Tag Archives: Inspector General

Serious Gap in Veteran TBI Care Found

On August 5, 2026, the VA Office of Inspector General (VA OIG) released a national review that found a serious gap in traumatic brain injury care for post-9/11 veterans: Of 301,177 veterans who agreed to a comprehensive TBI evaluation after screening positive between September 11, 2001 and March 31, 2025, only 158,907 received one, leaving 142,270 without the assessment.

Though the evaluation largely draws on the same screening data of VA’s congressionally mandated TBI Veterans Health Registry, this oversight review is distinct in auditing the screening-to-evaluation pipeline rather than cataloging diagnosed cases. While very much not excusing the lapse, it was found to have several causes. In a 100-record sample, 65% of veterans canceled the appointment or did not respond to VA’s attempts to schedule it. But investigators also faulted the VA itself, as in 15% of cases the staff never placed the required consult, and a single-use electronic template blocked repeat evaluations for redeployed veterans. One VA official told investigators that once completed, the template effectively “locks down.”

The VA Inspector General Cheryl L. Mason issued three recommendations: (1) review the referral process after positive screenings, (2) consider a uniform system for directing veterans to Polytrauma System of Care specialists, (3) revise the template’s one-time-use limitation. The VA has agreed with the first two and agreed with the third, in principle.

Congress Has Been Flying Blind on Veteran Brain Injury Spending for Years

Shiny golden dollar sign with stacks of bills and coins behind

The Special Disabilities Capacity Report is Congress’s primary tool for deciding how much to invest in VA’s TBI treatment infrastructure. If the numbers feeding that decision are wrong, the veterans who depend on that care pay the price.

A February 2026 review by the VA Office of Inspector General revealed that in FY 2023, the VA reported the wrong financial data for traumatic brain injury, using obligations rather than actual expenditures, thereby overstating actual TBI spending. More so, they failed to report TBI spending at both the geographic service area and national levels as required by law. The DVA Office of Inspector General’s Report 25-01863-31 also determined that VA’s capacity data did not capture community care services or the extent to which bed capacity was used at its specialized rehabilitation centers.

Pointedly, these data errors are the same as those that have been flagged in prior years. This raises questions about whether Congress receives an accurate picture of VA’s TBI treatment infrastructure. As Iowa Rep. Mariannette Miller-Meeks, Chairwoman of the House VA Health Subcommittee, stated at a March 2026 oversight hearing: “Wrong data takes resources away from [other] areas of need.”