Improvements in oversight and auditing are surely part of the solution here, but there's a much more fundamental change that needs to happen: Regular line-level employees who see wrongdoing on the part of their coworkers, or are asked to engage in wrongdoing by their supervisors, need to be able to do something about it without threat of retaliation. Any human endeavor examined closely enough is a disgraceful mess, and most of us know this most directly from our jobs. But we also instantly recognize true malfeasance when we directly encounter it. So, of all the people who were involved or knew about these terrible practices who worked at the VA, why did it take so long for the truth to come out? A recent CNN report quotes Dr. Sam Foote, a doctor who had worked for the VA for 24 years.

"I feel very sorry for the people who work at the Phoenix VA," said Foote. "They're all frustrated. They're all upset. They all wish they could leave 'cause they know what they're doing is wrong. "But they have families, they have mortgages and if they speak out or say anything to anybody about it, they will be fired and they know that."

It's telling that Foote went to the press only after retiring. Despite the Whistleblower Protection Act of 1989, the federal government during the Bush and Obama administrations has grown increasingly hostile to whistleblowers. Barack Obama campaigned on transparency and whistleblower protection; his transition agenda said, "Often the best source of information about waste, fraud, and abuse in government is an existing government employee committed to public integrity and willing to speak out. Such acts of courage and patriotism, which can sometimes save lives and often save taxpayer dollars, should be encouraged rather than stifled." Since taking office, however, he has prosecuted twice as many people under the 1917 Espionage Act as all the previous administrations combined. These are the most extreme cases, but they represent a culture and ethos that appears to permeate the federal government.

In 2011, the Office of Special Counsel received more than 1,000 whistleblower disclosures of waste, fraud, abuse, and health/safety problems. It referred only 62 of those cases back to the relevant agency for further investigation. Meanwhile, the protections for whistleblowers who remain in their jobs are famously porous, and many are fired or retaliated against. The Obama administration was widely lauded for the passage of the Whistleblower Protection Enhancement Act, but its effects are apparently not being felt in the front lines of government offices. Since the Phoenix revelations, employees from VA offices around the country have gone to the press with reports that similar practices exist at their offices. Had there been a robust and reactive system for internal whistleblowing, this would not have happened.