When President Obama was a candidate back in 2007, he pledged to remake the Department of Veterans Affairs (VA) for the 21st century. Seven years later, and six years into his presidency, it's still a goal that in many ways seems out of reach, especially with thousands more servicemembers returning home as wars overseas wind down.
The VA is roiled in scandal over allegations that numerous VA medical centers maintained secret waiting lists to conceal the number of patients who were not able to see doctors within the 14-day goal period.
It's hardly the first time the agency was accused of failing to give veterans timely access to care: the nonpartisan Government Accountability Office reported on evidence of VA wait time failures as far back as 2000, while the Office of the Inspector General at the VA (the agency's internal watchdog) looked at this problem in 2005, 2007, and again in 2012. The scandal has led to a raft of other accusations.
Mr. Obama spoke publicly about the issue for the first time in three weeks Wednesday, saying he "will not tolerate" mismanagement at the nation's VA hospitals. But what will it take?
The solution that most members of Congress and veterans groups are turning to is a major management overhaul, one that some believe should include the departure of VA Secretary Eric Shinseki.
The prevailing narrative from some, said Nick McCormick, a legislative associate for the Iraq and Afghanistan Veterans of America (IAVA), is that "there's a few bad apples but overall the VA has a spotless record...that's not really the case."
"The accusations we've heard in the last month or so, it's not the first time they've shown up," McCormick added.
In an interview with CBS' "Face the Nation" last weekend, American Legion National Commander Daniel Dellinger called for a "cultural" change across the VA that starts with Shinseki. Roscoe Butler, the group's assistant director for health care, told CBS News that the agency needs far more accountability.
"The secretary, whoever that is, needs to be empowered so that when he's plagued with issues of people who are asleep...and are not telling him what's going on, then he needs to go and he needs to put somebody in there that is able to manage the system in such a way that its favorable for veterans," Butler said.
That was the aim of a bill that passed the House with an overwhelming bipartisan majority Wednesday that gives the VA secretary increased power to fire or demote senior officials in an attempt to reduce the red tape that leads to them staying in their jobs once they are deemed to be ineffective. The bill was authored by House Veterans Affairs Committee Jeff Miller, R-Fla.
Miller's Democratic counterpart, Rep. Mike Michaud, D-Maine, would have gone even further. His own bill would have covered the entire senior management system of the VA, instead of the few hundred managers identified in Miller's bill, and would have sought to introduce more accountability into the management system with performance objectives tied to organizational goals and veterans outcomes that were assessed during annual performance reviews.
Indeed, there are indications that a shortage of money is not the VA's problem.
While reports of long wait times for care and a huge backlog of disability claims goes back more than a decade, the VA saw its budget increase more than $20 billion during Mr. Obama's first two years in office, yet the problem persists.
"Every year VA submits a budget to Congress and Congress has given VA every dollar that they've requested, over and above that. So I don't think it's a matter of Congress giving them the money. If it's not enough they need to ask," Butler said.
The real problem, McCormick added, is that VA leaders haven't been honest in identifying and fixing their own weaknesses. "Members of Congress have a hard time getting straight, open, direct answers," he said. It's a problem that will only get worse as veterans of the Iraq and Afghanistan wars all return home and need care.
By and large, McCormick said that the longstanding bipartisan nature of veterans' care means that even in a time of budget-cutting, the agency will likely continue to enjoy deep pockets from Congress, though there may be political speed bumps along the way. For example, a $21 billion bill that would have greatly expanded to veterans - including VA health care - failed in the Senate earlier this year over partisan disputes that are symptomatic of the gridlock issues that have plagued the Senate recently.
There also doesn't appear to be a major quality problem among the agency's doctors and nurses either, even though it appears that not enough veterans can get through the door to see them. Veterans' advocates who appeared before Congress last week agreed that once veterans get access to care within the VA system, it is high-quality care. The problem is getting access to that care in the first place.
The American Customer Satisfaction Index (ACSI), the nation's only cross-industry measure of customer satisfaction, ranks VA customer satisfaction among the best in the nation -- equal to or better than ratings for private sector hospitals. When asked if they would use a VA medical center the next time they need inpatient or outpatient care, veterans in the 2013 ACSI survey overwhelmingly indicated that they would (96 and 95 percent, respectively).
"When I see [my health care provider], they offer me top-notch care," said Ryan Gallucci of the Veterans of Foreign Wars of the United States.
There are smaller changes that would be easier to achieve than a massive management overhaul. Butler said a modernized, online scheduling system is key, as is higher pay caps that will make it easier to recruit physicians, especially in rural areas.
But it all seems to come back to leadership, no matter what the person's partisan leanings.
"Right now we have got to hold people accountable for not taking the kind of actions that should be done," Senate Veteran Affairs Committee Chairman Bernie Sanders, I-Vt., said on MSNBC Wednesday.