Twenty-five years ago that was the situation at Fresno. It serves an area about the same size as Maine (in square miles) including the poorest county in the state.

The improvemt didn't come from above. A few stubborn, dedicated staff members, and a lot of volunteers worked hard and eventually it did percolate up so that now it has support from above as well as on location.

For models of what can be done best to look at the good, not just the failures.

Another VA hospital I have (one) experience with is in Portland, Oregon. From what I saw it is also one of the best.

The biggest difference between the VA experiences I've had and the others is that at VA I'm treated with respect.