Six years have gone by since Osama bin Laden allegedly masterminded attacks on The World Trade Center and Pentagon. Although The FBI lists Usama bin Laden (their spelling) as a Most Wanted Terrorist, he seems to have gotten away with it.

What Have We Done?

Representative Bennie Thompson (D-MS), Chairman of the Committee on Homeland Security, answered this question yesterday. In a Press Release titled: Honoring the Victims of 9/11 with a Commitment to Secure America. Thompson said:

“Congress acted swiftly to respond and federalized aviation security, realigned the Federal government to meet the challenges of a post—9/11 world and ordered the formation of the 9/11 Commission to conduct an independent review of the attacks and develop recommendations to make America more secure.

By January 2007, when I became chairman of the Homeland Security Committee, many of the 9/11 recommendations had been implemented. However, some of the most difficult challenges remained unaddressed. I am proud to say that the first order of business for the 110^th Congress was consideration of H.R. 1 —a bill to fulfill the 9/11 Commission recommendations and address other emerging threats.”

Emerging Threats

On December 8, 2004, after The Intelligence Reform and Terrorism Prevention Act of 2004 was enacted, Senator Hillary Clinton (D-NY) said:

“We do not know where the next Afghanistan will spring up”

Senator Joseph Lieberman (I-CT) is betting on Iran.

Speaking before the House Armed Services Committee today, during a hearing on the situation in Iraq and progress made by the Government of Iraq, Lieberman blamed the deaths of “hundreds of American troops” on Iran, and asked General David Petraeus, Commander of American troops in Iraq:

“Is it time to give you authority, in pursuit of your mission in Iraq, to pursue those Iranian Quds Force operations in Iranian territory, in order to protect America’s troops in Iraq?”

Petraeus replied:

“I think that really the Multinational Force Iraq should just focus on Iraq and that any kinds of operations outside the borders of Iraq would rightly be overseen by the Central Command.”

Of course, Lieberman missed the point.
Hundreds of troops didn’t die from the Quds, those troops shouldn’t have been there at all. Sending more troops to the region would just compound the error a little further, and make the casualty list a little longer.

Politicians have weakened our defenses, by sending our troops overseas, to die in meaningless wars, when Americans need security at home.

While the boys were playing…

The Allentown Morning Call reported that New Jersey State Police caught, and then released, a suspected terrorist today.

Truckers along (Interstate) Route 80, near the borders of New Jersey and Pennsylvania, reported a possible Arab photographing the Milford-Montague Toll Bridge, which connects New Jersey to Pennsylvania.

Imrah H. Ahmed, 25, told police that he had stopped to admire the scenery, and also so his wife could feed their baby. After police found Ahmed’s name on a list of suspected terrorists, they searched his car, found no camera, and sent him on his way.

Captain Al Della Fave, of the New Jersey State Police Office of Public Information, said:

“We conferred and there was no further reason for detention”

Does that make you feel safe?

The program was announced by Illinois Governor Rod R. Blagojevich, and Tammy Duckworth, director of the Illinois Department of Veterans Affairs.

The New York Times, in Screening for Brain Injury Is Set for Illinois Veterans, by Libby Sander, quoted Dr. Felise S. Zollman, medical director of the brain injury program at the Rehabilitation Institute of Chicago, who described the program:

“The mandatory screening would consist of a written questionnaire, an assessment by a medical professional, and a professional interpretation of the results. Service members believed to show symptoms of a brain injury would be referred for assessment and further treatment at a veterans’ center.”

In Illinois Unveils Mental Health Services for Returning Guardsmen, Veterans, by Donna Miles, reporting for American Forces Press Service, quoted Dr. Samuel Ward Casscells, assistant secretary of defense for health affairs, who explained why mandatory testing is necessary:

“We’ve got these post-deployment questionnaires that you fill out when you leave theater.

When I left Iraq, I filled out a questionnaire that said: ‘Were you near an (improvised explosive device) that went off? Are you having trouble sleeping? Are you having trouble controlling your feelings?’ And so forth, and so on.

A lot of people check ‘no’ because they want to get home.

[Questionnaires have been retooled so that] even if they check ‘yes,’ they’re going to get home and get the care when they get home, he said, adding that this will help promote more honest responses.”

The Defense and Veterans Brain Injury Center, says that:

In prior conflicts, TBI was present in at least 14–20% of surviving combat casualties; preliminary information from the current conflict in the Middle East suggests that this number is now much higher.

It is about time that someone is taking some steps to identify this problem.

Senator Durbin described this legislation as:

“A bill to ensure that the Department of Defense and the Department of Veterans Affairs provide to members of the Armed Forces and veterans with traumatic brain injury the services that best meet their individual needs, and for other purposes; to the Committee on Armed Services.”

How Will It Help?

• The Department of Defense will screen military personnel for traumatic brain injuries before and after they are deployed. It is not clear if recruits will be affected by a TBI diagnosis.
• “Traumatic Brain Injury Program” which will be jointly administered by DOD and VA which will establish guidelines for the treatment and care of military personnel with traumatic brain injuries. This will allow patients with traumatic brain injuries to be treated at facilities run by the DOD, and VA, as well as private facilities. This is a huge improvement over the current system which places patients at one of four polytrauma centers. Additionally, patients will have a standardized appeals process to complain about their treatment, and will be guaranteed a referral to a physician in the private sector. However patients will be limited to one outside referral every three months.
• The DOD and VA will also develop a training program for medical personnel at public and private centers, “to ensure that such personnel are consistently using the most up-to-date and best practices and procedures for the screening, treatment, and rehabilitation of members of the Armed Forces and veterans with traumatic brain injury.” Medical records will be transferred “expeditiously” between these agencies.

My favorite portion of this bill is:

“The Secretary of Defense shall, upon the request of any former member of the Armed Forces who served in the Armed Forces after October 6, 2001, and has been discharged from the Armed Forces under other than honorable conditions, conduct a review (including a medical evaluation) to determine whether a traumatic brain injury was a cause of the actions of the member that precipitated the discharge under other than honorable conditions. Such request may also be made by an authorized representative of the member.”

Where Did My Brain Go? will be following this legislation, and I hope it is ratified.

This bill amends Title 38 to improve the treatment and care of military personnel with traumatic brain injuries. It adds a new subchapter to the code: “Traumatic Brain Injuries.”

Some key points of this bill are:

• Mandatory screening of veterans for TBI
• Long-term rehab for soldiers who:
  • were in combat after November 11, 1998
  • were diagnosed with moderate to severe TBI
  • require daily supervision or assistance
• establishment of a “traumatic brain injury transition office” at each polytrauma center for veterans who require additional services, which are not available at their location
• Establish a “traumatic brain injury registry” with the names of everyone who was treated for TBI, plus their medical information, if they agree to provide it, or are deceased.
• Establish “centers for traumatic brain injury research, education, and clinical activities” to improve the treatment and care of TBI patients
• Establish a “Committee on Care of Veterans with Traumatic Brain Injury” to improve the care of TBI patients

Representative Michael Michaud (D-ME), who sponsored this legislation, wrote on his Web site:

“TBI is considered by many to be the signature injury of the wars in Iraq and Afghanistan,” said Michaud. “It is important to remember that not all the wounds from this war are visible. Severe TBI is often easily recognizable, but mild and moderate TBI can be harder to detect. Because of this, some veterans may not even know that they are suffering from TBI and may go untreated. Passing this bill is a huge step forward for the detection and treatment of this long-term injury.”

Michaud’s legislation, the Traumatic Brain Injury Health Enhancement and Long-Term Support Act of 2007 (H.R. 2199), is the result of the efforts of members from both sides of the aisle to address TBI and to begin to improve the outreach and oversight of health care provided to our rural veterans. The bill requires screening of veterans for TBI; establishes a comprehensive program for long-term TBI rehabilitation to be located at four geographically dispersed locations; creates TBI transition offices at each of the polytrauma network sites; requires the development of a TBI registry; authorizes funds for the establishment of centers for TBI research, education, and clinical activities; and forms the Committee on Care of Veterans with TBI.

The Associated Press reported:

‘House Speaker Nancy Pelosi, D-Calif., in a meeting with veterans service organizations Wednesday, said Democrats promised a new direction when they captured the congressional majority and “nowhere is that more important than in our treatment of our troops and our veterans.”’

My Opinions

We have four polytrauma centers, this bill allocates funds for eight instead of the 21 which Representative Altmire proposed in The Veterans Traumatic Brain Injury Act. However, it will also create ten mobile centers in rural areas.

It is terrific that Title 38 was amended to recognize TBI, and this bill is certainly a step in the right direction.

Update: I misunderstood the finances until I read the Cost Estimate, so I included the Budget Cost Estimate to make everything clear.

CONGRESSIONAL BUDGET OFFICE COST ESTIMATE

May 22, 2007

H.R. 2199
Traumatic Brain Injury Health Enhancement and Long-Term Support Act of 2007

As ordered reported by the House Committee on Veterans’ Affairs on May 15, 2007

SUMMARY

H.R. 2199 would expand the health care available to veterans with traumatic brain injuries and would create a pilot program to provide mental health care and services to veterans in rural areas.

CBO estimates that implementing this bill would cost the Department of Veterans Affairs (VA) $27 million in 2008 and $138 million over the 2008-2012 period, assuming the appropriation of the necessary amounts. Enacting the bill would not affect direct spending or revenues.

H.R. 2199 contains no intergovernmental or private-sector mandates as defined in the Unfunded Mandates Reform Act (UMRA) and would impose no costs on state, local, or tribal governments.

ESTIMATED COST TO THE FEDERAL GOVERNMENT

The estimated budgetary impact of H.R. 2199 is shown in the following table. The costs of this legislation fall within budget function 700 (veterans benefits and services).

BASIS OF ESTIMATE

For this estimate, CBO assumes the legislation will be enacted near the end of fiscal year 2007, that the necessary funds for implementing the bill will be provided each year, and that the outlays will follow historical spending patterns for the VA medical services program. H.R. 2199 would require the Secretary of VA to create several programs that would enhance the care provided to veterans with traumatic brain injuries. The bill also would establish a pilot program that would use mobile centers to provide counseling and other health services to veterans in rural areas. CBO estimates that implementing H.R. 2199 would cost $27 million in 2008 and $138 million over the 2008-2012 period, subject to appropriation of the necessary amounts.

Traumatic Brain Injury Centers

Section 2 would require VA to establish and operate up to five centers for research, education, and clinical activities focused on traumatic brain injury. CBO expects that those centers would be located within existing VA medical centers and would be established after a facility submits a proposal to be designated as a traumatic brain injury center and a peer review panel determines that the proposal meets certain standards. H.R. 2199 would authorize the appropriation of $10 million in 2008 and $20 million in each of years 2009 through 2011 to support those centers. CBO estimates that implementing this provision would cost $9 million in 2008 and $70 million over the 2008-2012 period.

Long-Term Care for Traumatic Brain Injury

Section 2 also would require a program of long-term care, to include residential facilities, community-based care, and home-based care for veterans with moderate-to-severe traumatic brain injuries. The program would be carried out at four VA medical centers that already specialize in care for servicemembers with multiple injuries. VA already provides long-term care for veterans with severe traumatic brain injuries, either at a VA medical facility, at a state-run veterans’ nursing home, or through contract care provided in the veteran’s community. VA has indicated that it would meet the requirements of this section by creating four centers that would specialize in caring for veterans with brain injuries, in addition to the four centers that already exist. Based on information from VA regarding the number of employees needed to staff these centers and the renovation and equipment needed to establish a center, CBO estimates that implementing this provision would cost $11 million in 2008 and about $45 million over the 2008-2012 period, assuming appropriation of the necessary amounts each year.

Mobile Health Centers for Rural Veterans

Section 3 would authorize a three-year pilot program in which VA would use mobile health centers to provide readjustment counseling and related health services to veterans in rural areas. The bill would require the use of two mobile centers in each of five specific geographic areas. Other mobile centers could be established if the Secretary determined they were needed. In addition to counseling and mental health services, the mobile centers would advise veterans of other benefits they may be eligible for and, to the extent possible, would help the veterans to apply for those additional benefits.

H.R. 2199 would authorize the appropriation of $7.5 million a year for three years to fund the mobile centers. CBO estimates that implementing this section would cost $7 million in 2008 and about $22 million over the 2008-2012 period.

Other Provisions

Section 2 also would require VA to:

• Screen all veterans for signs and symptoms of traumatic brain injury—which VA has already begun;
• Establish a committee to assess VA’s traumatic brain injury programs;
• Create a registry of veterans being treated for traumatic brain injury; and Establish offices at polytrauma centers to assist veterans who need care outside of VA.

CBO estimates that implementing those additional provisions would have an insignificant impact on discretionary spending.

INTERGOVERNMENTAL AND PRIVATE-SECTOR IMPACT

H.R. 2199 contains no intergovernmental or private-sector mandates as defined in UMRA and would impose no costs on state, local, or tribal governments.

ESTIMATE PREPARED BY:

Federal Costs: Michelle S. Patterson
Impact on State, Local, and Tribal Governments: Melissa Merrell
Impact on the Private Sector: Victoria Liu

ESTIMATE APPROVED BY:

Peter H. Fontaine
Deputy Assistant Director for Budget Analysis

Representative Altmire introduced this bill to modify U.S. Code Title 38, “Veteran’s Benefits”, which was enacted on September 2, 1958, and signature injury of the war seems to be everywhere, so this is certain to pass.

FYI: I just found 884 references to “signature injury” on Google, and 537 on Yahoo, up from 883 and 479 yesterday!

Of course, this bill might be amended, but it should improve the chances of returning Vets receiving better TBI care, in whatever form passes.

What follows is Representative Altmire’s original press release, on April, 19, 2007, followed one week later, by his initial testimony, and then the VFW’s statement.

1. ALTMIRE INTRODUCES BILL TO IMPROVE VETERANS’ HEALTH CARE

   Bipartisan coalition supports essential health care legislation to screen and treat traumatic brain injury

   (Washington, DC)—Rep. Jason Altmire (PA-4) introduced bipartisan legislation to ensure the proper screening and treatment of traumatic brain injuries (TBI) for America’s returning veterans.

   The Veterans Traumatic Brain Injury Act, H.R. 1944, would require the Veterans Affairs Administration to institute a program to screen veterans for symptoms of TBI; develop and operate a comprehensive program of long-term care for post-acute TBI rehabilitation; establish a TBI transition office at each of the 21 polytrauma network sites nationwide; and create and maintain a TBI veteran health registry. This legislation is a continuation of Rep. Altmire’s advocacy on behalf of the nation’s veterans.

   “More than 24,000 American troops have been wounded in Iraq and Afghanistan, many of whom have sustained multiple injuries due to confronting suicide bombers and improvised explosive devises,” said Rep. Altmire. “More than half of combat casualties in Iraq have associated brain injuries. Most of them include mild TBI, which often goes undiagnosed and is subsequently left untreated.”

   According to the National Institute of Neurological Disorders and Strokes, TBI occurs when a sudden trauma causes damage to the brain. Symptoms of TBI vary depending on the extent of damage to the brain, but include headaches, confusion, dizziness, blurred vision, fatigue, and behavioral and mood changes. Cases of mild TBI are under-diagnosed, especially when a service member has an external injury such as a burn or other life-threatening condition that requires immediate medical attention.

   “Traumatic brain injury has become the signature injury of both Operation Enduring Freedom and Operation Iraqi Freedom. Among veterans and service members returning from combat overseas, 65 percent have TBI,” said Rep. Altmire. “. The Veterans Traumatic Brain Injury Act will help the VA better coordinate care for our wounded warriors to ensure that veterans are properly screened, diagnosed and receive the treatment that they deserve.”

2. House Committee on Veterans’ Affairs
   Statement of the Honorable Jason Altmire, a Representative in Congress from the State of Pennsylvania

   Testimony Before the Subcommittee on Health of the House Committee on Veterans’ Affairs

   April 26, 2007
   I would like to thank Chairman Michaud, Ranking Member Miller and members of the committee for the opportunity to testify today about H.R. 1944, the Veterans Traumatic Brain Injury Act of 2007, bipartisan legislation that I introduced to increase the screening and treatment of traumatic brain injuries (TBI) for our nation’s veterans.

   Mr. Chairman, we are facing an impending crisis in this country. Our brave men and women are returning from Iraq and Afghanistan with TBI at an alarming rate. Of those treated at Walter Reed Army Medical Center, 65 percent have been diagnosed with TBI as a primary or co-morbid diagnosis.

   Many now consider TBI to be the signature injury of the wars in Iraq and Afghanistan.

   I am concerned that the Veterans Affairs Administration may not be properly identifying and treating TBI among the nation’s veterans.

   It is estimated that more than half of all combat casualties have associated brain injuries. Most of them include mild TBI, which is often missed in initial exams as physicians attend to other more apparent injuries.

   The Veterans Traumatic Brain Injury Act improves the coordination of TBI care for our nation’s veterans by requiring the Veterans Affairs Administration to screen veterans for symptoms, develop and operate a comprehensive program of long-term care for post-acute TBI rehabilitation, establish TBI transition offices at all poly-trauma network sites, and create and maintain a TBI veteran health registry.

   In our first four months, the 110th Congress has taken enormous strides in meeting its commitment to veterans. We have provided more than $11 billion in increased funding for veterans health care and passed the Wounded Warrior Assistance Act to improve the management of their medical care.

   I believe that we owe no greater debt than to our veterans and, while we have made some progress, we can do more to improve their health care. To this end, the bipartisan Veterans Traumatic Brain Injury Act will allow us to properly screen America’s returning heroes for TBI and improve their treatment.

   Thank you for the opportunity to speak today.

3. H.R. 1944

   The VFW offers our strong support for this legislation which would require VA to implement a screening program for traumatic brain injuries (TBI).

   TBI is the signature wound of this war, as thousands of our men and women in uniform are being exposed to blasts and other traumas which are doing great damage to their brains. This is an area where this nation clearly must do more to care for our sick and disabled, the wounded warriors of this war.

   TBI manifests itself in a number of ways. While some are able to live with its effects, it makes life extremely difficult for others. We know much about its causes and immediate symptoms, but we most know more about it. We have repeatedly called for more studies to fully understand the injuries, their causes, their effects, and especially their long-term impacts.

   This legislation considers the long-term impact, and for those who need it, it would establish programs to provide long-term care and rehabilitation. This is sorely needed.

   Further, it fosters the development of partnerships with other health care institutions through the creation of a TBI transition office, which is charged with coordinating services that are not readily available through VA.

   Given the difficulties we have sadly seen with some of these wounded warriors receiving the care they need, especially for those who live far from the polytrauma centers, this is an excellent step. Many of these clinics and specialty care facilities have great experience with brain injuries and can provide these patients the care they desperately need, and VA with the expertise and training it needs to fulfill its most sacred of missions.

The first bill, the Wounded Warrior Assistance Act of 2007 was introduced by Rep. Ike Skelton (D-MO), who is Chairman of the House Armed Services Committee, on March 15, 2007.

This bill’s stated purpose was to amend Title 10 to “improve the management of medical care, personnel actions, and quality of life issues for members of the Armed Forces who are receiving medical care in an outpatient status, and for other purposes.”

This bill is good news for soldiers with a TBI. It includes the following new proposals:

• Military outpatients are guaranteed to see their case manager once a week, and each case manager should only have 17 clients.
• Patients will receive a “Service Member Advocate” to meet with them and their families, who will assist in resolving financial and other transitional problems.
• Patients are guaranteed the right to see an independent physician to serve as their advocate.
• Patients will have access to a toll-free telephone number to report problems.
• Patients can have the congressperson notified of their condition.

But the most important part for a patient with a TBI is Section 205 which states:

Not later than 90 days after the date of the enactment of this Act, the Secretary of Defense shall submit to the Committees on Armed Services of the Senate and the House of Representatives an interim report describing the changes undertaken within the Department of Defense to ensure that traumatic brain injury victims receive a proper medical designation concomitant with their injury as opposed to the current medical designation which assigns a generic “organic psychiatric disorder” classification.

On March 28, 2007, this bill passed the House, by a vote of 426 - 0.

Where Did My Brain Go? will keep you informed of its progress to President Bush’s desk.