WASHINGTON — From the critical moments after she suffered a gunshot wound to the head in January to her triumphant return to Congress last week for a vote on the debt-limit deal, Rep. Gabrielle Giffords owes her recovery in no small part to veterans with similar injuries.
Doctors and rehabilitation specialists have learned a great deal from the treatment of traumatic brain injuries in combat veterans of Iraq and Afghanistan. One in five veterans of those wars has suffered some form of traumatic brain injury, most commonly concussions from roadside bombs.
Yet veterans' health care doesn't consistently cover cognitive rehabilitation therapy, the same therapy that's helped Giffords and other well-known figures — such as Sen. Tim Johnson of South Dakota and ABC News correspondent Bob Woodruff — get their lives back to normal after major brain traumas.
"If we fail to give people the tools they need to do that, then we've shut them out of society," said Susan Connors, the president of the Brain Injury Association of America.
While some veterans are getting very good treatment, advocates say, others are finding it difficult to get therapy or even the testing to determine whether they need it.
"It is a national disgrace," said Paul Rao, the president of the American Speech-Language Hearing Association and Johnson's speech therapist.
When people suffer traumatic brain injuries, they need more than just to learn how to walk and talk again.
Cognitive rehabilitation can include speech and communication therapies, and therapies to boost memory and social skills and relearn routine tasks such as getting dressed and shopping at the grocery store.
Connors compared it to elementary school.
Except that "You aren't learning it for the first time; you are relearning it," she said.
Pentagon spokeswoman Cynthia Smith said in an email that under the Tricare insurance plan, which covers members of the military, rehabilitation therapy "must be medically necessary and appropriate care keeping with accepted norms for medical practice in the U.S."
Brain-injury advocates say Tricare and civilian health-insurance providers deny payment for cognitive rehabilitation on the basis that it isn't proven effective, despite its wide embrace in the medical community and by the Department of Veterans Affairs.
Part of the problem is cost, typically $27,000 for one hour a day of treatment over six months.
"Insurance companies don't want to pay for quality-of-life improvements," said Sandra Farmer, the president of the Brain Injury Association of North Carolina. But, she added, the future benefits outweigh the upfront costs. "If you go ahead and get maximum rehab early on, the long-term costs will be diminished because the person will become more independent."
Smith said the Defense Department provided 45,000 hours of treatments last year that incorporated cognitive rehabilitation techniques, but she wouldn't say how many hours an individual veteran might have received.
Farmer said that wasn't enough.
"They're lucky if they get three weeks of therapy," she said. "I think the military is trying much harder than they used to, but there are gaps."
The VA does provide cognitive rehabilitation, and for veterans who live in areas far from the nearest center, offers it in the form of a video conference.
"Cognitive rehab therapy is a well-established area of practice within VA rehabilitation services," said Josh Taylor, a spokesman. "Expanding access to VA is a top priority."
Giffords' return to Congress has renewed attention to efforts to close the gaps in coverage. The Arizona Democrat fought to designate such rehabilitation essential care under the health care overhaul that Congress passed last year, and her staff has continued to push it during her absence.
"We believe they deserve the best possible treatment," said C.J. Karamargin, a Giffords spokesman.
Closing the coverage gap has bipartisan support in both houses of Congress.
A Senate bill co-sponsored by Sens. John Boozman, R-Ark., and Mark Begich, D-Alaska, would improve rehabilitation services for veterans with traumatic brain injuries.
Reps. Pete Sessions, R-Texas, Bill Pascrell, D-N.J., and Todd Platts, R-Pa., crafted an amendment to the 2012 defense appropriations bill that would establish a five-year pilot program under which more veterans could seek treatment from private doctors.
In civilians, common causes of traumatic brain injury include strokes, sports, auto accidents and gunshots. But Connors said that until the Afghanistan and Iraq wars, the National Institutes of Health had dedicated "minuscule" resources to brain injury research.
"There's been a dearth of research in traumatic brain injury for years," she said.
Connors said that Giffords and others were case studies, so they weren't considered the "gold standard," a definition that usually requires years of research and trials, much the same way drugs are tested.
Tricare relies on the federal definition of "effective treatment" to determine what it will and won't pay for. But Connors said the standards were written years ago.
People's health outcomes and lives "shouldn't hinge on that sort of stuff," she said.
"We want people to get the care that they need, not just discharged to the couch."
Connors credits James Brady, President Ronald Reagan's press secretary, who was shot in the head in 1981 during an assassination attempt on the president, for first raising the profile of the issue. His survival and recovery have helped others with similar injuries.
There have been other examples in more recent years: Woodruff was critically injured by a roadside bomb in Iraq in 2006 and he's since returned to work at ABC. Johnson was absent from the Senate for nine months after a brain hemorrhage in 2006. He won re-election in 2008 and is now the chairman of the Senate Banking Committee.
"Those first-person accounts are hugely motivating to other people with brain injuries," Connors said.
Giffords was shot through the left side of her head Jan. 8 as she met with her constituents in Tucson, Ariz. Six people were killed in the shooting, including a member of Giffords' staff, a federal judge and a 9-year-old girl.
After emergency surgery, she spent weeks in the hospital, followed by months in rehabilitation. Although she was discharged in June from the nationally recognized Institute for Rehabilitation and Research in Texas, Giffords faces years of treatment.
"It's a lifelong recovery process," said Peter Rhee, the battlefield-trained trauma surgeon who helped save Giffords' life. "It's not something you just overcome."
Giffords' friends and colleagues have noticed a dramatic improvement.
"I can see the progress each time I see her," said her close friend Rep. Debbie Wasserman Schultz of Florida. "Her personality is 100 percent there."
Brain injury experts and advocates are thrilled about Giffords' prognosis.
"She's really rewriting the script," Rao said. "She may be doing even more than we thought she could."
"She has been a champion," Connors said. "And she looked great when she voted."
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