On Wednesday, a report found that between 2007 and 2015, the Department of Veterans Affairs (VA) gave 24,905 veterans a crucial medical examination with unqualified personnel. Traumatic brain injury (TBI) is a signature medical problem among veterans from Iraq and Afghanistan, and the examination determines how much disability compensation a veteran will receive for life. Even one misdiagnosis can cause harm, not just to the veteran but to his friends and family. Twenty-five thousand of them… is a national disgrace.

VA Secretary Robert McDonald responded by granting “equitable relief,” by offering new TBI examination to these veterans. The VA requires each examination to be conducted by one of four designated medical specialists, and now 24,905 veterans will have “the opportunity to have their claims reprocessed.” That’s about the least he could do.

“Traumatic Brain Injury is a signature inquiry in Veterans returning from the conflicts in Iraq and Afghanistan, and VA is proud to be an organization that sets the bar high for supporting these, and all, Veterans,” Secretary McDonald said in a press release. “Providing support for Veterans suffering from a TBI is a priority and a privilege, and we must make certain they receive a just and fair rating for their disabilities.”

Only one of four types of specialists — a psychiatrist, a physiatrist, a neurosurgeon, or a neurologist — can complete the TBI exams. The VA acknowledged that the agency “issued a number of guidance documents that may have created confusion regarding the policy,” but “has confirmed that its TBI policy guidance is now clear and being followed.” After 25,000 failures after 8 years, I would hope so.

McDonald made one more in a long list of late apologies, saying, “We let these Veterans down. That is why we are taking every step necessary to grant equitable relief to those affected to ensure they receive the full benefits to which they are entitled.”

The VA secretary may want to make it sound like the issue is solved, the case closed, but Americans should understand the gravity of this tragedy.

“While these injuries may not be visible, the wounds they leave are no less deep, and veterans should be able to count on the VA to help them heal,” Concerned Veterans for America (CVA) Press Secretary John Cooper told PJ Media on Thursday. “Instead, the VA has been negligent, allowing unqualified employees to treat these complex injuries, and veterans have suffered needlessly because of it.”

Next Page: What kind of reform the VA needs, and exactly how bad this TBI misdiagnosis scandal really is.

Cooper argued that Congress needs to pass laws to make the VA more accountable, so top staff can fire bad employees. He also advocated for new laws to create choice for veterans, “so they can see doctors of their choosing when the VA fails its primary mission: caring for veterans.”

In situations like this, where TBI was misdiagnosed, the consequences aren’t just medical — they’re economic for thousands of veterans. As Cooper explained, “Not only does this have obvious implications for the health of that veteran (what medications/treatments does he/she miss by such a diagnosis), but it has implications for his/her disability claims.” Some errors could lead to a 10 percent disability rating when a veteran should receive a 30 percent rating, and that has a large impact on the benefits he or she receives for getting wounded in service of our country.

Cooper also mentioned a personal case of the error — CVA Field Director Nate Anderson. Anderson, an Army green beret, was injured by an IED in Afghanistan. When he returned home, he was seen by an unqualified VA physician at the Minneapolis VA and it took eight years for the VA to diagnose his TBI.

This scandal is just one of many horrific failures of the VA, however. At the Tomah facility in Wisconsin, employees overprescribed medications to veterans, ultimately leading to two deaths. The number of veterans waiting a month or more for care has actually increased since October, 2014 — up by 140,000! As of the end of last month, more than 480,000 veterans continue to wait more than 30 days to get an appointment with a doctor.

The result of these wait times has a face — North Carolina veteran Wilbur Amos, who has waited over 9 months for surgery because the VA routinely delayed his appointments — and sent him to the wrong facilities! Debilitated by three excruciating hernias, Amos said he’s worried he might inadvertently twist his bowels and die from septic shock if he’s not treated with surgery soon. “These types of individual stories are common,” Cooper said, chillingly.

Next Page: So has the VA learned its lesson? Is it hiring more doctors and spending money more wisely?

The VA seems not to have learned its lesson at all. The agency added 39,454 new jobs between 2012 and 2015. Only 3,591 of those were doctors, meaning about 90 percent of jobs created at the VA in those four years were non-medical. During those same years, salary spending increased by 18.7 percent.

At the same time, Cooper pointed out, the VA spent $454 million on lawyers, and $303 million on “painting, gardening and interior decorating.” The agency also received $5 billion from Congress as part of the 2014 reform law specifically to hire doctors, but it will not say how the money was spent.

“The VA likes to say that if it had more funding, it would not be experiencing these problems,” Cooper explained, but the evidence runs very much to the contrary.

Check out Army green beret Nate Anderson’s video on the next page.