical surveillance program in place for the al-Assad veterans?
▶ 2:39:21I don't know an exact number, but I I know of a handful that nobody can get a hold of, and I don't know if they're suicidal, have addiction problems. Um, that's concerning.
▶ 2:39:33Would it be your testimony that these veterans are not getting the care they need at the moment?
▶ 2:39:37That's correct. Do you believe having a medical surveillance program in place would help make sure those veterans get the support that they need?
▶ 2:39:44Yes, sir.
▶ 2:39:45You also raised an interesting point about accountability regarding SPC Quetica's death. Did SPC Quetica have TBI before the Al-Assad attack?
▶ 2:39:54Nothing was indicated in his record to
▶ 2:39:56Did SPC quit have PTSD before the Al-Assad attack?
▶ 2:40:00Not that was indicated.
▶ 2:40:01Is SPC Quaka dead because the terrorist regime in Thran attacked Al-Assad? in my opinion and the opinion of experts at NTBI all agree. Yes.
▶ 2:40:12I I just uh with the remaining time um 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.
▶ 2:40:23Well, uh first and foremost, um I want to thank you and all of the panel for their commitment uh to the health and welfare of uh of our veterans. Um, we've made great strides uh in improving the lives of of our warriors um and families. We can't leave the families out of this um who deal with the the consequences of war at home on a daily basis, but there's always room for improvement.
▶ 2:40:48uh whether it's improving the equipment that protects us on the battlefield uh with uh with the gear that we wear uh passing legislation that holds terrorist countries accountable for what they do to uh innocent uh victims of of uh like in our case blast uh blast injury uh or funding for continued research to discover how to reduce or eliminate symptoms of TBI and PTSD.
▶ 2:41:13Uh we we rely on you uh Congress uh you were one of the conduits to solve these challenges. Um the challenges of our service members now that are facing in the Middle East and this couldn't be more timely um this isn't the last we're going to see about uh blast injuries and traumatic brain injuries continuing from the battlefield. It's just going to get worse um as we move into a more linear battlefield.
▶ 2:41:40uh these instances of recognizing TBI and appropriate care are going to be more prudent.
▶ 2:41:46Thank you very much, Madam Chair. I yield back.
▶ 2:41:49Thank you, Representative uh Stabber. I now yield myself five minutes to ask any questions I may have. Um all three of you are military veterans, correct? Sergeant Mscus, Lieutenant Colonel Johnson, Colonel Gore, Dr. Gore. Um so let me ask you a question. Um the VA budget is just under the VA healthcare budget is just under half a trillion dollars.
▶ 2:42:14And when we're talking about the Beacon Act, um which is not diverting funds from any entity, it's $60 million for the Beacon Act. Do you know what percentage of the entire health care budget that is for the VA? more like 1% of the entire VA healthcare budget. And I've heard a and so I'm a 24- year military veteran.
▶ 2:42:43You 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 Mscusi, when you went to Operation Mind, did you feel that they were culturally incompetent? No, I did not.
▶ 2:43:03And Lieutenant Colonel Johnson, as a PA or a medical flight, when you've received care outside the VA, did you feel that they were culturally incompetent?
▶ 2:43:15No, ma'am.
▶ 2:43:15And 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.
▶ 2:43:31Yeah. And might you as veterans know if you're receiving culturally incompetent you might well damn well know if you're see 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.
▶ 2:43:56they'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.
▶ 2:44:26Once 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 over pressure from breaching mortars, and how is this different from regular infantry and special operations forces?
▶ 2:44:55It's more common than we recognize these multiple subconussive events that happen daily over and over again in our line of
▶ 2:45:05Thank you. And Dr. Gore, do you think that we currently are meeting the need that you have perceived uh through the VA system as it currently I think we could do much better.
▶ 2:45:21And I think uh Sergeant Mchusi, you would probably echo that sentiment.
▶ 2:45:25Yes, ma'am.
▶ 2:45:26Yeah. Uh with that, I yield my time. I think it's very 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.
▶ 2:45:55and as well as the achievements of our VA health care system which are incredible achievements but also to the shortcomings of our system and it's been 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 war fighters could face.
▶ 2:46:17And 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?
▶ 2:46:39Uh, thank you, Madam Chair. Um, 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.
▶ 2:47:00What I'm just arguing for is we should be putting more money into the system to uh 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 entity entities outside of the VA. And uh general sitting over there, I'm happy to work with you on this.
▶ 2:47:29I have great respect for you. Um, we've served on the committee for a long, long time. We've had bills together. Um, and I would love to sit down and talk with you uh more about what our concerns are, what your concerns are, and see and I know Miss Elrith as well. Um, I've spoken with with her this morning. Um, and would love to see if we can come to an agreement between between us.
▶ 2:47:56Thank you. I yield back. And thank you, Rinky Member Brownley. Um, again, just want to state that uh 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 uh in what uh some might consider culturally competent care.
▶ 2:48:20I 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 will uh prepare uh and uh extend uh a system that meets the needs of veterans. I want to thank you uh for your participation in today's hearings and for the discussions that we've had on this very important topic.
▶ 2:48:45The complete written statements of today's witnesses will be extended uh 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.