Obama letter concerning treatment of TBI

United States Senate

Washington, D.C. 20510

August 4, 2008

The Honorable Robert M. Gates

Secretary, U.S. Department of Defense

1000 Defense Pentagon

Washington, DC 20301-1000


Dear Secretary Gates:

A recent study conducted by the RAND Corporation found that 320,000 troops, or 19 percent of all service members, returning from Operations Enduring Freedom and Iraqi Freedom may have experienced a traumatic brain injury (TBI) during deployment.We are concerned that at a time when TBI is recognized as the signature wound of the conflicts in Iraq and Afghanistan, one of the most widely accepted and critical rehabilitative treatments for this injury, known as cognitive rehabilitation therapy, is excluded by the military’s TRICARE health insurance program. Cognitive rehabilitation is a proven regime of medical and therapeutic services designed to improve brain functioning.

Service members who sustain brain injuries frequently have difficulties in attention, concentration, memory, problem-solving, and decision-making that impede their ability to function in everyday activities. Timely treatment of cognitive dysfunction is vital to the recovery process, as it impacts personal safety, functional independence, productive living, psychological health and social interaction. Therefore, we urge you to provide official TRICARE coverage for cognitive rehabilitation as an instrumental therapy in the recovery process of America’s wounded warriors.

While the Department of Defense and Veterans Administration have made recent strides to improve our institutional capacity to treat TBI at military and VA hospitals, often the best care for this complex injury is available only from private providers at outside care facilities. Given the rate of TBI among returning service personnel, we must redouble efforts to remove access barriers to proven therapies. The Department of Defense Task Force on Mental Health last year issued a recommendation that TRICARE access standards be changed to consider basic mental health care in the same category as primary medical care. Embracing this recommendation is central to any successful, time-sensitive strategy to treat the invisible wounds of war.

This is particularly true for our most gravely wounded combat veterans. According to figures provided by your office, 19,922 service members were medically retired with serious injuries in 2007 alone.

We believe these soldiers should be able to access cognitive rehabilitation services at outside care facilities.We understand that TRICARE authorities have cited a lack of evidence attesting to the efficacy of cognitive rehabilitation as a justification for not covering this treatment.

This assessment contradicts the clear clinical consensus of the American medical community, which recognizes the instrumental role that these therapies play in minimizing disability and maximizing recovery of function in patients with a TBI. Access to cognitive rehabilitation is a basic element of the continuum of care for brain injury patients.

The National Institutes of Health, the National Academy of Neuropsychology, the Brain Injury Association of America, and the American Speech-Language-Hearing Association validate cognitive rehabilitation as a proven, not an experimental, treatment for TBI. Numerous public and private insurers currently provide coverage for cognitive rehabilitation in recognition of its proven therapeutic value in treating severe brain injuries.

As of 2006, fourteen states included cognitive rehabilitation under the Medicaid Home and Community-Based Services Waivers.Individuals who have incurred a traumatic brain injury while serving their country deserve nothing less than the appropriate level of care based on currently accepted and widely utilized treatment modalities. As in every area of modern medicine, the research and evidence base for treatment of brain injuries continues to evolve.

Service members with a TBI need appropriate and timely treatment options to address cognitive impairments, and best practices must be based on the available body of knowledge at the current time. While further research in this area is ongoing and appropriate, our military healthcare system should err on the side of providing proven treatment given the serious lifelong consequences of an untreated or under-treated brain injury.

The national media have reported many anecdotal cases of individuals who attest to the vital role that cognitive rehabilitation plays in facilitating meaningful recovery from brain injury. One such example is ABC News journalist Bob Woodruff, who was injured by a roadside bomb in January 2006 while reporting from Iraq. His remarkable recovery from a severe TBI has been widely cited as a powerful example of the great innovations of our military healthcare system.

Mr. Woodruff has repeatedly emphasized that his cognitive rehabilitation therapy was a vital part of his healing process. Yet the treatment made available to Mr. Woodruff may be denied to U.S. military personnel who are similarly afflicted.Congress recently enacted a historic GI bill to honor our responsibility to Iraq and Afghanistan veterans who return home seeking an education and a better future for their families. We have no less of a responsibility to maximize the potential of our wounded warriors returning from battle nursing the wounds of war. Given the prevalence of TBI among returning service personnel, it is difficult to comprehend why the military’s managed healthcare plan does not cover the very therapies that give our soldiers the best opportunities to recover and live full and productive lives.

We are committed to appropriating the necessary funding to ensure that injured service members receive the world-class healthcare they deserve.Therefore, we urge the Department of Defense to provide official TRICARE coverage of cognitive rehabilitation therapies, so that all returning service personnel can benefit from the best brain injury care this country has to offer.

Thank you for your continued service.

Sincerely,Evan Bayh, United States Senator

Barack Obama, United States Senator

Hillary Rodham Clinton, United States Senator

Ken Salazar, United States Senator

Edward M. Kennedy, United States Senator

Joe Lieberman, United States Senator

Jeff Bingaman, United States Senator

John F. Kerry, United States Senator

Blanche L. Lincoln, United States Senator

Claire McCaskill, United States Senator

Cc: Brigadier General Loree Sutton,

Major General Elder Granger



To join our listserv, write to Marc Dubin, Esq., at mdubin@pobox.com.