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.