The Department of Veterans Affairs has been embroiled in scandal for more than a year, ever since a whistleblower alleged that 40 veterans had died while waiting for care at the Phoenix branch. A subsequent investigation by the department’s Office of Inspector General confirmed that some veterans had died while waiting for an appointment, but also uncovered broader problems like “unacceptable and troubling lapses in follow-up, coordination, quality, and continuity of care.” These signs of widespread mismanagement and incompetence led to an investigation into the entire department. In a scathing report released this week, investigators again found evidence of serious problems within the VA and few signs that meaningful steps are being taken to address them.

As of September 2014, almost 900,000 veterans had pending applications and more than 300,000 of these belonged to veterans who had died. Due to data limitations, investigators could not determine how many of these deceased veterans were actively seeking health care, which ties into one of the most troubling problems that this scandal has exposed. The VA has failed to “ensure the consistent creation and maintenance of essential data” which means in many cases it is impossible for investigators to know just how bad things are. More than half of the pending applications did not have an application date, which “makes [the enrollment system] unreliable for monitoring timelines.” In addition, the investigators were able to substantiate the claim that VA employees had incorrectly marked unprocessed applications as completed and may have deleted more than 10,000 transactions over the past 5 years. In many cases, it is impossible to determine how many veterans who have actively applied for care are waiting, how long they have been waiting, and how many have died while waiting. Some aspects of the VA are so mismanaged that we can’t even tell how badly it is failing.

To date, there has been little appetite for real reform within the department, with few steps being taken to hold those responsible accountable or to rectify some of the department’s most egregious shortcomings. Back in 2010, after management identified individual staff that had hidden applications in their desks in order to artificially shorten wait-times by processing them later, human resources officials “advised them against pursuing disciplinary action against staff.” Contrary to VA Secretary McDonald’s assertion that 60 people had been fired for their role in the initial scandal, internal documents later revealed that only three people had been removed from their jobs as of April.

In response to the new report, the agency has pledged to “work diligently to address the issues [the] report raised to continue to improve the enrollment system to better serve Veterans” and that serving the veterans is a responsibility they “do not take lightly.” Maybe this time will be different and this will be the report that finally spurs the VA to take action. Even if the VA was competently run, there are better ways to serve the health care needs of our veterans. My colleague Michael D. Tanner has proposed some practical reforms, while Michael F. Cannon and Christopher A. Preble have offered a new approach to veterans’ benefits.