MR. KOJO NNAMDIFrom WAMU 88.5 at American University in Washington, welcome to "The Kojo Nnamdi Show," connecting your neighborhood with the world. It's textbook example of a management mess in the making. Take the nation's largest healthcare system for veterans, inundate it with millions of new patients over a decade, add in a growing vacancy rate for doctors and administrators, then expect employees to keep up with the work load. These were just some of the conditions that led to the crisis currently rocking the Department of Veterans Affairs.

MR. KOJO NNAMDIReports that veterans died waiting for care at VA hospitals, plus allegations that VA employees manipulated patient wait times to meet job requirements and to receive bonuses. It's all prompted investigations by Congress and federal inspectors, with one leader out and an interim leader promising to quote, make dust, unquote, in fixing the VA's culture. It's hard to believe the status quo will hold for the nearly nine million vets under VA care. But how does one begin to cure this ailing bureaucracy? Do you start from the top-down? The bottom-up? Later in the broadcast, we'll be talking with Donald Kettl.

MR. KOJO NNAMDIHe's the Dean of Public Policy at the University of Maryland. And Alex Horton, he's a freelance writer and former blogger and social media editor for The Department of Veterans' Affairs. He's a US Army veteran. Right now, though, we'd like to start the conversation with Ed O'Keefe. He's a congressional reporter at the Washington Post who joins us from studios at the Post. Ed, thank you for joining us.

MR. ED O'KEEFEKojo, great to be with you.

NNAMDIEd, a little more than a week ago, Veteran Affairs Director Eric Shinseki stepped down and since then, we've had a flurry of proposals on Capitol Hill to address healthcare failures for veterans. Today, Sloan Gibson, the acting Secretary of the VA, released an audit that gives us an idea of how extensive problems at the VA are, nationwide. What do we know?

O'KEEFEWell, we know, based on an internal audit or a department wide audit that Mr. Gibson initiated, almost as soon as he got there, that started, actually, just a few days before he took over, that more than 57,000 patients are still waiting for their first medical appointment at a VA medical center, after at least 90 days. And that another 64,000, who enrolled in the VA healthcare system over the past decade, have never had appointments, because they haven't been able to get it. Now, as you said, that's in a universe of about nine million veterans, who, in one way or another, receive either VA benefits or receive VA healthcare.

O'KEEFEIn a bigger universe, of the tens of millions who've served the country in uniform. And it just is the latest demonstration of how this system, really the largest healthcare system providing veterans anywhere in the world, is so terribly strained, and has been unable to meet the requirements that it's been put under in recent years.

NNAMDI800-433-8850 is our number, if you have comments or questions. You can call us there. Send us an email to kojoshow@wamu.org or send us a tweet @kojoshow. Are you a veteran? What was your experience with service and care through the VA? 800-433-8850. Ed, the House Committee on Veterans Affairs is due to hear tonight from the Inspector General. What can we expect from that hearing?

O'KEEFEWell, we're gonna hear more from a separate audit that's underway by the VA Inspector General, who's the independent watchdog, and has been looking into these types of concerns for years, mostly under the radar, beyond the national -- the nation's attention. In this case, he too is expected to begin outlining not only what's going on across the system, but what was going on at the VA Medical Center in Phoenix, where the most recent damning allegations really center from.

O'KEEFEThis is the second largest veterans' community in the country after the Los Angeles area, and of course there are those allegations, and so far, they are only supposed allegations that as many as 40 veterans had died while awaiting care. Mr. Gibson, the new acting Secretary, went to Phoenix last week and confirmed that at least 18 veterans who had been on a waiting list, died before they were able to see a VA medical official. That doesn't mean they died because they were waiting. It's just that they had died.

O'KEEFEBut of those 18, 14 of them were seeking end of life care, which would suggest that perhaps it might have been in part because the VA wasn't there to help them. So, that IG investigation is going on. There is a separate investigation being done by the Government Accountability Office, which of course is Congress's independent watch dog that goes out and investigates these things. And increasingly, Democrats and Republicans are calling for the Justice Department to get involved and look at whether or not any crimes were broken.

O'KEEFEIf VA employees, perhaps, had been falsifying government records or destroying government records to cover up all of these problems.

NNAMDIWell, we've been hearing a lot about Arizona, Kansas, and Missouri. Anything yet about how these waits for appointments break down for veterans using facilities in this area?

O'KEEFEYou know, anecdotally, Kojo, those of us here at the Post certainly hear from people who have tried to use the system, saying that they have had concerns that the one here in Washington, or facilities in Virginia and Maryland. I, myself, have not seen anything terribly, on the scale of what happened in Kansas City and Phoenix and Atlanta and Augusta and other places. But, you know, you can very easily find people who have had concerns with their care. And yet, you look at nationwide customer service polls of those who use the VA system, and overwhelmingly, they say their care has been good.

O'KEEFEThey appreciate that it's there. They want it to continue to be there. The problem, really, has been getting into the system. Getting an appointment, getting the surgery in a timely manner. And it just shows you that supply is not meeting demand.

NNAMDIOur guest is Ed O'Keefe. He's a Congressional reporter with the Washington Post. Ed, any temporary or emergency measures, that we know of, that are being taken right now to make a dent in this backlog?

O'KEEFEWell, Gibson, in releasing this initial report today, notes that they're going to eliminate this 14-day scheduling goal. The problem with this is not only does it appear to have been unattainable, but it's been used as a big measure in performance bonuses for workers. And they say, because of that, it was being manipulated, so it's basically gone. The VA also plans to post updates twice monthly on access to care, sort of getting at the criticism from Congress, especially, that the department has been hiding details or perhaps not sharing all of its information.

O'KEEFEThey're opening themselves up to an independent external audit. They don’t say who, exactly, will do that, but they're gonna do it. They're sending more people to Phoenix, specifically, to deal with the ongoing problems there, and they're gonna continue dispatching people to other problem areas. And they're also, in some cases, deploying mobile medical units to some communities in order to start getting people into the system. On top of that, we know that Gibson was granted authority by Shinseki before he left, to start going through and finding senior managers who perhaps were not meeting the standards of care.

O'KEEFEOr perhaps manipulating data, and it's expected that the department will start taking steps to remove those people. As that happens, Congress, of course, is debating whether or not to give those powers to the Secretary permanently. It's a very popular proposal among Democrats and Republicans, and it's part of a big series of proposals that the House and Senate are considering. But considering how slowly Congress moves these days and how unproductive it can be, clearly the department trying to do whatever it can beforehand to address this still lingering problem.

NNAMDIWell, you mentioned that maybe 14 of those veterans in Arizona who died were seeking end of life care. Any stories coming out about how long it takes to get minor procedures done within the VA system?

O'KEEFEI can tell you, based on emails I've received from years, Kojo, cause you remember, you and I used to talk when I covered federal agencies.

NNAMDISure.

O'KEEFEAnd even then, I would hear from people who, every time you wrote about veterans' affairs, even just mentioned it in passing, it prompts mail. People tell you, you know, it can take weeks. It can take months. People trying to get colonoscopies, for example, have to wait way too long. And then, on the flip side, people getting their care and they've had problems with poor care. There was the case of veterans out in Pittsburgh, for example. Several from -- obtaining Legionnaires Disease, because they were given faulty medical care.

O'KEEFEOther examples of people being treated with unsterile equipment, that gave them other types of diseases. In some cases, I believe HIV even, because they were treated with poor equipment. So, it's not as easy, necessarily, as being able to call up and say, I want my routine colonoscopy in three weeks. Is that doable? And often, you hear that in some cases, it's not. And that's why you see, in this push, in the last two weeks, especially from lawmakers, to say let's, you know, allow these guys to take their veterans' benefits to maybe the minute clinic down the street.

O'KEEFEOr the, you know, the general practitioner who works around the corner. Get the basic medical care there, and then if you have something related to your war related injuries, or you need treatment for PTSD, or you need more significant surgery that the VA can perform, come to us for that. And if that plays out, there is some belief that that will help alleviate the problems and get more people into the system, and perhaps turn it around. But, you know, just the fact that people can't get in for basic procedures, let alone more significant ones, just shows you how strained the system really is.

NNAMDIFinally, Ed, this weekend, we heard that Cleveland Clinic Chief Toby Cosgrove took his name out of consideration to become the new VA Chief. Any other names floating out there for serious consideration?

O'KEEFEWell, you -- serious consideration's the key there, Kojo. A lot of peoples' names have been mentioned, everyone from Senator Tom Coburn, the retiring Republican senator of Oklahoma, to Pete Chiarelli, the former Army General, who in more recent years has worked on traumatic brain injury research out in Washington state. But beyond Toby Cosgrove, who is the head of the Cleveland Clinic, there have been no names seriously floated by government officials as of yet. And that should be surprise. This is a thankless job. Shinseki, when he was there, was doing Yeoman's work, everyone says, trying to steer this ship in a better direction.

O'KEEFEAs you can see, he got tripped up, and with only about two and a half years to go in this administration, and with no guarantee that the next President would want them to stay on, why would anyone necessarily want to devote themselves to this, at this point? And so it's very unclear. Look, Sloan Gibson, the Deputy or the acting right now, is a guy who has strong connections to the veterans' community. He used to work for the USO. He is an Army veteran himself. And has received decent remarks in his first few months on the job.

O'KEEFEBut he's only been there, really, since the beginning of the year. You talk to lawmakers, they say, we want someone from the outside, maybe someone who comes from a big healthcare management company. Someone like Toby Cosgrove, maybe someone from Blue Cross or from Aetna. Maybe someone who has military experience also, who can come in, start looking at this, treating it like a hospital system, and figuring out how to right this ship. But it will be a thankless task for whoever agrees to do it.

NNAMDIWell, we can guarantee that Ed O'Keefe is not applying for this job.

O'KEEFENo.

NNAMDIEd O'Keefe is a congressional reporter with The Washington Post. Ed, thank you so much for joining us.

O'KEEFEGreat to be with you, Kojo.

NNAMDIAs we mentioned, we also have, in studio, Donald Kettl. He is Dean of the School of Public Policy at the University of Maryland. Donald, good to see you again.

MR. DONALD KETTLGood to be back, Kojo.

NNAMDIAlso in studio with us is Alex Horton. He's a freelance writer, former blogger and social media editor for the Department of Veterans Affairs. And a US Army veteran. Alex Horton, welcome.

MR. ALEX HORTONGlad to be here, Kojo.

NNAMDIAs I said, we're taking your questions at 800-433-8850. If you have called, stay on the line. We will get to your calls. Don, can you give us some perspective on why the US government's largest agency has gotten so bogged down with its patient load, why they didn't even see this coming?

KETTLNow, this was just an amazing story here, because if you go back a decade, back before the 9/11 attacks and before the wars in Iraq and Afghanistan, the VA was largely an agency that was increasingly focused on geriatric care. Working on trying to ensure good care for, at that point, aging Vietnam and Korean War vets, and making sure that they could provide the care that was needed. And they were doing a pretty good job of that, having turned things around significantly back during the Clinton years.

KETTLBut then, what happened was a war that nobody really quite expected turned into a war that lasted a lot longer than anybody predicted, and turned out to produce a lot of veterans who, in previous wars, might have either died on the battlefield or wouldn't have suffered the kinds of traumatic brain injuries, and you put all that together, all of a sudden, there's just an avalanche of new kinds of patients of a different age, with different kinds of problems than what the VA had prepared for.

KETTLAnd all of a sudden, there is a load that the VA wasn’t prepared to meet, and it's been running as fast as it can, ever since, to catch up, but obviously not running fast enough.

NNAMDIWell, now we've got a bipartisan deal hammered out in the Senate that would allocate 500 million dollars to the VA. It would also allow the VA Secretary to clear out bureaucracy by firing or demoting officials tied to mismanagement. But this is a department where you've got a 9,000 to one ratio of career to political appointees. Is this going to be tough?

KETTLThis is gonna be a real, really tough job. As Ed pointed out, it is a thankless job and it's very much like trying to find a way to force a thousand gallons a minute through a water hose that can only take 50. We just have to spend strategies and figuring out how to catch up with the problems, how to try to make sure that these hospitals are managed much better on the front lines to change the culture and change it fast. But at some point it is a matter of resources and finding a way to get those resources much more quickly to the veterans who need them.

NNAMDIAlex, you're an Iraq veterans but you also occupied a unique role inside the VA until last year. You were a blogger and also a tough critic of the institution that you worked for. In fact, the VA hired you after you had written a blog post in 2009 that said, and I'm quoting here, "How many obscene scandals, misappropriations and misdiagnoses does it take to see there's a rotten core at the center?" Why did the VA hire you after that public tongue-lashing?

HORTONWell, I think there was an explicit admission by top VA officials that, you know, VA, since its inception, had trouble communicating with veterans, you know, explaining the benefits they needed, but also hearing about the problems that they're having. You know, when you communicate with the VA it was usually a one-way conversation. You know, they sent you something in the mail or you talk to your doctor but there was nothing really going back the other way from veterans to VA.

HORTONSo they brought me in in 2010, you know, back when Tammy Duckworth was heading Public Affairs. And under the direction of Secretary Shinseki they said, you know, this has gone on long enough and we have the tools out there to start listening to veterans and hearing what the issues are. And so a lot of my responsibilities centered on two things. One of them was getting out information on what veterans needed, you know, benefits, resources, things like that they were missing. Because when you talk to a veteran they say, I don't know what I qualify for. And it's always been a problem historically. So we wanted to project that.

HORTONThe second one was countering the bad things that were out there, going on with the veteran's conversation. One of the things that we're proud of when I was there was countering the veterans as victims and veterans as, you know, PTSD adult psychos that you see every once in a while when there's someone who has some connection to the military, you know, acting out or, you know, committing some kind of crime. So we were really on point with that and other issues like, you know, for profit schools and their predatory search for veterans.

HORTONSo there's a lot of things that we had to take issue on. You know, we had to listen to veterans. We had to speak on their behalf, but we also were there to get the kind of on-the-ground truth as some of these things that we're talking about today, unfortunate...

NNAMDII was about to ask, give your experience as a social media editor at the VA monitoring chatter by vets, were these agency-wide problems that have emerged a surprise to you when they were revealed?

HORTONIt wasn't a surprise to me at the macro level. I mean, when you talk to a veteran, the two things that they would have issues with at VA is getting my claim approved quickly and getting in the door when I want an appointment. And anyone who pays attention to the VA and veterans' issues realizes this is not a new problem. Since 2001 there's been close to 30 IG and VA audits and GAL (sp?) reports specifically on wait times alone going back more than a decade. So this is not something that has just cropped up in Phoenix in 2014. So...

NNAMDIDid the scale of the problem surprise you?

HORTONThe scale of the problem surprised me because for so long there was a national and very systemic problem with people misreporting actual wait times. And, you know, they're fudging the numbers and they were manipulating wait times and getting in the system and changing it. Because of what Ed O'Keefe talked about earlier, that there is this kind of bonus system in place that rewards this kind of behavior.

HORTONSo I think the secretary was caught off guard. I think the regional directors were caught off guard. The only people who knew the extent of this problem were the people messing with the numbers in the first place. And that's very troubling when you talk about a network that's supposed to catch these things before they become crises.

NNAMDIDon Kettl, does it really take a scandal of this magnitude to bring about real change in an agency like this?

KETTLIn a nutshell the answer's yes because it's not as if in some ways we haven't known about the frontline problems. And on top of that, as Alex pointed out, we have this additional problem of trying to find a way to manage the veterans benefit system out there, which is also a mess in which Jon Stewart among others have been savaging regularly every few weeks for the last couple of years here at this point.

KETTLThis is going to take fundamental change in the frontlines of the VA. It's going to take more action by congress to put in place money to try to make sure that we can actually provide the care the veterans deserve. But it's going to take a reengineered Department of Veterans Affairs too to make sure that as the more money arrives it's actually used in a good way. It's just a very hard problem.

NNAMDIWhat don't they understand about when John Stuart noticed it's a scandal in the making?

KETTLAnd the thing is that they did and he just -- he savaged them. It was just brutal but it was about a completely separate piece of problem. So they've been spending time and have actually made some progress, limited but some progress in reducing the wait time for processing veterans' benefits. But in the meantime, this wait time for veterans' care was out there lurking and was brushed under the rug. The numbers that the secretary was getting looked like they were making at least decent progress on that, but he wasn't getting the real numbers.

HORTONAnd it was hard for him to manage...

NNAMDIFudging the numbers. Got to take a short break. Hold that thought for a second, Alex. When we come back we'll continue our conversation. Many of you have called so if the lines are busy and you'd like to join the conversation, shoot us an email to kojo@wamu.org or send us a Tweet at kojoshow. What changes would you recommend at the VA? I'm Kojo Nnamdi.

NNAMDIWelcome back to our conversation about the fallout and fixes to the VA scandal. We're talking with Donald Kettl. He is dean of the School of Public Policy at the University of Maryland and Alex Horton. He's a freelance writer and former blogger and social media editor for the Department of Veterans Affairs. He's a U.S. Army veterans. I interrupted a thought you were about to express, Alex.

HORTONRight. And Donald was raising a very good point about how could we have missed this and why does it take these VA scandals to get anyone to pay attention? You know, in the last month I've fielded probably more than a dozen media requests and things like that. And it's just the interest nationally on this is unprecedented. The question is, why weren't we talking about this before? You know, what warning signs did we miss?

HORTONYou know, earlier I mentioned, you know, 30 IG probes going back to 2001 specifically on this issue alone. And, you know, there's no question that VA systemically failed to get people in on time. They manipulated data at perhaps dozens of facilities. They put people's lives at risk. There's clear failures there.

HORTONWhen you get to that level of systemic failure, there are watchdogs that are supposed to be there to catch mistakes before they become national issues and national crises. You know, people like Jeff Miller who chairs the House Veterans Affairs Committee receive these IG probes too. And, you know, he failed to do anything about it. You know, even in his home state in 2011 he received an IG report that said, veterans in Florida are waiting too long for cancer appointments after they've been diagnosed. He didn't do anything about that.

HORTONNational Veterans organizations like the American Legion who has led the calls for Secretary Shinseki's resignation, they have, you know, hundreds of thousands of members if not more than a million across the country and they missed this too. You know, organizations that are very vocal on this issue like Iraq and Afghanistan Veterans of America IAVA, you know, they've missed this also. You know, they have not been on this -- they've been on every other issue except this.

HORTONSo when we talk about the fundamental changes that need to happen within VA, we also need to talk about the fundamental powers and privileges and the influence that these groups have. Because obviously they're not doing their jobs either.

NNAMDIInstitutional failures in a variety of institutions. Here is Ben in Berryville, Va. Ben, you're on the air. Go ahead, please.

BENOh, well thank you for taking my call. You know, when you go to a fast food restaurant you put in your order at the register and you go on a clock. And a minimum-wage employee, when they hand you the order, takes your name off the clock and there's a camera on them. So they know they're being watched. And if they try to cheat the clock, they're fired. If we can do this for a minimum-wage employee, I don't understand why we can't do it with the VA.

BENAnd I'm not trying to cite the size and the scope of the problem. It's huge. It's massive and it's a massive government bureaucracy and I get that, but, you know, two years waiting on a resolution for a case to be processed is just unacceptable. I think we need to simply take this half a billion dollars and take a portion of it and say, look anybody who takes more than this number of days to get the claim processed gets sent out to an outside company. Something like account temps, but for this specific kind of stuff.

BENAnd, you know, get a company -- I'm sure there are tons of companies I this area who would love to gear up the process of this paperwork and they could be geared up in six months. You know, say look if we can't do it right in the right amount of time that we have to pay the extra to the private sector to get it done. And then we work on improving our metrics 5 percent a quarter per facility, 10 percent, you know, a year total or something. And so we can get to the point where we can handle the load ourselves. But if it needs to be sent -- I don't understand what the problem is.

NNAMDIBen said if you give people pay based on performance and ability to fudge the data then that's exactly what they'll do. Don, as the new leader of the VA looks to reform this agency, what previous examples of reform can he or she use as a guidepost?

KETTLWe've seen some turnarounds in government. We thought that FEMA was just broken beyond repair after hurricane Katrina. And what we have now is an agency that's dramatically different. And you go back to the big story that wasn't written after Super Storm Sandy, it was FEMA fails yet again because FEMA didn't. They did a terrific job after that. And on top of that the VA, during the Clinton years, is actually a story of radical reform that worked pretty well after that.

KETTLBut the core of the problem and what Ben's asking is to understand that the VA problem right now is not one problem but two. The quality of care that veterans receive for the most part seems to be pretty good. There are complaints here and there but for the most part the complaints are not that veterans don't get good care. The complaints are that it's too hard to get into the system to get the care to begin with.

KETTLSo that has to do in part with the problem of getting enough resources in there, and then secondly making sure that we have numbers that we could actually trust. And what happened here was that there was such incredible pressure on the people in the frontlines to meet their targets that when it turned out that they couldn’t because there just weren't enough resources, they swept the numbers under the rug to make it look like that they were hitting the targets but in fact that they weren't.

KETTLAnd the reason was that they were getting incentives to be able to do high quality work. And when they couldn't meet the targets, they just hid the numbers to make it look like that they were.

NNAMDI800-433-8850, does the VA need a post-9/11 veteran at its helm? What skills should the new leader have to fix this system? What's your view, 800-433-8850? Let's go to Arnold in Deal, Md. Arnold, you're on the air. Go ahead, please.

ARNOLDGood afternoon. Thank you very much for this call and subject. Briefly I just wanted to state that I'm a retired naval captain. I retired in the '70s. And for 20 years I did -- I had many, many customers. One was the VA in D.C. on North Capitol Street. And it was one of my best customers. And I later started working on a Masters in management and I could tell you that my experience with the VA was they ran a tight ship. It was perfect. It was like being in the military.

ARNOLDBut that was then. They've -- seven -- well, once -- and I hate to point at the turn of the century, but when the president -- when the direction of the country changed and veterans really didn't take precedent anymore, so much resources were diverted away because the system just kept working. And it's like politics. The squeaky wheel gets grease. And the service at D.C. was great. The purchasing was great. But that was then. You know, it's been 15 years since we've acknowledged our responsibility.

NNAMDIWhat do you mean by that? What changed in 2000?

ARNOLDWell, I tell you what. We'll get more recent. We'll point to the sequester.

NNAMDIYes.

ARNOLDAll right. My daughter works for the VA. She has for six years as an undergraduate and as a graduate. Now she's got a couple of masters. She's a social worker. She specializes in PTSD. Her husband works for the Navy Department. His building was shot up few months ago.

ARNOLDSo we're really familiar, have many, many veteran friends...

NNAMDIWell, I don't know. Donald Kettle, was there, in your view, a significant societal cultural change that happened at the change of the millennium that may have had an influence on this? Are we talking about the increase in numbers as a result of 9/11 and the two wars that we fought?

KETTLIf there's anything that's changed in the last 15 years or so it's been more attention to making sure that we treat our veterans well. It certainly isn't the case that we've decided, oh we just don't care about the vets or let's try to do it on the cheap. The problem has been that we have many more veterans with new kinds of problems, some of which are difficult to diagnose and to try to treat. The PTSD and traumatic brain injury cases are especially difficult. And then on top of that we have injuries that are now survivable but would not have been in pervious wars, which complicate the problem on top of that.

KETTLAnd then we have so many veterans scattered around so many parts of the country that in many cases are so away from the VA on top of that, they're not near a local VA hospital and that further complicates the problem of getting access to care. We just have got an enormously more complicated set of problems. So if there's anything that's changed it's not certainly our commitment. It's been how hard the problem has been to solve.

NNAMDIAlex, I wanted to get back to a point you made earlier about some of the other institutions. What kind of actions should groups like the American Legion or the Iraq and Afghanistan Veterans of America take now that this scandal is radioactive on Capitol Hill?

HORTONWell, just like VA found -- like their actions are coming too late. You know, people -- you know, veterans had their lives on the line and they were endangered by these systemic failures to get care on time. So anything that American Legion and IAVA and VFW and the DAV and the House VA Committee have done, they've already -- they're acting too late. But they too can learn from this as well. They respond to the media cycle just like any other organization. You know, if the story is not in the news then they're not talking about it.

HORTONSo there needs to be a more comprehensive focus on what these groups are doing. They need to be better attuned to what's going on in their community because out of all the hay that some of these groups make -- and they serve a very important function of oversight and aggressive advocacy -- but in a lot of ways they mirror VA in some of the problems that are fundamentally in the system.

HORTONFor one, they are reactive rather than proactive. You know, you see them coming to the Hill and making the case and calling for resignation after the fact and not before the fact. You know, they weren't there either so they have a problem detecting these systemic issues just as VA did. And another point is, you know, they suffer from the same inconsistent leadership and, you know, problems with resources and oversight because, you know, they're stretched thin too. You know, IAVA doesn't even have a national footprint. They're very internet based. And American Legion has very, you know, their population is older.

HORTONSo they have very inconsistent leadership and very inconsistent ways that their members are driving them to these issues that they need to solve. And that apparatus needs to be fixed as well.

NNAMDIWe got an email from Bill, Don Kettl, who says, "While there are probably as many problems at the Veterans Affairs as there are proposed solutions, the one silver bullet that seems likely to result in multiple positive outcomes is an additional qualification for the cabinet secretary in charge, a medical degree. This makes it more likely that whatever changes might be implemented would be directed toward better care for the population the institution is designed to serve."

NNAMDIBut even as I say that to you, I say if health care wasn't a complicated enough business, the VA also has huge benefits and disability divisions all with their own challenges. So simply have a medical degree wouldn't necessarily solve this problem, would it?

KETTLThat's not going to solve the problem at all because there -- not only are these huge wait times at too many of the veterans' hospitals around the country, but also this lingering problem that in the middle of all this we've forgotten which is the veterans' benefits problem out there, which is huge, and which is what it is that the VA had been focusing on which the media mainly has been focusing on for the last couple of years.

KETTLHaving a physician at the top certainly is not a bad idea but not all doctors necessarily know how to manage. And we obviously do have medical directors at each of the VA hospitals as well whose job it is to ensure the quality of care. The real problem is trying to find a way to get the strategy right, get the measures right and to make sure that the right amount of resources go to the right hospitals. And that's not necessarily just purely a medical problem.

NNAMDIAlex.

HORTONYeah, and the top-down leadership is very important. And, you know, you have to have the right mix of, you know, someone who has probably military experience. I think that goes a long way to establishing credibility with veterans inside the system. You're going to need someone who has, you know, profound and extensive experience in the private sector and running large organizations and budgets. That's important. That's going to be a focus over the next few days, weeks and months.

HORTONLong term, these problems originate at the local level and they become national problems. So not a lot of discussion has been on, how do we get midlevel managers at these hospitals or regional offices or these busy networks that, you know, they oversee large portions of the country? We're not talking about how we change the culture from the bottom up either. And that has to be an enormous focus because this is where the culture is changing.

HORTONThey don't care about who's -- these people that -- they're in their own orbits. You know, their own universe is a VA hospital in St. Louis or a medical facility in Shreveport. They don't care about who's at the top. A lot of them probably couldn't even name Secretary Shinseki. They care about what's happening in their office and in their place of business. So we really have to focus on getting the right people in at midlevel and lower level.

NNAMDII was about to say, can we do top down and bottom up at the same time?

KETTLWell, we have to. And the place where they meet is in the regions. And if there's a failure in all of this, it's something that we not talked very much about at all yet, which is that back 15 years ago and 20 years ago there were major reforms made to the way in which the regional offices, which is where they come together out there in the field, and there were small very nimble organizations that were created that overtime got larger and larger, more and more budgets, more and more employees. And that's where the wheels came off in some cases.

KETTLAnd you can't run a system as large as this from Washington. You need strong regional offices out there that can keep an eye on the hospitals. And that's something very clearly where the VA has failed and where a lot of management attention needs to be given. That's inside baseball but that's where the balls and the strikes are going to make a different in the end.

NNAMDIWant to go to Frank in Fairfax, Va. because Frank wants to talk about benefits over all. Frank, you're on the air. Go ahead, please.

FRANK CALLER)Thank you. I'm Korean vet but my real strength is that I've been in policy research like Dr. Kettle for the last 11 years. And I've made a study of federal agency operations, and want to say a couple of things that haven't been mentioned in the media so far except in the Post where it's pointed out that congress has distributed too many perks in an unwise way for their own reasons that have come to be a problem now.

FRANK CALLER)Second, a general is not necessarily the right person to run a system like this because they're used to giving orders and having them executed. They're not used to giving -- solving problems and understanding what's going on at the bottom. The third point is, there's no excuse for a leader at the top not to know what's going at the bottom if he really wants to know because there's all kinds of ways to pass the word to friends and to associates and people that know...

NNAMDIWell, allow me, Frank, to tell you how long that problem's been going on because, Don Kettl, communication between the low-level employees and the top brass was a problem for a long time. We're finding out that way back in 2005 federal auditors found that clerks were not entering patient wait time numbers correctly. Here we are nine years down the road, nothing was done about it. How do you being to bridge the gap between the field offices and Washington?

KETTLIn many ways that's the core of the problem. Again, it's worth remembering that the complaints are not about a poor quality of care, just about getting into the system to begin with. so the first thing that has to happen is to make sure that the numbers are things that people can actually pay attention to from top to bottom. And there has to be transparency from the outside in and the inside out as well.

KETTLThe second thing is that we've got to get the incentives right because on the one hand you don't want to tell people, well those are interesting numbers and you're meeting the numbers, you're not meeting the numbers but there are no consequences. There have to be consequences that drive the system in the right way without creating the wrong kind of incentives for people to make up the numbers or hide them.

KETTLAnd so that's a very hard thing to try to get things straight and which will be one of the really critical problems if somebody comes in and says, let's just run this like the private sector and we could end up replicating these problems all over again. We've got to get that straight.

NNAMDIWell, Alex, congressmen that have been providing a lot of oversight over what's been happening with wait times, but the point Frank seems to be making is because Congress has mostly been concerned with throwing more benefits at veterans all the time. And now that's becoming unmanageable.

HORTONRight. And, you know, when VSOs and the veterans groups, they say jump, congress jumps. They want to be seen as friends. They want to be seen as people who take care of veterans but only on the surface level. You know, congress, you know, in the House and in the Senate they're very concerned with like the service level, very easy fixes like, you know, we should put in VA accountability to fire senior leaders. It doesn't take care of the media problem. It doesn't take care of the problem that's going to be with us for decades if we don't get this -- getting the right culture and getting the right people in place.

HORTONYou know, when I took a look at what VA was putting together for today's audit when they said, you know, close to 60,000 people were waiting for initial appointments to get into care, there's -- very deep within it is this very explicit understanding that there is inconsistency when it comes to what kind of care you get in Phoenix versus what you get in Washington, D.C. or Ann Arbor. Some facilities perform better than others. It has to do with location.

HORTONYou know, the one in Palo Alto does great because people want to live in Palo Alto, you know, live in California, they don't want to work in, you know, Minnesota. So some of those things are understandable. But what you see here is you see VA saying that some of our facilities aren't up to snuff. And there are some facilities that do better than others, you know. And this is not like the McDonald system of quality when a Big Mac you get here is a Big Mac that you get somewhere else. That's not happening here. You know, people are missing their onions and their pickles on some of the Big Macs across the country.

HORTONSo the problem is they have to figure out why facilities are doing good. You know, is it the people? Is it the budget? Is it the kind of talent they can attract? And they have to duplicate that across the country.

NNAMDIGot to take a short break. If you've called, stay on the line. We'll try to get to your calls. If you'd like to call the number's 800-433-8850. Should there be a different health care strategy within the VA for treating older vets versus younger ones with complications from modern warfare? What do you think, 800-433-8850? I'm Kojo Nnamdi.

NNAMDIBack to our conversation about fallout and fixes to the VA scandal. We're talking with Donald Kettle, dean of the School of Public Policy at the University of Maryland and Alex Horton. He's a freelance writer and former blogger and social media editor for the Department of Veteran Affairs. He's a U.S. Army veterans. Alex, as we talk about fixes for the VA, it's also worth pointing out that the system is doing a lot of things right. Can you talk about why health care in the VA is so highly regarded despite its current issues?

HORTONRight. And, you know, Donald mentioned this earlier how well-regarded and efficient and professional it was during the Clinton Administration. You know, that was a time of rapid and very extensive transformational change. You know, new technology came aboard. You know, VA has always been the leader of electronic medical records. And you can do things through their web portals that no one in the private sector can do.

HORTONYou know, when I sign on to a portal called E-benefits at MyHealthyVet, I can email my primary care doctor, I can set an appointment, I can order prescriptions, I can get the results on my last blood test all from a computer.

NNAMDIAllow me to interrupt for a second because that's precisely what Carl in Washington, D.C. wants to talk about. Carl, your turn.

CARLWell, hi. I was listening to the discussion and I've heard it before about allowing vets to go to private docs and others, which I understand the motive behind that to clear things out with the -- of the backlog. But the VA system has an electronic health record system called Vista which is a gold standard of such systems and does a superb job of tracking the care that these veterans receive and storing the information and aiding docs.

CARLSo if you have an allergy to penicillin in Seattle, the VA doctor in Roanoke, Virginia's going to know about it instantly. And if they go off system to see these other docs, I want to know how their medical records will follow and how these doctors will be able to put information back in. I'd had to see a really excellent program become a victim of a fix which may be necessary but needs to be thought through.

NNAMDIDonald Kettl.

KETTLOne of the things after Hurricane Katrina that turned out to be an enormous surprise to everybody was that there were so many people scattered out of New Orleans ended up going to new docs. They didn't have the medical records with them. Nobody knew what prescriptions they were on except for the veterans who ended up scattered through other places, walked into a VA hospital someplace else and there their records were waiting for them because it was all electronic.

KETTLAnd that's something that is an enormous asset in the system. They are not only world class but they're one of the pioneers out there. There's some hope that as the Affordable Care Act begins to create online record systems for people that eventually that'll begin to catch up. But we're a long way from that. And one of the things we don't want to do is to make sure that the electronic records get disconnected from the veterans who are receiving care.

NNAMDISince 2009 there have been 1.4 million new patients to the VA system, mostly returning Iraq and Afghanistan vets. As we think about how to improve care at the VA, how do you balance the needs of a younger population of vets, like you, Alex, with the needs of an older generation who are dealing with the complications of aging? Do you just throw more money at the VA? Do you split things off?

HORTONAnd I want to address a point Donald made earlier.

NNAMDISure.

HORTONAnd, you know, if you want to send veterans outside the system, a funny paradox is, you know, if you say VA's inefficient at doing this and, you know, housing their medical records, asking them to take their medical record to the private sector would be a step back. You know, their systems can't talk to -- and they probably don't even have the electronic system to even read it. You know, it'd be like taking a DVD and trying to shove it into a VCR, you know, because VA's very advanced when it comes to medical records.

HORTONSo I think a lot of the issues that people are talking about of getting people in the private care are things that are kind of routine. Like if you have the flue or, you know, if you need to, you know, go to the ER for, you know, stitches or something like that. I think what really needs to hold veterans to VA is things like traumatic brain injury care, post traumatic stress disorder, you know, military sexual assault, amputee and prosthetics. Like, those are the things that VA has just an enormous well of experience to draw from.

HORTONBut when you talk about the kind of care that veterans are going to need, Iraq and Afghanistan veterans are going to need in the future, it's going to be difficult to balance because right now 36 percent of veterans who are in VA health care are in their -- in rural areas. You know, they live in -- you know, they live in Minnesota and Alaska and Montana. They're very far from VA facilities. So one of the solutions is tele health. You know, routine medical appointments or maybe counseling done via computer. That's one thing VA is always increasing is.

HORTONSecond thing is mobile vet centers which they're dispatching as we speak to take care of some of these long-standing issues in Phoenix. But when you talk about what they're going to need in the future. it's hard to predict. We can't follow the Vietnam model. When veterans came back from Vietnam they filed, you know, one, two or three claims, you know, probably for like a gunshot wound or something like that or amputation.

HORTONBut veterans are living through their injuries and they have grievous injuries coming back from these wars, and very hard to diagnose and very complex injuries like traumatic brain injury. So when you talk about what they're going to need, there is absolutely no precedent that we can draw from. So the next secretary has to be very nimble and very proactive on the very fluid and very elusive needs of veterans. Because they're quite frankly different than any other generation we've had in our history.

HORTONAnd that focus needs to stay on, you know, this population because right now we're the minority. You know, there's almost three times as many Vietnam veterans out there as Iraq and Afghanistan veterans. It's not the problem that we're flooding the system. We're coming into the system at a pretty good pace but we have very complex injuries to take care of.

NNAMDIHere is Lee in Centerville, Va. Lee, you're on the air. Go ahead, please.

LEEHi, Kojo. Thanks for -- I wonder if -- one of the things I hear -- this is a great topic to go over medical coverage for veterans. I'm a veteran myself. But one thing that's not being talked about either is sort of the rest of the short fallings with VA counselors when it comes to the GI bill. I lost several thousand dollars due to my counselor didn't want to work with me on changing my program. Another issue is converting your SGLI to VGLI.

LEEThere's always different benefits that veterans are eligible for, but they're not adequately trained or -- yeah, there's really -- the two-day class before you check out of the service, which your commanders generally make you -- give it to you a week before you get out, you're certainly not going to remember all the stuff that they throw at you. Next thing you know, you find out that, well, I could've converted my -- a citizen's group life insurance into a veterans group life insurance. But I found out ten years too late. Those are issues also that aren't being addressed.

NNAMDIOkay. Thank you very much for your call. Alex.

HORTONYou know, Lee points to an important point that the handoff from DOD to VA is -- it's never been good. It's never going to -- it seems like that's one of the crux of the issues when we talk about, you know, transition from DOD to VA systems. Their medical records don't talk to each other. Even though VA has -- you know, a caller mentioned earlier -- Vista, they have a better system for medical records than DOD does. But DOD refuses to transition over.

HORTONYou know, it was a pride thing. It was a pissing contest thing. And they didn't want to be onboard. So they've abandoned all hopes of connecting the system. But he's talking more about the transition from when you leave active duty and you become a veteran and what are the benefits and what are the things you qualify for? The amount you learn is only as good as the counselor. And most of the counselors are inept. They're incompetent. They don't know what's going on on the VA side because they work for DOD.

HORTONSo they speak an entirely different language and they have no idea how to measure your needs. You know, when I -- I was an enlisted infantryman. You know, I didn't have a great rank when I got out. I mean, I was just -- I just did one tour. So there were not a lot of options for me when I got out. You know, when I took the career aptitude test, you know, I got security guard, truck driver. You know, and I wanted to go to school. I mean, I was -- you know, I was writing stuff that was in the L.A. Times and, you know, they're telling me that I have to go be a truck driver, you know.

HORTONSo there's -- even these portals that have cropped up for veterans for, you know, job banks and things like that that measure, you know, their military job and their aptitude, it's -- it totally misses the mark and it's a huge issue.

NNAMDIRunning out of time. Very quickly, what one recommendation that groups like IAVA is making is that the new leader of the VA be a younger post 9/11 veteran. I'd like you both, in the time you have left, to respond to that. First you, Don.

KETTLThe symbolism is important. If you have someone who's a young eager go getter with a lot of managerial experience, that helps but that helps for about the first 60 seconds. And after that point, everything else is going to be determined by how good the results are. And it's going to depend ultimately within days about whether or not the new secretary can get results. And that is what's going to be most important of all.

NNAMDIWhat do you say, Alex Horton?

HORTONThe problem with these groups when they make solutions like this is it's all about appearances. And, you know, the appearance of a young go getter veteran is good but it's not going to solve the systemic problems. You know, what I mentioned earlier is, like, there's a real leadership problem at the lower level and midlevel. That's what we need to address so how about we get the young Iraq and Afghanistan veterans in there who are young go getters and they can wrangle out some of these issues. I think that's where our population and my, you know, new culture will think about addressing those problems at that level, not necessarily at the top.

NNAMDIAlex Horton is a freelance writer. He's also a former blogger and social media editor for the Department of Veterans Affairs and a U.S. Army veteran. Alex, thank you for joining us.

HORTONThanks for having me.

NNAMDIDonald Kettl is dean of the School of Public Policy at the University of Maryland. Don, always a pleasure.

O'KEEFEGreat to be with you there, Kojo.

NNAMDIAnd thank you all for listening. I'm Kojo Nnamdi.