6. The endemic and systemic problems in the VA go back decades. Presidents from George H.W. Bush on have struggled to bring functionality to the VA, both when it was an agency and after it became a Cabinet department. Some presidents, notably Bill Clinton, did better than others, but none succeeded in creating an agency that worked smoothly and well. Of course, the failure to coordinate between the Defense Department and the VA over care for current and former military personnel, along with the sharp increase in veterans requiring complex care for physical and mental injuries and traumas, has not helped. But neither has the relative indifference of administrations, including Obama's, or the failure, government-wide, to modernize information technology, which itself is at the root of many of the VA's health and disability system problems.
7. The problems are there in significant part because of the size and complexity of the agency and the problems it is supposed to ameliorate. As Phillip Carter pointed out in Slate, "The VA is the second-largest Cabinet agency, and the nation's largest health care and benefits provider, with an overall fiscal 2015 budget of $165 billion (greater than the State Department, USAID, and entire intelligence community combined), including $60 billion for health care. The VA employs more than 320,000 personnel to run 151 major medical centers, 820 outpatient clinics, 300 storefront 'Vet Centers,' more than 50 regional benefits offices, and scores of other facilities. This massive system provides health care to roughly 9 million enrolled veterans, including 6 million who seek care on a regular basis."
8. General Eric Shinseki was neither the cause nor the perpetrator of this. He had flaws. He was too passive in his public performance, did not show enough indignation when he became aware of the problems, or push Congress strongly enough for the resources he needed. He was too trusting of his subordinates (although it is now clear he did not sit in his ivory tower, but traveled regularly to VA sites, interviewing employees and imploring them to be honest with him). His problem, as a military man, was the same as the one Dwight Eisenhower faced when he moved from general to president; as Harry Truman pointed out: "Poor Ike, he is used to saying, 'Do this, do that,' and actually having it happen." Shinseki also had many strengths, and he did some remarkable and positive things for homeless veterans and many others. Given the nature of modern politics and media, where politicians and pundits call for heads to roll and journalists cover the bloodsport far more than the real problems, it was inevitable that he would resign. But it was not very fair and does not solve much of anything.
9. There is an immediate problem requiring triage, and a longer-term set of issues to deal with. Privatizing the VA, given its high quality of care and focus on the unique problems of veterans, may sound good, but it is foolish. The VA does need more money, and more flexibility from Congress to allocate it to fix the problems. But it makes immediate sense to give veterans who cannot get appointments for care or consultation on a timely basis temporary Medicare cards to find providers now until the wait times can actually be reduced. More broadly, we must take a truly serious look at civil-service rules and a concerted effort, perhaps led by top tech professionals outside government, to find appropriate ways to create 21st-century information systems. And we need a better way to attract and keep medical professionals, and technical experts, in government. Multiyear pay freezes and blanket denial of bonuses is not the answer.