Opinion ID: 3065770
Heading Depth: 3
Heading Rank: 1

Heading: APA Challenge to Mental Health Care Delivery

Text: Delays Given the provisions of the APA and controlling Supreme Court law, the district court properly denied Veterans’s APA challenge to the VHA’s delays in providing timely and effective mental health care, notwithstanding the many evident deficiencies in the VHA’s provision of such care. Under the APA, courts are empowered to “compel agency action unlawfully withheld or unreasonably delayed.” 5 U.S.C. § 706(1). In Norton v. Southern Utah Wilderness Alliance, however, the Supreme Court interpreted the scope of this statutory provision and held that “a claim under § 706(1) can proceed only where a plaintiff asserts that an agency failed to take a discrete agency action that it is required to take.” 542 U.S. 55, 64 (2004). With regard to the discreteness requirement, the Court stated that the “failure to act” is “properly understood as . . . a failure to take one of the agency actions (including their equivalents) earlier defined in [5 U.S.C.] § 551(13).” Id. at 62. Agency actions defined in 5 U.S.C. § 551(13) include issuance of a rule, order, license, sanction, relief or equivalent benefit. The Norton Court suggested that, for example, “the failure to promulgate a rule or take some decision by a statutory deadline” would constitute the failure to take a discrete agency action. Norton, 542 U.S. at 63. An agency action may therefore be reviewed and compelled by a federal court under § 706(1) only if that action is one which is legally required. Id. Quoting the Attorney General’s Manual on the APA, the Norton Court stated “§ 706(1) empowers a court only to compel an agency ‘to perform a ministerial or non-discretionary act,’ or ‘to take action upon a matter, without directing how it shall act.’ ” Id. at 64 (quoting Attorney General’s Manual on the Administrative Procedure Act 108 (1947)). In limiting APA review to required agency actions, the Court held, Congress “rule[d] out judicial 6334 VETERANS FOR COMMON SENSE v. SHINSEKI direction of even discrete agency action that is not demanded by law” under the APA. Id. at 65. Veterans assert here that the VA has unreasonably delayed the provision of timely and effective mental health care to eligible veterans by failing to implement the Mental Health Strategic Plan and the Feeley Memorandum. Implementation of the Plan and Memorandum would undoubtedly improve the lot of veterans who are suffering unduly as a result of delays in the provision of their mental health care. Such implementation does not, however, fall within the definition provided by the Supreme Court in Norton of a “discrete action” that the agency is “required” to take, because no statute or regulation demands it. Veterans contend that the VA is statutorily required to provide timely and acceptable medical care under 38 U.S.C. § 1710(a) and 38 U.S.C. § 1705. True, but those requirements are not so specific as the particular action Veterans seek to compel. In relevant part, 38 U.S.C. § 1710 requires that the VA furnish hospital care and medical services to certain veterans: The Secretary . . . shall furnish hospital care and medical services which the Secretary determines to be needed— (A) to any veteran for a service-connected disability; and (B) to any veteran who has a service-connected disability rated at 50 percent or more. 38 U.S.C. § 1710(a)(1). Veterans “who served on active duty in a theater of combat operations . . . after November 11, 1998” are eligible for health care and services for five years following discharge. 38 U.S.C. § 1710(e)(1)(D), (e)(3)(C)(i). Section 1705(a) then obligates the Secretary “[i]n managing the provision of hospital care and medical services under secVETERANS FOR COMMON SENSE v. SHINSEKI 6335 tion 1710(a)” to prescribe, establish, and operate a system of annual patient enrollment. In designing this “enrollment system,” the Secretary “shall ensure that the system will be managed in a manner to ensure that the provision of care to enrollees is timely and acceptable in quality . . . .” 38 U.S.C. § 1705(b)(1). [3] Veterans claim that § 1705(a) creates an obligation to ensure that the VHA as a whole is managed so as to provide timely care of acceptable quality. We agree. We disagree, however, with Veterans’s contention that this statutory obligation mandates the implementation of the Mental Health Strategic Plan and the Feeley Memorandum, which Veterans characterize as the VA’s “own determination of what § 1710 requires.” Such a reading overstates the reach of the specific provisions of § 1705 — particularly in light of the fact that Veterans have not filed any direct challenge to the Secretary’s management of the enrollment system itself. [4] The VA does not dispute that it is required to provide mental health care to certain veterans. Nor should it dispute that a delay in providing necessary mental health care would amount to a wholesale failure to provide care to at-risk veterans under § 1710 and § 1705, insofar as some at-risk veterans will take their own lives during the delay. The VA is, thus, obviously required to take action to ensure that, system-wide, mental health care is provided to at risk veterans in a timely manner. There is, however, no statutory language that would specifically obligate the VA to fully implement the remedies sought by Veterans — the Mental Health Strategic Plan or the Feeley Memorandum. We are therefore bound by the Supreme Court’s instruction in Norton that: “General deficiencies in compliance, unlike the failure to issue a ruling . . . lack the specificity requisite for agency action.” Norton, 542 U.S. at 66. As the Norton Court recognized, however, agencies may be required to take actions not only by Congress, but also by 6336 VETERANS FOR COMMON SENSE v. SHINSEKI themselves. Agency action “demanded by law . . . includes, of course, agency regulations that have the force of law.” Norton, 542 U.S. at 65. Even a less formal agency “plan” may “itself create[ ] a commitment binding on the agency,” if there is “clear indication of binding commitment in the terms of the plan.” Id. at 69, 71. Thus we have held that “agencies may be required to abide by certain internal policies,” such as their own “internal procedures.” Alcaraz v. INS, 384 F.3d 1150, 1162 (9th Cir. 2004) (citing Morton v. Ruiz, 415 U.S. 199, 235 (1974)). Veterans argue that the Mental Health Strategic Plan and Feeley Memorandum are such required internal policies. But neither document supports that view. The Plan was designed to “identif[y] overlap, include[ ] gap analyses, and present[ ] goals and objectives that articulate a set of proposed strategies that directly support all the mental health needs of the enrolled veteran population.” The VA cast the Plan’s particular strategies as “recommendations.” Nowhere did the agency commit to binding itself, and we do not find any implied intent to do so. The Feeley Memorandum, by contrast, does impose the affirmative obligation that procedures to ensure veterans receive mental health evaluations within twenty-four hours of seeking help “must be implemented by August 1, 2007.” But the memorandum — a document sent from the Deputy Under Secretary for Health for Operations and Management to the VA’s Network Directors — is an internal administrative communication that lacks the force of law. See Rank v. Nimmo, 677 F.2d 692, 698-99 (9th Cir. 1982). Unlike an internal rule that is officially published within an agency and binding on its employees, for example, the Memorandum is merely a charge from a supervisor to his subordinates. [5] Veterans’s APA claim concerning timely and acceptable mental health care therefore cannot proceed because Veterans do not assert that the VA “failed to take a discrete VETERANS FOR COMMON SENSE v. SHINSEKI 6337 agency action that it is required to take” within the meaning of § 706(1), Norton, 542 U.S. at 64, and so we affirm the district court’s ruling on Veterans’s APA-based challenge. B. Due Process Clause Challenge to Mental Health Care Delivery Delays Veterans also claim that the lack of adequate procedures to ensure that veterans will not suffer needlessly because of severe delays in the receipt of mental health care violates the Due Process Clause of the Fifth Amendment. We agree. 1 We first consider whether the VJRA deprives us of jurisdiction to consider this claim. We note at the outset that while the VA argues vigorously that the VJRA forecloses our consideration of Veterans’s second due process claim, regarding the disability benefits adjudication process, it does not contend that it affects this claim at all. To the contrary, the VA acknowledges that “the general nature of plaintiffs’ claims — which asserted ‘systemic’ delays in the provision of health care” — falls outside the VJRA’s jurisdictional bar to “challenges to the medical care or other benefits provided in specific cases.” Gov’t Br. 33 n.7. A potential jurisdictional flaw is not a litigant’s issue to waive, of course, so we must consider the issue ourselves notwithstanding the parties’ agreement. See Arbaugh v. Y & H Corp., 546 U.S. 500, 514 (2006). Still, because the sole participant in this case to even suggest that the VJRA precludes review of Veterans’s constitutional challenge to the mental health care delays is our dissenting colleague, we discuss the issue only briefly. Section 511(a) provides, The Secretary shall decide all questions of law and fact necessary to a decision by the Secretary under a law that affects the provision of benefits by the 6338 VETERANS FOR COMMON SENSE v. SHINSEKI Secretary to veterans or the dependents or survivors of veterans. . . . [T]he decision of the Secretary as to any such question shall be final and conclusive and may not be reviewed by any other official or by any court, whether by an action in the nature of manda- mus or otherwise.25 The “question of law” presented here is whether the VA’s lack of procedural safeguards to ensure that veterans timely obtain the mental health care to which they are entitled — such as an appeals process to challenge appointment scheduling — violates the Due Process Clause by providing insufficient process. It is debatable whether that question of law is one that is “necessary to a decision by the Secretary” affecting veterans’ benefits, like the question of what evidence is required to make out a benefits claim for service-connected PTSD. See, e.g., Stressor Determinations for Posttraumatic Stress Disorder, 75 Fed. Reg. 39,843, 39,843 (July 13, 2010); see 38 C.F.R. § 3.304(f)(3) (2010). We need not resolve the issue of necessity, however, because the Secretary has not actually issued a “decision” answering this constitutional question at all. The VA may assume and even argue that its system for providing mental health care services is constitutionally sound, but it has not issued a “decision” on the question that is “final and conclusive and” unreviewable, the way it might issue, for example, a “rating decision” concerning a particular veteran’s degree of disability for purposes of calculating compensatory benefits. See 38 U.S.C. § 1156(b)(1)(B). The dissent argues that “there is simply no way to adjudicate the due process claim without ‘determining first’ whether the VA’s administrative staff ‘acted properly in handling’ vet25 Section 511(b) provides for four exceptions, none applicable here: (1) the review of VA rules and regulations under § 502, (2) suits in district court concerning claims related to federally provided insurance, (3) suits under specific provisions relating to housing and small business loans, and (4) review by the Board of Veterans’ Appeals and the Veterans Court. VETERANS FOR COMMON SENSE v. SHINSEKI 6339 erans’ requests for appointments,” which “will depend on the facts of each veteran’s case” — which we may not review. Dissenting op. at 6383 (quoting Price v. United States, 228 F.3d 420, 422 (D.C. Cir. 2000) (per curiam) and citing Thomas v. Principi, 394 F.3d 970, 974 (D.C. Cir. 2005)) (internal alterations omitted)). But of course there is: Veterans challenge the lack of adequate procedural safeguards to ensure that veterans receive timely care. To make out that claim they must simply demonstrate “the risk of an erroneous deprivation” of care “through the procedures [currently] used, and the probable value, if any, of additional of substitute procedural safeguards.” Mathews v. Eldridge, 424 U.S. 319, 335 (1975) (emphasis added). Veterans need not, and do not, seek to relitigate in federal court whether VA staff actually “acted properly in handling” individual veterans’ requests for appointments, dissenting op. at 6383; no individual veteran is before us seeking to challenge the timing of an individual appointment that he just received. Rather, Veterans point to the past as evidence of the “risk of an erroneous deprivation” their members now face. Put differently, this is not a tort suit brought by an individual veteran, as in the two cases cited by the dissent, where “underlying the claim is an allegation that the VA unjustifiably denied him a veterans’ benefit.” Thomas, 394 F.3d at 974 (emphasis added). The relevant “decision[s]” as to “question[s] of law and fact” in those cases were “decision[s]” about individual benefit determinations, which were insulated from review as soon as the Secretary had made those “decision[s].” Instead, this is a suit for an injunction to require that “additional or substitute procedural safeguards” be provided in the future, if the cost to the government of such safeguards is justified by the reduction in risk they would produce. Mathews, 424 U.S. at 335. The relevant “decision” here as to a “question of law” is whether the existing safeguards are constitutionally sufficient; the Secretary has not rendered a “decision” on that question, so the triggering condition for § 511’s preclusive effect does not now exist — assuming the 6340 VETERANS FOR COMMON SENSE v. SHINSEKI Secretary’s answer to a “question of law” such as this could ever fit within the meaning of “decision,” which is most unlikely. See infra, at 6355. The VA is not mistaken in understanding that the nature of Veterans’s suit falls outside the reach of § 511(a). 2 [6] We turn, then, to the merits of Veterans’s due process claim. The record before us shows that some veterans with severe depression or PTSD are forced to wait over eight weeks for mental health referrals. During that period, some of those veterans take their own lives. The district court found that there are about 18 suicides per day among veterans, including four to five suicides per day among veterans enrolled to receive VA health care.26 In 2008, one VHA physician identified “about 1,000 suicide attempts per month” among the veterans seen in VHA facilities.27 The precise con26 The VA’s statistics do not differentiate between veterans who are simply enrolled with the VA, veterans who are receiving other types of (nonmental health related) medical treatment, veterans who are on waiting lists for mental health treatment, and veterans currently receiving mental health care. 27 This figure comes from an email written by the Deputy Chief of Patient Care Services for VA’s Office of Mental Health on February 13, 2008. The email read as follows: Shh! Our suicide prevention coordinators are identifying about 1000 suicide attempts per month among the veterans we see in our medical facilities. Is this something we should (carefully) address ourselves in some sort of release before someone stumbles on it? That email was obtained by Veterans during discovery in this litigation, and first made public as a result. This message and others like it generated significant media attention. See, e.g., Armen Keteyian, VA Hid Suicide Risk, Internal E-Mails Show, CBS News (Apr. 21, 2008), available at http://www.cbsnews.com/stories/2008/04/21/cbsnews_investigates/main 4032921.shtml. That attention, in turn, prompted a congressional investigation. See The Truth About Veterans’ Suicides, Hearing Before the H.R. Comm. on Veterans Affairs, 110th Cong., 2d Sess. (May 6, 2008). VETERANS FOR COMMON SENSE v. SHINSEKI 6341 stitutional question with which we are presented is whether the VA’s delays in the provision of care amount to a deprivation of “property” without due process, a violation of the Fifth Amendment. a [7] First we must find that Veterans allege a deprivation of life, liberty, or property. As we discuss above, 38 U.S.C. § 1710 creates an entitlement to health care for eligible veterans. The VA does not dispute that this entitlement creates a property interest protected by the Due Process Clause. Indeed, it is well-established that “the interest of an individual” in receipt of government benefits or services to which he is entitled “is a statutorily created ‘property’ interest protected by the Fifth Amendment.” Mathews, 424 U.S. at 332. b Second, we must determine whether Veterans’s members have been deprived of their property interest. In cases involving the termination of government benefits, the “deprivation” is clear. See, e.g., Goldberg v. Kelly, 397 U.S. 257 (1970). Similarly, we have long held that the outright denial of benefits to which an individual is entitled constitutes deprivation The dissent gets political reality exactly backwards when it asserts that “Congress already exercises vigorous oversight of the VA through its ability to hold hearings on the agency’s operations,” and that “[b]ecause Congress is already actively involved in the agency’s affairs, programmatic improvements should be made in the offices of the VA or the halls of Congress, not through litigation.” Dissenting op. at 6397 (internal quotation marks and brackets omitted). To the contrary, this case demonstrates the crucial role for litigation initiated by injured parties in forcing the government to respond. Had the resulting oversight then yielded actual solutions, this case might have become moot. It is only because the government continued to fail to correct the VA’s problems that we are compelled to address the constitutional questions presented here. 6342 VETERANS FOR COMMON SENSE v. SHINSEKI of a recognized property interest. See, e.g., Nat’l Ass’n of Radiation Survivors v. Derwinski, 994 F.2d 583, 588 n.7 (9th Cir. 1992) (denial of application for veterans’ benefits implicates due process); Griffeth v. Detrich, 603 F.2d 118, 120-21 (9th Cir. 1979). Veterans’s claim differs somewhat. They argue not that their members’ requests for care have been decided by the VA and finally rejected, but instead that the delay in the provision of care sought “is tantamount to a denial of care,” particularly for veterans who are suicidal. We agree. In a related context, the Supreme Court has recognized that “the possible length of wrongful deprivation of . . . benefits is an important factor in assessing the impact of official action on . . . private interests.” Fusari v. Steinberg, 419 U.S. 379, 389 (1975). Thus in Fusari, the Court found that excessive delay in the adjudication of claims for unemployment benefits, during which time benefits were withheld, could yield a deprivation in its own right regardless of whether benefits were ultimately restored. And in Cleveland Board of Education v. Loudermill, 470 U.S. 532 (1985), the Court reasoned that “[a]t some point, a delay in [a] post-termination hearing would become a constitutional violation,” though that point had not been reached in that case. Id. at 547; see also Barry v. Barchi, 443 U.S. 55, 66 (1979) (“[I]t was necessary that Barchi be assured a prompt post-suspension hearing, one that would proceed and be concluded without appreciable delay. Because the statute as applied in this case was deficient in this respect, Barchi’s suspension was constitutionally infirm under the Due Process Clause of the Fourteenth Amendment.”). Indeed, “at some point delay must ripen into deprivation, because otherwise a suit alleging deprivation would forever be premature.” Schroeder v. City of Chicago, 927 F.2d 957, 960 (7th Cir. 1991) (Posner, J.). [8] We understand these cases to support the commonsense proposition that an unreasonable delay in the delivery of an entitlement can amount to a deprivation of that entitleVETERANS FOR COMMON SENSE v. SHINSEKI 6343 ment.28 Veterans who are deprived of timely mental health care are denied the opportunity to rehabilitate in a more timely manner and to avoid sinking deeper into depression and disability. And, of course, for those veterans whose illness causes them to take their own lives in the interim, the deprivation is final. c Finally, we must decide whether the process designed to protect veterans against the deprivation of their property interest is sufficient, or whether additional process is due. We apply the traditional balancing test Mathews v. Eldridge in the context of veterans’ entitlements. See, e.g., National Ass’n of Radiation Survivors v. Derwinski, 994 F.2d 583, 588 (9th Cir. 2002).29 The Mathews Court explained that “procedural due 28 Whether that deprivation is actually unconstitutional, because inflicted without due process, is a distinct question to which we turn next. 29 Contrary to the dissent’s suggestion, Walters v. National Association of Radiation Survivors, 473 U.S. 305 (1985), did not create a new, special “high hurdle” for all due process challenges involving veterans. See Dissenting op. at 6390, 6396. Walters applied the Mathews formulation and determined that, in light of the government’s strong, centuries-old interest in maintaining a veterans’ claims system that is “as informal and nonadversarial as possible,” “[i]t would take an extraordinarily strong showing of probability of error under the present system — and the probability that the presence of attorneys would sharply diminish that possibility — to warrant a holding that the fee limitation denies claimants due process of law.” Id. at 323, 326. Moreover, Walters was clear that government’s interest in an “informal and nonadversarial” system, as defined by that case, was limited to “the system for administering benefits” within the VA. Id. at 321. The dissent cannot be serious when it suggests that the government has an interest in an “informal and nonadversarial” resolution to the years of federal-court litigation in this case. Dissenting op. at 6373, 6390. Although our decision today is the product of adversarial litigation and results in an injunction being entered against the VA, it does nothing to compromise the “informal and nonadversarial” procedures within the VA during the initial adjudication of claims for veterans benefits. Indeed, in part IV of this opinion we reaffirm Walters’s holding that the limitation on payments to attorneys during regional-level agency adjudications does not violate due process. 6344 VETERANS FOR COMMON SENSE v. SHINSEKI process imposes constraints on governmental decisions which deprive individuals of ‘liberty’ or ‘property’ interests within the meaning of the Fifth . . . Amendment,” Mathews, 424 U.S. at 332. According to Mathews, the “identification of the specific dictates of due process” with regard to a deprivation of a protected interest “generally requires consideration of three distinct factors: First, the private interest that will be affected by the official action; second, the risk of an erroneous deprivation of such interest through the procedures used, and the probable value, if any, of additional or substitute procedural safeguards; and finally, the Government’s interest, including the function involved and the fiscal and administrative burdens that the additional or substitute procedural requirement would entail.” Id. at 335. (1) The district court correctly concluded that, with respect to the first Mathews factor, “the private interest of veterans in receiving health care is high.” Proper care can alleviate the severe toll that PTSD takes on veterans and their families, and it reduces the incidence of suicide. The district court erred, however, in its conclusion that the risk of erroneous deprivation was low, and in its determination that Veterans had failed to prove a systemic denial or unreasonable delay in mental health care provision that would create a high risk of erroneous deprivation. It similarly erred in its conclusion that the third Mathews factor weighs against imposing additional procedural safeguards, based upon its erroneous assumption that such safeguards would impose undue administrative burdens on the VA. We examine each of the latter two factors in turn. (2) In weighing the second Mathews factor, the district court substantially underestimated the risk of erroneous deprivation faced by veterans with serious mental illnesses and disorders. Veterans did not prove conclusively at trial that veterans seeking mental health care face a high risk of detrimental delays in the provision of care, but the district court’s factual findings support the conclusion that there is a significant risk that delays in treatment will harm veterans. Mathews VETERANS FOR COMMON SENSE v. SHINSEKI 6345 requires us to balance that risk of erroneous deprivation against the “probable value, if any, of additional . . . procedural safeguards.” Mathews, 424 U.S. at 335. In the area of scheduling veterans for mental health care appointments, the marginal value of “additional” procedural safeguards is extraordinarily high, because at present no procedure is in place to ensure that mental health appointments are provided soon enough to be effective. Although a “clinical” decision made by a mental health care professional — such as a nurse, doctor, or psychologist — to place a veteran on a waiting list for care may be appealed, a veteran has no opportunity at all to appeal a receptionist or call center’s “administrative” decision that he must wait to receive mental health care.30 In the district court, Dr. Murawsky, the chief medical officer of one of the VA’s 21 national regions, was asked what would happen “if the veteran is told that ‘You get an appointment in 60 days,’ and the veteran wants an earlier appointment.” He responded that the VA’s “policy doesn’t cover appointment time.” (Emphasis added.) Indeed, veterans whose delayed care stems from administrative decisions have no right to speak with a supervising administrator about their need for more immediate care, nor to insist that they be evaluated by a medical professional, nor to secure any other review that would lessen the likelihood that diagnosis and treatment are delayed too long for their cases. Only if a scheduling decision were made by a medical professional — for example if a “nurse or physician sa[id] ‘You’re medically stable . . . — an appointment in six weeks is appropriate’ ” — would a veteran have any opportunity to request a review, through the clinical appeals process. Of course, at that point the veteran would at least have been evaluated by a medical professional — something that a veteran 30 Veterans do not challenge the clinical appeals process, described supra at 6308-09, here, and so we do not address its adequacy. 6346 VETERANS FOR COMMON SENSE v. SHINSEKI calling by phone or speaking to a receptionist would not automatically get, unless he walked into a VA emergency room or clinic and actually “expressed suicidal intentions.” Like most medical patients, veterans are generally scheduled first by administrative staff, and then seen second by medical personnel (at their scheduled appointments) — not the other way around, as the dissent suggests. There is, quite simply, no process for review of a scheduler’s assignment of a mental health care appointment weeks in the future. The district court’s suggestion that the clinical appeals process offers a sufficient procedural safeguard for all veterans on VHA waiting lists, including those placed on such lists by administrators, is clearly contrary to the record. So too does the dissent improperly confuse the distinction between clinical delays, for which some process is provided, and administrative ones, for which there is none.31 [9] The record before us is replete with examples of deleterious delay in the VHA’s provision of mental health care, and shows that many veterans throughout the country have no means available to appeal the delays to which they are subjected. The record contains one story, for example, of a veteran who committed suicide after calling the VA to report his suicidal thoughts but was told he would be over 25 places down on a waiting list for treatment. In another case, a former U.S. Marine who was at the Pentagon on September 11, 2001, and later served in Iraq, reported a delay of almost eight weeks before the VA would see him after “telling the VA repeatedly that I was suicidal” and having already been diagnosed with PTSD. All told, over 84,000 veterans are on wait31 We have not “misunderst[ood] [the] evidence” of the existing procedural safeguards, as the dissent suggests, dissenting op. at 6390; we have simply avoided the error made by the district court and the dissent of improperly confusing the distinction between clinical delays and administrative ones and conflating the issues unique to each. See Dissenting op. at 6390-95. VETERANS FOR COMMON SENSE v. SHINSEKI 6347 ing lists for mental health care. The district court made no finding as to the number of veterans who were placed on waiting lists by administrators, as opposed to clinicians. Veterans argue that vast numbers of veterans are denied access to mental health care by administrators, and the VA offers no evidence to rebut this claim. What is clear is that veterans have no recourse when they are told that they cannot be scheduled sooner for a mental health appointment. This absence of procedural safeguards is particularly alarming in view of the apparent ineffectiveness in the scheduling system. In July 2005, an “Audit of the Veterans Health Administration’s Outpatient Scheduling Procedures” conducted by the VA’s Office of Inspector General found that the “VHA did not follow established procedures when scheduling medical appointments for veterans seeking outpatient care,” including mental health care. Two years later, a follow-up audit revealed that five of the eight recommendations for improvement made in 2005 had not been implemented. Specifically, the 2007 report found: 72 percent of patient appointments had “unexplained” delays between dates care was requested by veterans and their clinicians and the dates appointments were scheduled; schedulers were not adequately trained, particularly on scheduling consult appointments with specialists; and that pressure to reduce the length of patient waiting lists had caused schedulers to avoid placing patients on lists for appointments at all. Similarly, a 2005 U.S. Government Accountability Office report on VA services for PTSD found that the VA had not developed referral mechanisms to provide PTSD services when those services were not available at community-based clinics, and challenged the “VA’s capacity to identify and treat veterans returning from military combat who may be at risk for developing PTSD, while maintaining PTSD services for veterans currently receiving them.” And the district court found that, while the Feeley Memorandum states that veterans who present to a Medical Center or Community Based Out6348 VETERANS FOR COMMON SENSE v. SHINSEKI reach Center for the first time with mental health issues should be evaluated within 24 hours, the VA lacks any method to ensure compliance with this 24-hour evaluation policy and does not know whether the policy has been implemented. [10] This is therefore not a case in which existing procedures are sufficient, such that additional process is unlikely to produce significant marginal reductions in the risk of erroneous deprivation. See, e.g., Mathews, 424 U.S. at 343-46. Instead, the underlying scheduling system is flawed, and there is no procedure whatsoever for veterans to challenge their delays. Consequently, any additional procedure would produce a meaningful improvement in ensuring that veterans are not left to wait too long to get the care they need. (3) The district court’s weighing of the third Mathews factor was similarly erroneous. It concluded that “additional safeguards” in the VHA’s system for treating veterans with mental health issues would impose unwarranted “burdens on the VA.” The district court did not make any specific factual findings based on the record in the case before us as to the nature and extent of additional administrative burdens that would be imposed upon the VA, if additional procedural safeguards were introduced to facilitate veterans’ ability to secure their entitlement to mental health care in a timely and effective manner. Instead, it appears to have based this conclusion solely on a quotation plucked from a Supreme Court case regarding the government’s “ ‘genuine interest in allocating priority to the diagnosis and treatment of patients . . . rather than to time-consuming procedural minuets.’ ” (Quoting Parham v. J.R., 442 U.S. 584, 605 (1979)). The VA now cites this same language. Cases are not quotations, however, to be relied upon like entries in Bartlett’s purely for their convenient turns of phrase.32 32 See BARTLETT’S FAMILIAR QUOTATIONS: A COLLECTION OF PASSAGES, PHRASES, AND PROVERBS TRACED TO THEIR SOURCES IN ANCIENT AND MODERN LITERATURE (17th ed. 2002). VETERANS FOR COMMON SENSE v. SHINSEKI 6349 Rather, cases are clusters of facts and applications of legal principles to those facts that must be read in whole. Parham, which examined the due process rights of minors committed to state psychiatric facilities by their parents, emphasized Georgia’s “significant interest in not imposing unnecessary procedural obstacles that may discourage the mentally ill or their families from seeking needed psychiatric assistance.” 442 U.S. at 605. That is, the Court was concerned that additional procedure would create delay, which would harm the state’s interest in making hassle-free treatment available to families that need it. Indeed, the unabridged sentence from Parham is: “The State also has a genuine interest in allocating priority to the diagnosis and treatment of patients as soon as they are admitted to a hospital rather than to time-consuming procedural minuets before the admission.” Id. (emphasis added). Here, the government is not prioritizing the diagnosis and treatment of patients over unnecessary delay. To the contrary, it is embracing delay over effective treatment. If there is any justification for the VA’s interest in maintaining the status quo, it has not told us, and we cannot imagine one. Cost — often claimed by the government as an interest in less robust process — does not seem to be at issue here. The VA does not mention expense, and as the district court found, “the VHA’s Chief Financial Officer testified that the VHA is not currently facing a budget crisis and has adequate money to ‘meet the mission requirements.’ ” Moreover, the VA has hired more than 3,800 new mental health staff over the past few years, and 500-600 positions still remain unfilled. In fact, the only governmental interest we can conceive of is the same as Veterans’s: expediting the provision of mental health care to save the lives of men and women who have fought for our country. As the government represented at oral argument, “The VA is firmly committed to ensuring that our nation’s veterans receive top-quality health care.” Oral Arg. Audio at 25:12.