What that means in plain English is that when you put reforms in place, you can’t just rip out the stuff that’s not working and do something different. What you’re actually reforming is the process, and because many of the current elements of the process are functionally mandated by other government rules, or court rulings, or bits of legislation that your reform effort didn’t amend, you have to layer your reform on top of the system you wanted to reform, rather than in place of it. Many of your reforms simply stack another layer of bureaucracy on top of the bureaucracy that was already causing problems. This is a problem that CEOs don’t face, unless they’re in some heavily regulated business such as banking or oil refining.

Most important, it is easier to change some parts of the system than others, and much easier to give something than to take something away. So it was relatively easy for Barack Obama to tell the VA that they had to do more to treat post-traumatic stress disorder. It seems to have been very hard to change the claims process to make it move faster or to hire more staff to help things move more quickly. The result was an even bigger backlog — and, since the reforms commanded the staff to move more patients, more quickly, the temptation to “juke the stats” to make the waiting lists appear shorter than they were.