Over the weekend we saw another story emerge which reminds us that the lingering effects of the VA scandal are far from gone and too much work remains to be done. It’s not that we haven’t seen some signs of progress at the agency. Shortly after President Trump decided to keep David Shulkin around and place him in charge of the VA, the new Secretary begged for expanded authority to fire failing workers. That prompted the President to create what I like to think of as the Office of Your Butt is Fired inside the VA.

That office clearly has their work cut out for them in California. As the Washington Free Beacon revealed this weekend, a recent Inspector General’s office report on one Los Angeles hospital revealed that more than 100 veterans died while waiting to be seen at the facility.

More than 100 veterans died while waiting for care at a Veterans Affairs hospital in Los Angeles, Calif., over a nine-month span ending in August 2015, according to a new government report.

The VA Office of Inspector General found in a recent healthcare inspection that 225 veterans at the VA Greater Los Angeles Healthcare System facility died with open or pending consults between Oct. 1, 2015 and Aug. 9, 2015. Nearly half—117—of those patients died while experiencing delays in receiving care.

The inspector general reported that 43 percent of the 371 consults scheduled for patients who ended up dying were not timely because of a failure by VA employees to follow proper procedure. The report was unable to substantiate claims that patients died as a result of the delayed consults.

The period in question actually ran from October of 2014 through August of 2015, and it can’t be shown that the delay in getting an appointment directly led to the deaths of specific veterans, but the results speak for themselves. Now, the period in question ended almost two years ago, so why are we just now hearing about it? Because nobody had their hand on the tiller for such a long time and there are so many VA centers around the country that it’s taking what must feel like an interminable amount of time to go through them all. But one thing has become increasingly clear and it’s the fact that the reforms put in place after the scandal first came to light have made improvements in some areas, but they weren’t nearly enough. In 2014 Congress rushed through the Veterans Choice and Accountability Act which channeled significant funding into the agency for hiring more staff and streamlining their processes for patient care, while offering veterans who couldn’t get a timely appointment at a VA center the option of going to a civilian facility.

That was a good first step and some of the resources definitely made a positive impact, but three years on into the program too many of the same old problems stubbornly persist. In this January report from NPR it was revealed that wait times on average had decreased, but were still unacceptably long and several individual hospitals were showing virtually no progress at all. What’s worse is that some of the centers receiving significant funds for staffing and referrals weren’t seeing any real improvements despite the increased resources.

An investigation by NPR and local member stations found that: the VA has about the same number of new hires as the VA would have been projected to hire without the additional $2.5 billion; the new hires weren’t sent to VA hospitals with the longest wait times; and the VA medical centers that got new hires were not more likely to see improved wait times.

San Diego’s experience is typical. The Southern California city is home to one of the largest concentrations of post-9/11 veterans, and when the Veterans Choice Act passed, the San Diego VA had some of the country’s worst wait times for mental health care in particular. The act was meant to help former soldiers like Charlie Grijalva, who was diagnosed with PTSD when he was still in the Army.

The story of Charlie Grijalva is heartbreaking and you can read the entire thing at the link. But the real tragedy is that Charlie’s problems are hardly unique in the veterans community. The challenges facing David Shulkin today seem to fall into two separate categories. First of all, he needs to be able to clean house and get rid of the incompetent and the corrupt with a wide sweeping broom. That’s still problematic because of the limitations of the established bureaucracy. But at the same time, better management is needed to oversee the distribution of funds and monitor the results. Dumping more taxpayer money down a rat hole just to look like you are doing something isn’t helping the veterans if it’s not being intelligently applied and managed.

This story should serve as a reminder that the VA scandal is far from over. Even if it’s not on the front pages every day anymore, it remains a critical area of need and the White House can’t afford to ignore it.

UPDATE: (Jazz) The VA responded to this article with the following statement from James Hutton, Deputy Assistant Secretary (Acting), Office of Public Affairs, Department of Veterans Affairs.

“The Department of Veterans Affairs (VA) takes seriously any allegations related to the quality of care provided to Veterans. At the request of former Chairman Jeff Miller, of the House Committee on Veterans Affairs, a team from the VA Office of Inspector General (OIG) reviewed consults within VA Greater Los Angeles Health Care System (GLA) from October 2014 through August 2015. In a final report, issued on May 4, 2017, OIG found no evidence substantiating allegations that any patients died or experienced long term consequences as a result of delayed consults. While not a formal allegation, the OIG did identify two (2) patients who experienced minor impacts to their care as a result of delayed consults due to incorrect administrative information in the consult.

Since the initial allegations in 2014, GLA has taken many steps to enhance the consult processes and minimize the potential for administrative error. These steps include:

• Increased staff training to ensure proper documentation for all consults;
• Fully comply with consult management guidelines to maintain full accountability;
• Created a Consult Management Dashboard, an application now adopted by numerous facilities around the nation, which allows for regular monitoring and improvement of facility consult performance and results;
• Utilizing the VA Electronic Medical Record (CPRS), any cancellations or discontinuations of consults generates an alert back to the requesting provider which ensures collaborative and effective communication.

VA takes very seriously our mission to provide the highest quality, safest, most compassionate and timely care available to all Veterans. In the interest of full transparency, both VA and GLA leadership will continue to provide Veterans, their families and other stakeholders with updates on the significant strides being made to implement comprehensive improvements to care and improved oversight of administrative practices.”