Traumatic Brain Injury Program Reauthorization Act of 2018 (HR 6615, 115th Congress)

The Policy

Synopsis

HR 6615, the Traumatic Brain Injury Program Reauthorization Act of 2018, would implement a national concussion surveillance system to determine “the prevalence and incidence of concussion.” This surveillance system would act under the authority of the Department of Health and Human Services (HHS) through the Centers for Disease Control and Prevention (CDC). It would provide $5 million in funds to carry out the national concussion surveillance system.

In addition, state grants for concussion rehabilitation, protection, and advocacy services would be handled by the Administration for Community Living. The bill would increase funding for state grants to improve access to both rehabilitation and other traumatic brain injury (TBI) services from $5.5 million to $7.321 million in fiscal years 2019 through 2024. It would also increase state grant funding for TBI protection and advocacy services from $3.1 million to $4 million in fiscal years 2019 through 2024.

Context

The first piece of legislation addressing TBI was the TBI Act of 1996 during the Clinton Administration. It addressed primarily TBI prevention, research, and service through state grants. Since the passage of that Act, all 50 states and the District of Columbia have adopted laws addressing TBI through both prevention and accurate diagnosis and treatment of TBI. These laws are largely a response to TBI caused by youth sports. In fact, in 2017, 2.5 million high school students were affected by concussions or other forms of TBI. This has led a majority of the policies adopted by the states to focus on concussion education, athlete removal when a concussion is suspected, and evaluation by a health professional. In addition, recent state laws have focused on TBI in military veterans, requiring treatment of veterans with TBI and allocating money to programs specifically focused on TBI treatment.

Recently, the CDC has released new diagnostic guidelines focused on treating children with mild TBI and concussions. These guidelines stem from years of research conducted by the CDC to accurately diagnose and treat mild TBI in young adults and children, spurred by the heightened concerns of the consequences of contact sports. The NIH, as well, through the National Institute of Neurological Disorders and Stroke (NINDS), has a focus research group and awards grants specifically targeting TBI research.

The Science

Science Synopsis

As defined by the CDC, TBI is caused by abnormal movement to the head that disrupts the normal functioning of the brain. TBIs can vary from very mild to incredibly severe, with symptoms ranging from brief and subtle changes in mental state (like mild confusion and disorientation) to drastic changes (like loss of consciousness, amnesia, coma) or even death. Mild TBIs are often referred to as concussions. Approximately 2.8 million emergency department visits, hospitalizations, and deaths occurred in 2013 related specifically to TBI. The estimated cost of TBI in the United States is $76.5 billion.

TBI represents a significant number of hospitalizations and emergency department visits, according to statistics cited by the CDC. Nearly half of all TBIs in 2013 occurred from falls, while 15% occurred from being struck by or colliding with an object. However, in children, nearly a quarter of all TBIs in 2013 occurred from being struck by or colliding with an object. This category includes many youth-sports related TBI. In addition to falls and collisions, motor vehicle crashes accounted for a significant portion of hospitalization and emergency department visits.

The CDC also estimates that 1.6 to 3.8 million concussions occur annually as a result of sports activities. It is suspected that these figures, however, underestimate the total number of TBIs that occur within the United States each year. This is because most TBIs are mild in nature, causing subtle symptoms which go unreported and untreated. Recently, public awareness of TBI and concussions has increased with the NFL concussion settlement.

Despite the renewed focus on TBI as related to sports, the CDC notes that TBI disproportionately affects both the young and old as a result of falls. This also neglects the high rate of TBI in the armed forces. Between 2000 and 2018, nearly 400,000 service members were diagnosed with TBI.

Scientific Assumptions

  • The incidence and prevalence of concussion need to be determined (Section 2 (1)): There are extensive statistics from the CDC detailing the incidence of concussion in the early 2000s. However, some researchers argue that many milder forms of TBI go unreported or unrecognized as a TBI, indicating a need for better reporting or documenting systems.

The Debate

Scientific Controversies / Uncertainties

A few prominent scientific questions exist regarding concussions and TBI. First, it is currently difficult to gauge an accurate incidence rate of mild TBI (i.e., concussions) in the United States. This is because many sufferers do not seek treatment for milder forms of TBI. This has led to questions regarding the current state of our statistics surrounding TBI, especially in mild cases.

In addition, there are questions surrounding the treatment for TBI. The current accepted form of treatment for mild TBI is a “return to play” or “return to activity” protocol, wherein the patient undergoes a short period of rest before gradually returning to normal functioning. However, recent literature reviews, particularly Burke et al. 2015, have called into question many standard forms of treatment, including return to play or return to activity, and have shown a need for more clinical trials to review the efficacy of return to activity protocols. Other studies have shown that return to activity protocols can be effective, even weeks after a concussion, and can be effective in treating persistent concussion symptoms.

Chronic traumatic encephalopathy (CTE) is another neurological disorder which appears to affect persons who have suffered from frequent TBIs, and is especially prominent among players in the National Football League (NFL). A current issue, however, with CTE is that no diagnosis can be made premortem; the brains of individuals with suspected CTE can only be analyzed through autopsy. While there appears to be some connection between CTE and TBIs, some have questioned the strength of  this relationship. By comparison, others have shown a strong correlation between CTE and TBI as evidenced by one study that found that 87% of autopsied brains from deceased American football players had CTE.

Endorsements & Opposition

At present, there have not been any publicly reported endorsements of or opposition to this bill.

Potential Impacts

There are a few past versions of the TBI Reauthorization Act, most notably in 2013. In that year, the National Association of State Head Injury Administrators (NASHIA) issued a letter to Joe Pitts, the Chairman of the Subcommittee on Health, and Ranking Member Frank Pallone, Jr. to express support for the reauthorization of the act, saying: “Programs authorized under this Act are critical in helping states to address these unique needs to help individuals with TBI to return to home, school, work and community following their injuries… The federal TBI State Grant Program has provided states with flexibility to target gaps in service delivery to meet the array of services needed across all ages, and regardless of cause and severity of injury.”

Both the 2013 and 2018 bills are quite similar in their reauthorization of funds. The main difference between the 2013 version of the bill and the proposed 2018 version is the administrator of the law. The 2013 version designates particularly the Department of Health and Human Services as administrator of the state grants. The 2018 version, however, moves that responsibility to the Administrator for Community Living.