# Veterans for Common Sense v. Eric K. Shinseki > Court of Appeals for the Ninth Circuit · May 10, 2011 · 644 F.3d 845 URL: https://www.frixlaw.com/law-library/cases/3065770 ## Case - **Full name:** VETERANS FOR COMMON SENSE, a District of Columbia Nonprofit Organization; Veterans United for Truth, Inc., a California Nonprofit Organization, Representing Their Members and a Class of All Veterans Similarly Situated, Plaintiff-Appellants, v. Eric K. SHINSEKI, Secretary of Veterans Affairs; United States Department of Veterans Affairs; James P. Terry, Chairman, Board of Veterans’ Appeals; Michael Walcoff, Acting Under Secretary, Veterans Benefits Administration; Bradley G. Mayes, Director, Compensation and Pension Service; Robert A. Petzel, M.D., Under Secretary, Veterans Health Administration; Pritz K. Navara, Veterans Service Center Manager, Oakland Regional Office, Department of Veterans Affairs; United States of America, Defendants-Appellees - **Court:** Court of Appeals for the Ninth Circuit - **Decided:** May 10, 2011 - **Citations:** 644 F.3d 845; 2011 U.S. App. LEXIS 9542; 2011 WL 1770944 - **Precedential status:** Published - **Opinion:** Opinion - **Judges:** Kozinski, Hug, Reinhardt - **Nature of suit:** Civil - **Cited by:** 27 later opinions in the Frix Law Library ## Citator (automated) - **Red flag:** Vacated by Veterans for Common Sense v. Shinseki, 678 F.3d 1013 (2012). - Negative treatments: 1 - Distinguished by: 0 - Full citator and citing cases: https://www.frixlaw.com/law-library/cases/3065770 ## Opinion text FOR PUBLICATION UNITED STATES COURT OF APPEALS FOR THE NINTH CIRCUIT VETERANS FOR COMMON SENSE, a  District of Columbia nonprofit organization; VETERANS UNITED FOR TRUTH, INC., a California nonprofit organization, representing their members and a class of all veterans similarly situated, Plaintiffs-Appellants, v. ERIC K. SHINSEKI, Secretary of Veterans Affairs; UNITED STATES No. 08-16728 DEPARTMENT OF VETERANS AFFAIRS; JAMES P. TERRY, Chairman, Board  D.C. No. 3:07-cv-03758-SC of Veterans’ Appeals; MICHAEL WALCOFF, Acting Under Secretary, OPINION Veterans Benefits Administration; BRADLEY G. MAYES, Director, Compensation and Pension Service; ROBERT A. PETZEL, M.D., Under Secretary, Veterans Health Administration; PRITZ K. NAVARA, Veterans Service Center Manager, Oakland Regional Office, Department of Veterans Affairs; UNITED STATES OF AMERICA, Defendants-Appellees,  Appeal from the United States District Court for the Northern District of California Samuel Conti, District Judge, Presiding 6293 6294 VETERANS FOR COMMON SENSE v. SHINSEKI Argued August 12, 2009 San Francisco, California Submitted September 14, 2009 Filed May 10, 2011 Before: Alex Kozinski, Chief Judge, Procter Hug, Jr. and Stephen Reinhardt, Circuit Judges. Opinion by Judge Reinhardt; Dissent by Chief Judge Kozinski 6298 VETERANS FOR COMMON SENSE v. SHINSEKI COUNSEL Gordon P. Erspamer (argued), Heather A. Moser, Ryan G. Hassanein, M. Natalie Naugle, and Stacey M. Sprenkel, Mor- rison & Foerster LLP, San Francisco, California; and Sidney M. Wolinsky, Ronald Elsberry, Katrina Kasey Corbit, and Jennifer Bezoza, Disability Rights Advocates, Berkeley, Cali- fornia, for the plaintiffs-appelants. Michael F. Hertz, Acting Assistant Attorney General; Joseph P. Russoniello, United States Attorney; and William Kanter and Charles W. Scarborough (argued), Appellate Staff, Civil Division, Department of Justice, for the defendants-appellees. OPINION REINHARDT, Circuit Judge: On an average day, eighteen veterans of our nation’s armed forces take their own lives. Of those, roughly one quarter are enrolled with the Department of Veterans Affairs (“VA”) health care system. Among all veterans enrolled in the VA system, an additional 1,000 attempt suicide each month. Although the VA is obligated to provide veterans mental health services, many veterans with severe depression or post- traumatic stress disorder (“PTSD”) are forced to wait weeks for mental health referrals and are given no opportunity to request or demonstrate their need for expedited care. For those who commit suicide in the interim, care does not come soon enough. Like the cavalry of Alfred, Lord Tennyson’s “Charge of the Light Brigade,” these veterans may neither “make reply” nor “reason why” to the “blunder” of those responsible for their safety. Veterans who return home from war suffering from psy- chological maladies are entitled by law to disability benefits VETERANS FOR COMMON SENSE v. SHINSEKI 6299 to sustain themselves and their families as they regain their health. Yet it takes an average of more than four years for a veteran to fully adjudicate a claim for benefits. During that time many claims are mooted by deaths. The delays have worsened in recent years, as the influx of injured troops returning from deployment in Iraq and Afghanistan has placed an unprecedented strain on the VA, and has overwhelmed the system that it employs to provide medical care to veterans and to process their disability benefits claims. For veterans and their families, such delays cause unnecessary grief and priva- tion. And for some veterans, most notably those suffering from combat-derived mental illnesses such as PTSD, these delays may make the difference between life and death. In this context, two non-profit organizations, Veterans for Common Sense and Veterans United for Truth (collectively “Veterans”1), seek injunctive and declaratory relief to remedy the delays in (1) the provision of mental health care and (2) the adjudication of service-connected death and disability compensation claims by the VA. Among other issues, Veter- ans ask us to decide whether these delays violate veterans’ due process rights to receive the care and benefits they are guaranteed by statute for harms and injuries sustained while serving our country. We conclude that they do. We do not reach this answer lightly. We would have pre- ferred Congress or the President to have remedied the VA’s egregious problems without our intervention when evidence of the Department’s harmful shortcomings and its failure to properly address the needs of our veterans first came to light years ago. Had Congress taken the requisite action and ren- dered this case unnecessary even while it was pending before us, we would have been happy to terminate the proceedings and enter an order of dismissal. Alternatively, had the VA agreed with Veterans following oral argument to consider a 1 We use the term Veterans to refer to the two plaintiff organizations as well as to their members throughout. 6300 VETERANS FOR COMMON SENSE v. SHINSEKI practical resolution of the complex problems, the end result surely would have been more satisfactory for all involved. We joined in our dissenting colleague’s suggestion that we defer submission of this case in order to permit the parties to explore mediation, and we regret that effort proved of no avail. We willingly acknowledge that, in theory, the political branches of our government are better positioned than are the courts to design the procedures necessary to save veterans’ lives and to fulfill our country’s obligation to care for those who have protected us. But that is only so if those govern- mental institutions are willing to do their job. We are presented here with the question of what happens when the political branches fail to act in a manner that is con- sistent with the Constitution. The Constitution affirms that the People have rights that are enforceable against the govern- ment. One such right is to be free from unjustified govern- mental deprivation of property — including the health care and benefits that our laws guarantee veterans upon completion of their service. Absent constitutionally sufficient procedural protections, the promise we make to veterans becomes worth- less. When the government harms its veterans by the depriva- tions at issue here, they are entitled to turn to the courts for relief. Indeed, our Constitution established an independent Judiciary precisely for situations like this, in which a vulnera- ble group, that is being denied its rights by an unresponsive government, has nowhere else to turn. No more critical exam- ple exists than when the government fails to afford its injured or wounded veterans their constitutional rights. Wars, includ- ing wars of choice, have many costs. Affording our veterans their constitutional rights is a primary one. There comes a time when the political branches have so completely and chronically failed to respect the People’s con- stitutional rights that the courts must be willing to enforce them. We have reached that unfortunate point with respect to veterans who are suffering from the hidden, or not hidden, wounds of war. The VA’s unchecked incompetence has gone VETERANS FOR COMMON SENSE v. SHINSEKI 6301 on long enough; no more veterans should be compelled to agonize or perish while the government fails to perform its obligations. Having chosen to honor and provide for our vet- erans by guaranteeing them the mental health care and other critical benefits to which they are entitled, the government may not deprive them of that support through unchallengeable and interminable delays. Because the VA continues to deny veterans what they have been promised without affording them the process due to them under the Constitution, our duty is to compel the agency to provide the procedural safeguards that will ensure their rights. When the stakes are so high for so many, we must, with whatever reluctance, fulfill our obli- gation to take this extraordinary step.2 We affirm the district court’s rulings with respect to Veter- ans’s various claims for specific forms of relief under the Administrative Procedure Act, including their claims for system-wide implementation of various VA mental health care initiatives and their claims for the alteration of disability compensation adjudication procedures in VA regional offices. We conclude, as did the district court, that the relevant provi- sions of the Administrative Procedure Act prevent us from granting Veterans the statutory relief that they seek. We reverse, however, the district court’s rulings on Veterans’s constitutional claims. We hold that the VA’s failure to pro- vide adequate procedures for veterans facing prejudicial delays in the delivery of mental health care violates the Due Process Clause of the Fifth Amendment, and that the district court erred when it found otherwise. We further hold that the district court erred in concluding that it lacked jurisdiction to review Veterans’s due process challenge to delays and proce- dural deficiencies in the compensation claims adjudication 2 We emphasize that we are presented with grave questions of life and death, and fundamental structural problems with the government’s fulfill- ment of its duty to veterans. This is a serious matter, which deserves to be taken seriously, rather than as an opportunity to employ military meta- phors in a failed effort to entertain the reader. 6302 VETERANS FOR COMMON SENSE v. SHINSEKI system, and that it erroneously denied Veterans the relief to which they are entitled under the Due Process Clause. We therefore affirm the district court in part, reverse in part, and remand for further proceedings. BACKGROUND There are approximately 25 million veterans in the United States. As of May 2007, roughly one-quarter of them were enrolled for health care with the VA,3 the mission of which is “to fulfill President Lincoln’s promise ‘To care for him, who shall have borne the battle and for his widow and for his orphan’ by serving and honoring the men and women who are America’s veterans.”4 The VA has three branches: the Veter- ans Health Administration (“VHA”), the Veterans Benefits Administration (“VBA”), and the National Cemetery Admin- istration (“NCA”). This case involves statutory and constitu- tional challenges to the actions of two of those branches, the VHA and the VBA. I. Veterans Health Administration Under Chapter 17 of Title 38 of the United States Code, veterans have a statutory entitlement to hospital care and other medical services. See 38 U.S.C. § 1710. This care is provided by the Veterans Health Administration. The VHA is required by law to provide free medical care to all veterans who served in any conflict after November 1, 1998, for up to five years from the date of separation from military service 3 The district court found these facts. We take judicial notice of the more current official figures provided by the VA: 23 million veterans, of whom one-third (8 million) are now enrolled for health care with the Veterans Health Administration, and of whom 3 million receive disability benefits. See VA Benefits & Health Care Utilization (July 30, 2010), available at http://www1.va.gov/VETDATA/Pocket-Card/4X6_summer10_sharepoint .pdf. 4 United States Department of Veterans Affairs, Mission Statement, available at http://www4.va.gov/about_va/ mission.asp. VETERANS FOR COMMON SENSE v. SHINSEKI 6303 for any medical condition, even if the condition is not attribut- able to military service. 38 U.S.C. §§ 1710(e)(3)(C)(i); 1710(e)(1)(D). Medical services that the VHA is required to provide to veterans include “medical examination, treatment, and rehabilitative services.” 38 U.S.C. § 1701(6). The VHA is also required, by statute, to provide readjust- ment counseling and related mental health care services to eli- gible veterans. See 38 U.S.C. § 1712A. The Secretary of Veterans Affairs is required to “furnish counseling to the vet- eran to assist the veteran in readjusting to civilian life. Such counseling may include a general mental and psychological assessment of the veteran to ascertain whether such veteran has mental or psychological problems associated with read- justment to civilian life.” 38 U.S.C. § 1712A(a)(1)(A). If a veteran requests a “general mental health assessment” the VA must provide such an assessment “as soon as practical after receiving the request, but not later than 30 days after receiv- ing the request.” 38 U.S.C. § 1712A(a)(3). If the physician or psychologist who conducts the mental health evaluation deter- mines that the veteran requires mental health services “to facilitate the successful readjustment of the veteran to civilian life” the veteran shall be “furnished such services.” 38 U.S.C. § 1712A(b)(1). The VHA provides healthcare services to veterans via 21 regional Veterans Integrated Service Networks, which admin- ister 153 VA hospitals (or medical centers), approximately 800 community-based outpatient clinics, and 200 Readjust- ment Centers (or “Vet Centers”) throughout the United States. The Secretary is required by statute to ensure that this health care system is “managed in a manner to ensure that the provi- sion of care to enrollees is timely and acceptable in quality.” 38 U.S.C. § 1705(b)(3). Most veterans enrolled with the VA receive medical care at the VHA’s community-based outpatient clinics. These clinics do not provide mental health care services, even though an 6304 VETERANS FOR COMMON SENSE v. SHINSEKI unprecedented number of newly-discharged veterans have been diagnosed as suffering from mental disorders, in particu- lar PTSD, as a result of military service in Iraq or Afghani- stan. Approximately one out of every three soldiers returning from Iraq was seen in a VHA facility for mental health related treatment within a year of his return to the United States. The total number of patients is high; since October 2001, more than 1.6 million military personnel have served in Iraq or Afghanistan, and as of the end of 2007, over 800,000 veterans of the wars in Iraq and Afghanistan were eligible for VA health care. PTSD is a leading mental health disorder diagnosis for those veterans.5 According to Dr. Arthur Blank, a psychiatric expert who testified before the district court, this disorder is a “psychological condition that occurs when people are exposed to extreme, life-threatening circumstances, or [when they are in] immediate contact with death and/or gruesome- ness, such as [what] occurs in combat, severe vehicular acci- dents or natural disasters. It produces a complex of psychological symptoms which may endure over time.” Those symptoms include anxiety, persistent nightmares, depression, uncontrollable anger, and difficulties coping with work, fam- ily, and social relationships. From 2002 to 2003 there was a 232 percent increase in PTSD diagnoses among veterans born after 1972. A 2008 study by the RAND Institute shows that 18.5 percent of U.S. service members who have returned from Iraq and Afghanistan currently have PTSD, and that 300,000 service members now deployed to Iraq and Afghanistan “cur- rently suffer PTSD or major depression.” Delays in the treat- ment of PTSD can lead to alcoholism, drug addiction, homelessness, anti-social behavior, or suicide. 5 As the Commander-in-Chief recently acknowledged, PTSD is one of the two “signature wounds of today’s wars.” President Barack Obama, Remarks by the President in Address to the Nation on the End of Combat Operations in Iraq (Aug. 31, 2010). VETERANS FOR COMMON SENSE v. SHINSEKI 6305 Veterans in general face a heightened risk of suicide. Studies show that suicide rates among veterans are much higher than among the general population. One such study considered by the district court, the “Katz Suicide Study” of February 2006, found that suicide rates among veterans were approximately 3.2 times higher than among the general popu- lation. The author of that study, a senior physician and admin- istrator at the VHA, also estimated that “[t]here are about 18 suicides per day among American’s 25 million veterans” and that there are four to five suicides per day among veterans currently receiving treatment from the VA. Dr. Katz subse- quently noted that the VHA’s “suicide prevention coordina- tors” had identified approximately 1,000 suicide attempts per month among the veterans treated in VHA medical facilities. In July 2004, the VA developed and adopted a five-year Mental Health Strategic Plan to improve the provision of mental health care services. One of its core objectives was to “[r]educe suicides among veterans.” In May 2007, however, the VA Office of Inspector General (“OIG”) issued a report concluding that many components of the Mental Health Stra- tegic Plan, including those relating to suicide reduction, had not been implemented. Moreover, the district court record shows that even in areas in which the VA has attempted to follow the Mental Health Strategic Plan, the measures intro- duced have fallen short of the Plan’s express goals. For exam- ple, the Plan called for thorough mental health screening for “[e]very returning service man/woman . . . as part of the post- deployment and separation medical examination.” Mental health screening is now a component of the primary health care examination when veterans first enroll in the VA, but that screening is not rigorous and does not always evaluate veterans’ risk of suicide. Although veterans are screened for PTSD, depression, traumatic brain injury, military sexual trauma, and problem drinking, their risk of suicide is not auto- matically assessed. All veterans who specifically present6 with 6 The intransitive verb “present” is used by healthcare professionals to mean “to come before a physician (with a particular symptom, medical history, etc.)” Webster’s New World College Dictionary (2010). 6306 VETERANS FOR COMMON SENSE v. SHINSEKI mental health or addiction disorders are screened for suicide risk, but just two questions are asked: (1) “During the past two weeks, have you felt down, depressed, or hopeless?” (2) “During the past two weeks, have you had any thoughts that life was not worth living or any thoughts of harming yourself in any way?” Veterans who answer “yes” to the first question, but “no” to the second question are not given any further suicide risk screening, unless they are being admitted to an inpatient psy- chiatric unit.7 The May 2007 OIG report concluded that there was a wide- spread absence of effective suicide prevention measures at VHA facilities. The report found that 61.8 percent of VHA facilities had not introduced a suicide prevention strategy to target veterans returning from Iraq and Afghanistan and that 42.7 percent of such facilities had not introduced a program to educate first-contact, non-medical personnel about how to respond to crisis situations involving veterans at risk for sui- cide. This report also found that 70 percent of VHA facilities had not introduced a system to track veterans who presented risk factors for suicide and 16.4 percent of VHA facilities had not implemented a medical referral system for veterans with risk factors. By 2009, each of the 153 VHA Medical Centers had a suicide prevention officer, charged with overseeing the clinical care of at-risk patients.8 There were, however, no sui- cide prevention officers at any of the approximately 800 7 Although the record does not state explicitly that those who answer “no” to both questions also receive no further treatment, even if they expe- rienced frequent suicidal impulses previously, we note that this is also a logical inference. 8 The district court noted that these officers receive just two and one half days of special training for their role. VETERANS FOR COMMON SENSE v. SHINSEKI 6307 community-based outpatient clinics, where most veterans receive their medical care. The effect of VHA’s failure to implement a systematic pro- gram designed to reduce veterans’ risk of suicide has been magnified by its failure to adopt measures to ensure that vet- erans with mental health disorders are swiftly identified and offered treatment. As the district court found, the May 2007 OIG report identified significant delays that prevented veter- ans from obtaining timely physician referrals for the treatment of depression and PTSD. For example, the report found that where a primary care provider refers a veteran suffering from depression with symptoms of moderate severity, only 40 per- cent of VA facilities reported a same-day evaluation, whereas 24.5 percent of VA facilities reported a waiting period of two to four weeks, and 4.5 percent of facilities reported a waiting period of four to eight weeks. Similarly, only 33.6 percent of VA facilities reported same-day evaluation for individuals referred with symptoms of PTSD, while 26 percent reported wait times of two to four weeks, and 5.5 percent reported wait times of four to eight weeks. These extensive waiting times can have devastating results for individuals with serious men- tal illnesses. The VA has acknowledged the crucial importance of timely clinical treatment for individuals with mental illnesses, and the district court record is replete with examples of state- ments, both written and oral, by senior VHA physicians and administrators underscoring the importance of timely medical care. One such example is a memorandum written by William Feeley, who, until April 2009, was the Deputy Under Secre- tary for Health Operations and Management at the VHA. In June 2007, he issued a memorandum instructing the directors of all 21 Veterans Integrated Service Networks to begin implementing the specific initiatives set forth in the 2004 Mental Health Strategic Plan, including those guaranteeing timely mental health treatment. The memo instructed that a veteran who presents with mental health issues for the first 6308 VETERANS FOR COMMON SENSE v. SHINSEKI time at a medical center or community-based outpatient clinic should be evaluated within 24 hours. It also provided that a veteran who seeks an appointment for mental health issues should be given a follow-up appointment within 14 days. Yet, VA administrators testified before the district court during the 2009 trial that they had no reports showing that either initia- tive mentioned in the Feeley memo had been implemented system-wide. Indeed, the district court found that as of April 2008, approximately 85,450 veterans remained on VHA wait- ing lists for mental health services.9 Veterans suffering from mental illnesses who are told that they must wait for extended periods of time before receiving treatment have little recourse. A veteran has neither the right nor the opportunity to appeal an administrative decision to place him on a wait list, if that decision is made by a clerical appointment scheduler such as a medical center receptionist. By contrast, a veteran may appeal a doctor or nurse’s clinical decision that he must wait for a certain period of time before receiving mental health care. To do so, he must complain to a so-called “Patient Advocate,” an employee of the VHA Medical Center at which the veteran was treated who is a col- league of the doctor or nurse who placed the veteran on the wait list. The Patient Advocate logs the veteran’s complaint in a database and refers the complaint to the Medical Center’s Chief of Staff, who must decide how to respond to the com- plaint within seven days. If the veteran disagrees with the Chief of Staff’s decision, he may further appeal to the Direc- tor of the Veterans Integrated Service Network, who makes a final decision on the veteran’s complaint. If the veteran dis- agrees with the Director’s decision, he may ask the Director 9 These numbers may, however, significantly under-represent the num- ber of veterans actually awaiting mental health care. During the trial before the district court, the chief medical officer of the Veterans Inte- grated Service Network in the Great Lakes Region testified that, in his region, a veteran was only placed on the wait list for a mental health appointment after he had already waited for 30 days to see a mental health professional. VETERANS FOR COMMON SENSE v. SHINSEKI 6309 to request an external review. The veteran himself may not request such a review; only the Director may do so. More- over, even if the Director does request an external review, the veteran has no right to know the results of that review. The veteran’s only way to independently learn the outcome of an external review is to file request under the Freedom of Infor- mation Act. II. Veterans Benefits Administration The Veterans Benefit Administration is the branch of the VA responsible for veterans’ benefits programs, including pensions and “Service-Connected Death and Disability Com- pensation” benefits. Veterans with service-connected disabili- ties — i.e., disabilities that are the result of a disease or injury incurred through, or aggravated during, active military service — are entitled to monetary benefits as compensation. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(d). Approximately 3.4 mil- lion veterans currently receive monetary benefits from the VBA. The district court found that many recipients of service- connected death or disability compensation benefits are totally or primarily dependent upon those benefits for finan- cial support. The application procedures for such benefits are complex, and the district court found that, in light of statistics showing the limited formal education of the majority of recent veterans, many of them may have difficulty applying for the benefits to which they are entitled without substantial third- party assistance. A The labyrinthine process of applying for benefits from the VBA begins at one of the 57 VA Regional Offices located throughout the United States. To apply for service-connected disability compensation benefits, a veteran must complete a 23-page application and submit it to the VA Regional Office in his area. In support of his application, the veteran must present evidence of his disability, service in the military that 6310 VETERANS FOR COMMON SENSE v. SHINSEKI would entitle him to benefits, and a nexus between the dis- ability and the military service.10 The Veterans Claims Assistance Act, 38 U.S.C. § 5103, states that the VBA has a “duty to assist” veterans, requiring it to aid them in developing all evidence in support of their disability claims. Under the Act, upon receipt of a veteran’s benefits claim application, a VBA Veterans Service Represen- tative must contact the veteran and notify him of any further evidence that the VBA requires in order to adjudicate the claim. Id. The Veterans Service Representative must send the veteran a “duty to notify letter” detailing what information the veteran is expected to provide and what evidence the VBA will seek on his behalf under the Veterans Claims Assistance Act. In accordance with its “duty to assist” under the Act, the VBA must seek all government records that may pertain to the claim, including, inter alia, service personnel and medical records, VA medical records, and social security records. The “duty to assist” also requires the VBA to undertake “reason- able efforts” to acquire non-federal records, most notably pri- 10 A veteran whose claim includes PTSD must additionally provide proof of a “stressor” event that occurred during his military service. See 38 C.F.R. § 3.304(f)(1) (“if the evidence establishes that the veteran engaged in combat . . . and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary . . . the vet- eran’s lay testimony alone may establish the occurrence of the claimed in- service stressor.”) According to Ronald Aument, formerly Deputy Under Secretary for Benefits, this additional requirement renders PTSD-based disability benefit claims among the most difficult claims that the VA adju- dicates. Specifically, the district court found that veterans often make mis- takes completing their application forms and submitting evidence in support of their disability claims, and veterans suffering from PTSD had a particularly hard time furnishing the information properly. We note, however, that the VA recently amended its regulations “by liberalizing in some cases the evidentiary standard for establishing the required in- service stressor” to make it simpler for veterans to file claims for PTSD based on stressors “related to the veteran’s fear of hostile military or ter- rorist activity.” 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). VETERANS FOR COMMON SENSE v. SHINSEKI 6311 vate medical records identified by the veteran, if the veteran furnishes the VBA with a signed release form. Veterans have 60 days to respond to the “duty to notify letter” and to furnish the VBA with any applicable releases. Section 5103A of the Veterans Claims Assistance Act states that the VBA’s “duty to assist” also includes “providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a deci- sion on the claim.” 38 U.S.C. § 5103A. This medical exami- nation is intended to confirm that a disability exists and to assess the medical implications of that disability in order to assist the claim adjudicator in determining the percentage the veteran will be considered disabled pursuant to the VBA’s rating schedule. The VBA arranges and pays for Compensa- tion and Pension Examinations, and the current wait time for such examinations is approximately 30-35 days. Individuals who have been treated for a recognized disability, such as PTSD, at a VHA medical facility may nonetheless be required to undergo a Compensation and Pension Examination. More- over, a veteran who has been previously diagnosed by a phy- sician at a VHA medical center as having PTSD, may nonetheless be diagnosed as not having PTSD during a VBA Compensation and Pension Examination. Once all of the evidence in support of a veteran’s service- connected disability compensation benefits claim has been gathered, a Rating Veterans Service Representative (known as a “rating specialist”) decides whether the veteran’s disability is service connected, and, if it is, assigns a rating to his claim. Approximately 88 percent of all ratings claims are at least partially granted. The rating given operates on a sliding scale from zero percent disabled to 100 percent disabled, with increases at ten percent increments. Compensation currently ranges from $123 per month for a ten percent rating to $2,673 per month for a 100 percent rating. 38 U.S.C. § 1114. 6312 VETERANS FOR COMMON SENSE v. SHINSEKI During the pendency of a veteran’s claim to his local VBA Regional Office, he is statutorily barred from paying a lawyer to represent him. See 38 U.S.C. § 5904. He may, however, be represented by a pro bono attorney or a representative from a Veterans Service Organization — a non-profit organization that is dedicated to working on behalf of veterans.11 If a veteran disagrees with the rating accorded him by the ratings specialist in his local Regional Office he may appeal. The multi-phase appeals process is, however, extremely diffi- cult to navigate, especially for those suffering from mental disabilities such as PTSD, and embarking upon an appeal may delay a veteran’s receipt of benefits for many years. A veteran may initiate his appeal of a rating specialist’s rat- ing decision by filing an informal Notice of Disagreement with his local Regional Office, or by filing a direct appeal to the Board of Veterans’ Appeals with that Regional Office. A Notice of Disagreement may be filed within one year of the issuance of the VBA Regional Office’s ratings decision. The veteran may appeal any part of the rating decision, including the denial of a ground of disability, the percentage of the dis- ability assigned to the veteran, or the effective date of the dis- ability. During the appeals process, the veteran’s record remains open, and the veteran may submit additional evidence at any time. When a Regional Office receives a Notice of Disagreement from a veteran it sends the veteran an election letter asking the veteran to choose between two non-exclusive appeals pro- cesses: (1) de novo review of his claim by a Decision Review 11 VSOs are not affiliated with the VA. The district court found that in some cases, the VA provides VSOs with office space in its VBA Regional Offices, computer systems, and access to VA databases. The court also found, however, that the VA does not provide training to VSOs regarding how to assist veterans, and that all of the VSOs combined cannot meet the needs of all the veterans seeking benefits. VETERANS FOR COMMON SENSE v. SHINSEKI 6313 Officer (a senior ratings specialist) who is empowered to reverse the initial rating decision if he believes that it is not warranted; or (2) issuance of a Statement of the Case by the Regional Office, providing a more detailed rationale for the underlying ratings decision, to be used in a formal appeal to the Board of Veterans’ Appeals. See 38 U.S.C. § 7105. A vet- eran is entitled to retain paid counsel at this stage of the pro- ceedings. See 38 U.S.C. § 5904. If the veteran elects de novo review by a Decision Review Officer, and that officer resolves some, but not all of the appeal, or if the officer fails to resolve the appeal, a Statement of the Case will be prepared and the veteran may pursue a for- mal appeal to the Board of Veterans’ Appeals. If the veteran decides to file a formal appeal with the Board, the veteran must file a VA Form 9 with his local Regional Office within 60 days of receiving the Regional Office’s Statement of the Case, or within a year of receiving the Regional Office’s rat- ing decision, whichever is longer. See 38 U.S.C. § 7105(d)(3). The Regional Office must then certify the veteran’s appeal to the Board of Veterans’ Appeals. 38 C.F.R. § 19.35. A veteran who disagrees with the Board’s decision can fur- ther appeal the decision to the Court of Appeals for Veterans Claims (“Veterans Court”), an independent Article I court created by the Veterans’ Judicial Review Act of November 18, 1988, Pub. L. No. 105-687.12 A veteran claimant must file a notice of appeal with the Veterans Court within 120 days of the Board of Veterans’ Appeals’ final decision. 38 U.S.C. § 7266(a). He may then further appeal an adverse decision by the Veterans Court to the U.S. Court of Appeals for the Fed- eral Circuit, which has authority to “decide all relevant ques- tions of law,” 38 U.S.C. § 7261(a), and he may ultimately 12 The Court of Appeals for Veterans Claims has seven judges, who are appointed by the President and confirmed by the Senate to serve a fifteen- year appointment. 6314 VETERANS FOR COMMON SENSE v. SHINSEKI petition for certiorari in the Supreme Court of the United States. B More than 830,000 ratings claims are filed with the VBA each year. On April 12, 2008, there were 400,450 claims for service-connected death and disability compensation pending before the VBA. The district court found that approximately 11 percent of all ratings claims lead to a Notice of Disagree- ment being filed by a veteran and four percent of all ratings claims proceed to an appeal to the Board of Veterans’ Appeals. Throughout the appeals process, veterans (or their surviv- ing relatives) seeking service-connected death and disability compensation are constrained by various time limits, and a failure to timely file at any point in the process can result in forfeiture of the appeal.13 In contrast, the VBA is not subject to any statutory or regulatory time limits at any step of the process. Veterans experience long delays in the consideration and adjudication of service-connected death and disability claims, particularly when such claims are appealed. The VBA’s stated goal is to process all initial ratings claims within 125 days. The district court found, however, that it takes, on average, 182 days for a regional office to issue an initial decision on a veteran’s claim for service-connected death and disability compensation. Indeed, as of April 12, 2008, there were 101,019 rating-related claims that had been pending for over 13 Following the Supreme Court’s recent decision in Henderson ex rel. Henderson v. Shinseki, 131 S. Ct. 1197 (2011), the 120-day deadline within which veterans may file an appeal from the Board of Veterans’ Appeals to the Veterans Court is no longer treated as jurisdictional. Id. at 1206. The deadline is nevertheless strict, and it remains unclear whether it is subject to equitable tolling or any other exception. Id. at 1206 & n.4. VETERANS FOR COMMON SENSE v. SHINSEKI 6315 180 days. The district court found that, because of the inher- ent complexities in proving a PTSD diagnosis, service- connected death and disability compensation claims that are based on PTSD take longer to adjudicate than other “average” claims. In cases in which a veteran files a Notice of Disagreement with a Regional Office, the district court found that in 2008 it took approximately 261 days for a Regional Office to mail a Statement of the Case to the veteran. In some cases, veter- ans had to wait more than 1,000 days for the Regional Office to issue the Statement of the Case. The district court found that upon receipt of the Statement of the Case, it took the vet- eran 43 days, on average, to file a Form 9 substantive appeal. The district court then found that it took 573 days, on average, for the Regional Office to certify an appeal to the Board of Veterans’ Appeals upon receipt of the veteran’s Form 9 — a merely ministerial act. Some veterans have had to wait more than 1,000 days for the Regional Office to certify their appeal to the Board. The district court found that veterans who appeal directly to the Board wait, on average, 336 days for the Board to issue a decision in their cases. Some veterans elect to have a hear- ing — at their own expense — in front of a Board of Veter- ans’ Appeals judge. Those veterans who receive hearings are more likely to prevail on their appeal, but they must wait an average of 455 days for that hearing. For veterans who pursue an appeal by filing a Notice of Disagreement with the Regional Office’s initial decision, seeking a Statement of the Case, and then file an appeal with the Board, the district court found that it takes on average 1,419 days (3.9 years) from the veteran’s initial filing of the Notice of Disagreement to the veteran’s receiving a decision from the Board. It therefore takes approximately 4.4 years from the date of the veteran’s initial filing of a service- connected death and disability compensation claim to the final 6316 VETERANS FOR COMMON SENSE v. SHINSEKI decision by the Board (not including any time that may have elapsed between the Regional Office’s initial rating decision and the veteran’s filing of his Notice of Disagreement, which may be up to one year). During the district court proceedings in this case, senior VA officials were questioned about the extraordinary delays in the VBA’s claims adjudication appeal system. None of those officials, however, was able to provide the court with a sufficient justification for the delays incurred. Bradley Mayes, the Director of Compensation and Pension Services at the VBA, testified at a deposition that the VBA had not “made a concerted effort to figure out what [wa]s causing” the lengthy delays in its resolution of the appeals of veterans claims for service-connected death and disability compensation. And at trial, James Terry, the Chairman of the Board of Veterans’ Appeals, was unable to explain the lengthy delays inherent in the appeals process before the Board. The record before the district court suggests that errors made by ratings specialists at the Regional Office level play a significant role in the lengthy delays that veterans experi- ence in the adjudication of their claims. On average, the Board affirms a Regional Office’s disposition of a case only 40 percent of the time, grants a veteran’s appeal 20 percent of the time, and remands the case to the VBA for further pro- ceedings in 40 percent of cases. Between 19 and 44 percent of these remands are so-called “avoidable remands,” defined as occurring when “an error is made by the R[egional] O[f- fice] before it certifies the appeal to the B[oard].” The district court found that almost half of the “avoidable remands” between January 1, 2008, and March 31, 2008, occurred as a result of violations by VBA employees of their duty to assist veterans. Approximately 75 percent of the claims that are remanded by the Board of Veterans Appeal are subsequently appealed to the Board a second time. The district court found that it takes the Board, on average, 149 days to render a sec- VETERANS FOR COMMON SENSE v. SHINSEKI 6317 ond decision on a claim that it has already remanded once to the VBA. The district court found that, following remand, it takes the VBA an average of 499.1 days to grant or withdraw a service- connected death and disability compensation claim, or to return it once again to the Board. It takes even longer, on average, for PTSD claims to be processed on remand — 563.9 days. Many veterans suffering from serious disabilities, including PTSD, suffer substantial and severe adverse conse- quences as a result of this lengthy delay. In just the six months between October 2007 and April 2008, at least 1,467 veterans died during the pendency of their appeals. III. History of the Case On July 23, 2007, Veterans for Common Sense and Veter- ans United for Truth filed a complaint in the district court seeking declaratory and injunctive relief, on behalf of them- selves, their members, and a putative class composed of all veterans with PTSD who are eligible for or receive VA medi- cal services, and veteran applicants for and recipients of service-connected death or disability compensation benefits based upon PTSD. In the complaint, Veterans raised numer- ous statutory and constitutional challenges to the procedures the VA employs in its provision of health care services and adjudication of benefits claims.14 With respect to the VHA’s duty to provide veterans with mental health care, the Veterans challenged the following VHA practices and procedures, which, they claim, violate vet- erans’ statutory entitlements and constitutional right to due process: 14 Not all of these claims are maintained on appeal, and this opinion addresses only those that are. 6318 VETERANS FOR COMMON SENSE v. SHINSEKI (1) VHA mental health care waiting lists are extremely long, resulting in lengthy delays and in some cases “the absence of any care,” and there are no transparent procedures in place for a veteran to appeal his placement on such a waiting list (2) Mental health care is unavailable or inaccessible at some VHA facilities and there are no procedures in place to improve accessibility (3) The VHA has no procedure through which Veter- ans can obtain expedited relief in urgent cases such as an imminent suicide threat (4) The VHA had delayed implementing governmen- tal recommendations for improve procedures per- taining to clinical care and education With respect to the VBA’s duty to provide veterans with service-connected death and disability benefits, the Veterans challenged the constitutionality of the following VBA prac- tices and procedures: (1) The VBA acts as both the trier of fact and adver- sary at the Regional Office stage of the adjudication of claims for service-connected death and disability compensation claims (2) There are no neutral judges or trial-like proce- dures at the VBA Regional Office stage of the adju- dication of claims for service-connected death and disability compensation claims (3) There is no procedure through which veterans may obtain discovery to support SCDDC claims (4) There is no procedure whereby a veteran might compel the attendance of any VA employees or most VETERANS FOR COMMON SENSE v. SHINSEKI 6319 other witnesses to testify and support their claims at service-connected death and disability compensation claim hearings (5) There is no class action procedure available in front of the VA (6) The Veterans Court has a limited role and is unable to award injunctive or declaratory relief (7) There is no judicial authority or mechanism to enforce judicial decisions or to require the agency of original jurisdiction (the Regional Offices of the VBA) to obey or comply with the rule of law (8) The attorney’s fee prohibition of 38 U.S.C. § 5904(c)(1) and the related provision for criminal penalties, 38 U.S.C. § 5905 prejudice veterans by curtailing their ability to bring suit Veterans therefore sought declaratory and injunctive relief. Veterans asked the district court to declare, among other things, that: (1) The challenged VA practices, including the lack of procedures to remedy delays in the provision of medical care and treatment, violate Veterans’s right to due process (2) Veterans are not barred from pursuing remedies in the federal courts (3) The VA has a mandatory obligation to provide medical care to returning veterans under 38 U.S.C. § 1710(e)(1)(D) Veterans sought to compel the VA to: 6320 VETERANS FOR COMMON SENSE v. SHINSEKI (1) Implement the recommendations of the Mental Health Strategic Plan (2) Implement the recommendations of the Feeley Recommendation (3) Provide free medical care to all returning veter- ans for the maximum period specified in 38 U.S.C. § 1710(e)(1)(2) (5 years)15 (4) Expand the VHA clinical appeals process to allow for appeals of administrative scheduling delays for the provision of mental health care And Veterans sought to enjoin the VA from: (1) Permitting very protracted delays in the provision of medical care to individuals with PTSD and in the adjudication of PTSD benefits claims (2) Destroying, altering, or doctoring records in vet- erans’ claim files (3) Prematurely denying PTSD and other service- connected death and disability compensation claims (4) Allowing Washington, DC-based officials to assert extra-judicial pressure and influence upon the adjudication of individual claims by VA Regional Offices The VA filed a motion to dismiss, which the district court 15 Veterans’s complaint states that this period is “two years.” The statute, however, specifies that the relevant period is five years. See 38 U.S.C. § 1710(e)(1)(D), (e)(3)(C)(i). The district court correctly found “that this language create[s] an entitlement to health care for veterans for five years after separation from active duty.” VETERANS FOR COMMON SENSE v. SHINSEKI 6321 denied. After Veterans moved for a preliminary injunction on their mental health care claims, the district court held an evi- dentiary hearing. Instead of ruling on the motion for a prelim- inary injunction, the district court deferred its ruling and merged the hearing with a trial on the merits, which began six weeks later. The trial addressed both Veterans’s mental health care claims and their compensation adjudication claims. Veterans objected to the expedited trial schedule and limi- tations on discovery, and the district court overruled the objections. To meet the advanced trial date, the district court created a modified, expedited discovery schedule. On appeal, Veterans challenge two discovery rulings — one relating to the production of suicide incident briefs and the other relating to an interrogatory concerning the average length of time to process a PTSD compensation claim at the initial Regional Office level — which are addressed further in the Analysis, infra. Veterans argue that, in each instance, they were sub- stantially prejudiced by the district court’s ruling. The district court held a seven-day bench trial. Two months later, the district court issued a thorough Memorandum of Decision, Findings of Fact and Conclusions of Law. Veterans for Common Sense v. Peake, 563 F. Supp. 2d 1049 (N.D. Cal. 2008). The district court concluded that Veterans had standing to bring suit on behalf of their members, because the interests at stake in the case were germane to the purposes of both organizations, both organizations’ members had suffered inju- ries in fact, there was a causal connection between the injuries and the VA’s conduct, and the relief sought would likely result in the amelioration of the injuries. 563 F. Supp. 2d at 1077 (citing Friends of the Earth, Inc. v. Laidlaw Envtl. Servs., Inc., 528 U.S. 167, 181 (2000); Lujan v. Defenders of Wildlife, 504 U.S. 555, 560-561 (1992)).16 (Text continued on page 6323) 16 We agree with the district court’s conclusion on this point, and the government does not challenge it. Veterans’ members would individually have standing; the “interests [they] seek[ ] to protect are germane to the 6322 VETERANS FOR COMMON SENSE v. SHINSEKI organization[s’] purpose[s]”; and because their challenge is a systemic one seeking prospective relief — not an attack on past, individual benefits determinations — “neither the claim asserted nor the relief requested requires the participation of individual members in the lawsuit.” See Hunt v. Washington State Apple Advertising Comm’n, 432 U.S. 333, 343 (1977). We note that in a recent case, the D.C. Circuit concluded that a different veterans’ organization did not have standing to bring a suit against the VBA on behalf of its members because the suit expressly sought judicial review of “the average processing time at each stage of the claims pro- cess.” Vietnam Veterans of Am. v. Shinseki, 599 F.3d 654, 662 (D.C. Cir. 2010). The D.C. Circuit, noting that “an association has standing to sue only if one member would have standing on his or her own right,” inter- preted the organization’s claim as not seeking relief for an injury to any individual member of the organization, because “the average processing time does not cause affiants injury; it is only their processing time that is relevant.” Id. Here, by contrast, Veterans complain of a variety of injuries actually being experienced or likely to be experienced in the near future by their members, including stalled disability claims pending in the VBA, and mental health that is deteriorating in the absence of treatment by the VHA. They allege that those injuries are caused by the VA’s systemic failures, particularly the lack of adequate procedures for processing veterans requests for health care from the VHA or claims adjudication by the VBA, and that appropriate procedural safeguards would redress their members’ injuries by ensuring that the services and benefits to which they are enti- tled are delivered before it is too late — i.e., before their illnesses worsen or result in their deaths, and before their families are financially ruined. Veterans do rely upon average waiting times, among much other data and evidence, to illustrate those failures, but, unlike in Vietnam Veterans, Vet- erans do not allege that the “average” wait times themselves cause their members’ injuries. Rather, they argue that it is the absence of constitution- ally required procedural safeguards that causes those injuries and the high risk of future injury. In a suit for prospective relief, that potential for immediate harm is sufficient to establish organizational standing. See, e.g., Florida State Conference of NAACP v. Browning, 522 F.3d 1153, 1160 (11th Cir. 2008) (“When the alleged harm is prospective, we have not required that the organizational plaintiffs name names [of individual mem- bers] because every member faces a probability of harm in the near and definite future.”) (emphasis added). Veterans may represent their members VETERANS FOR COMMON SENSE v. SHINSEKI 6323 The district court nonetheless denied each of Veterans’s claims. With respect to their APA challenge to the VHA’s untimely and/or ineffective healthcare appeals procedures and the inadequacies of the implementation of the Mental Health Strategic Plan, the court concluded that Veterans’s claim did not pertain to a discrete, “final agency action,” and thus it could not be raised under the APA. See 5 U.S.C. §§ 704, 706(1); Norton v. S. Utah Wilderness Alliance, 542 U.S. 55 (2004). Moreover, the court found that 38 U.S.C. § 1710 “commits decisions about the provision of medical care to the Secretary’s discretion,” and that “courts [have] no meaningful standards against which to judge the agency’s exercise in dis- cretion.” Finally, the court found insufficient evidence of system-wide delays in the provision of mental health care to support a determination that agency action was “unreasonably delayed” under the APA, even if the VA’s action were reviewable. The district court further ruled that it did not have jurisdic- tion to order the VA, within 150 days, to fully implement the Mental Health Strategic Plan, because Veterans’s request was barred by the APA for three separate reasons. First, the dis- trict court considered Veterans’s complaint to be one pertain- ing to the manner and speed with which the plan had been implemented — the sufficiency of an agency action, rather interests now; individual members need not wait to bring individual claims until it is too late to obtain meaningful relief. Cf. Sandusky County Demo- cratic Party v. Blackwell, 387 F.3d 565, 574 (6th Cir. 2004) (“[Plaintiff organizations] have not identified specific voters who will seek to vote at a polling place that will be deemed wrong by election workers, but this is understandable . . . . [A] voter cannot know in advance that his or her name will be dropped from the rolls, or listed in an incorrect precinct, or listed correctly but subject to a human error by an election worker who mistakenly believes the voter is at the wrong polling place. It is inevitable, however, that there will be such mistakes. The issues [plaintiffs] raise are not speculative or remote; they are real and imminent.”). Veterans have simply done a better job alleging the facts required to establish their stand- ing than did the plaintiff organization in Vietnam Veterans. 6324 VETERANS FOR COMMON SENSE v. SHINSEKI than a complaint about the agency’s failure to act. Second, because the MHSP “consists of 265 recommendations” the district court found it “dubious” that it could be characterized as “discrete agency action” and found that such “recommen- dations” were not “actions the VA ‘is required to take.’ ” Third, and finally, the district court found that as the MHSP was a five-year plan and was, at the time of the court’s ruling, in its fourth year of implementation, it was still ongoing, and thus was not a final agency action. The district court used the same rationale to reject Veterans’s request that it order the VA to fully implement the recommendations of the Feeley memo within 150 days. As to Veterans’s due process challenge to the VHA’s fail- ure to provide timely care, the district court found no constitu- tional violation. It reasoned that while veterans presenting with mental health emergencies are not treated immediately “every time,” Veterans “did not prove a systemic denial or unreasonable delay in mental health care.” The court deemed adequate the VA’s clinical appeals process, which struck “an appropriate balance between safeguarding the veteran’s inter- est in medical treatment and permitting medical treatment without overly burdensome procedural protections.” The district court also denied each of Veterans’s claims pertaining to benefits adjudication. The district court con- cluded that 38 U.S.C. § 511 prevented it from reviewing delays in the adjudication of individual veterans’ claims, and “the issue of whether a veteran’s benefits claim adjudication has been substantially delayed will often hinge on specific facts of that veteran’s claim.” Furthermore, it concluded that if it were to provide the injunctive relief that Veterans sought, including ordering the VBA to shorten its average wait times, “such an order would invariably implicate VA regulations,” which are subject to judicial review in the Federal Circuit only under 38 U.S.C. § 502. The district court further concluded that neither the delays in adjudicating service-connected death and disability com- VETERANS FOR COMMON SENSE v. SHINSEKI 6325 pensation benefits claims, nor the lack of procedural protec- tions for individuals making such claims, was unreasonable under the APA or violative of due process. While the court found these delays “significant” and did not “dispute that the health and welfare of veterans is at stake,” it determined that it could not find the delays “unreasonable” under the APA because Congress had established no specific timetable for claims adjudication and because the delays resulted, in part, from “the VA’s decision to emphasize initial claim adjudica- tion at the expense of appeals.” Finally, the court found no due process violation because “ ‘[d]elay is a factor but not the only factor’ ” in “ ‘determining when due process is no longer due process because past due.’ ” (Quoting Wright v. Califano, 587 F.2d 345, 354 (7th Cir. 1978)). Ultimately, the district court concluded that the remedies sought by Veterans were beyond its power “and would call for a complete overhaul of the VA system, something clearly outside of this Court’s jurisdiction.” The district court there- fore denied Veterans’s request for a permanent injunction, and granted judgment in favor of the VA. Veterans timely appealed.17 ANALYSIS I We begin by confirming our jurisdiction to hear Veterans’s constitutional claims.18 17 The district court denied Veterans’s request for injunctive relief based upon its answers to questions of law, so we review its decision de novo. See Gathright v. City of Portland, 439 F.3d 573, 576 (9th Cir. 2006). We rely on the facts as they were found by the district court, except to the extent those findings were clearly erroneous. Preminger v. Peake, 552 F.3d 757, 765 n.7 (9th Cir. 2008). 18 For the reasons that are set forth below, the agency actions Veterans challenge under the Administrative Procedure Act are not reviewable under the terms of that statute, so we need not consider other bars to review of those claims. 6326 VETERANS FOR COMMON SENSE v. SHINSEKI A. Sovereign Immunity By seeking an injunction against the VA and its agencies, Veterans have brought suit against the federal government. The federal government has historically enjoyed immunity from suit, notwithstanding that the principle of sovereign immunity derives from the English legal notion that “the King can do no wrong”; this surely was not a principle that those who fought for our country’s independence happily imported into our legal system. Nevertheless, it is well-established that “the United States cannot be lawfully sued without its consent in any case.” United States v. Lee, 106 U.S. 196, 205 (1882). The VA does not assert that it is immune from suit over Vet- erans’s constitutional claims, but we address the issue because the district court determined that sovereign immunity pre- cluded consideration of those claims. [1] We hold that sovereign immunity does not bar adjudi- cation of Veterans’s constitutional claims, because Congress has expressly waived such immunity. The second sentence of § 702 of the APA states: An action in a court of the United States seeking relief other than money damages and stating a claim that an agency or an officer or employee thereof acted or failed to act in an official capacity or under color of legal authority shall not be dismissed nor relief therein be denied on the ground that it is against the United States or that the United States is an indispensable party. 5 U.S.C. § 702. As the Supreme Court has held with regard to this provision, “complaints [for] declaratory and injunctive relief [are] certainly not actions for money damages.” Bowen v. Massachusetts, 487 U.S. 879, 893 (1988). Veterans’s prayers for declaratory relief and an injunction thus fit squarely within this waiver. VETERANS FOR COMMON SENSE v. SHINSEKI 6327 The district court nonetheless found that “waiver of sover- eign immunity under § 702 of the APA is limited by § 704.” Section 704 states, in relevant part, “Agency action made reviewable by statute and final agency action for which there is no other adequate remedy in a court are subject to judicial review.” The district court reasoned that because the delays Veterans challenge are neither made reviewable by any statute nor a “final agency action,” even their constitutional claims fall outside of § 702’s waiver of sovereign immunity. This was error. Whether the challenged delays constitute “final agency action” is an inquiry that is relevant to Veterans’s claims under the APA itself, which are addressed below. But § 704 in no way limits § 702’s broad waiver of sovereign immunity with respect to suits for injunctive relief against the federal government — suits for which the APA itself is not the cause of action. In Presbyterian Church (U.S.A.) v. United States, 870 F.2d 518 (9th Cir. 1989), we held that “§ 702’s waiver of sovereign immunity is [not] limited to instances of ‘agency action’ ” as defined by the APA. Id. at 525. We found that the first sen- tence of § 702 does address “agency action” specifically: “A person suffering legal wrong because of agency action, or adversely affected or aggrieved by agency action within the meaning of a relevant statute, is entitled to judicial review thereof.” 5 U.S.C. § 702. But we determined that the waiver of sovereign immunity in the second sentence, which was added to the statute in 1976, “contains no such limitation.”19 19 Reviewing the legislative history of the 1976 amendment, we explained: Congress observed that before the amendment to § 702, litigants seeking such nonmonetary relief were forced to resort to the “legal fiction” of naming individual officers, rather than the gov- ernment, as defendants an approach that was “illogical” and “be- cloud[ed] the real issue whether a particular governmental activity should be subject to judicial review, and, if so, what form of relief is appropriate.” The need to channel and restrict judicial 6328 VETERANS FOR COMMON SENSE v. SHINSEKI Presbyterian Church, 870 F.2d at 525. To the contrary, “[n]othing in the language of the amendment suggests that the waiver of sovereign immunity is limited to claims challenging conduct falling in the narrow definition of ‘agency action.’ ” Id. We therefore found that sovereign immunity had been waived as to the Church’s First and Fourth Amendment chal- lenges to surveillance conducted by the Immigration and Nat- uralization Service in its congregations, even though the INS’s investigations did not constitute “agency action” under the APA. Id. The district court noted, however, that nine years after Presbyterian Church, we stated summarily: “[T]he APA’s waiver of sovereign immunity contains several limitations. Of relevance here is § 704, which provides that only ‘[a]gency action made reviewable by statute and final agency action for which there is no other adequate remedy in a court, are sub- ject to judicial review.’ ”20 Gallo Cattle Co. v. Department of Agriculture, 159 F.3d 1194, 1198 (9th Cir. 1998). But it is Presbyterian Church and not Gallo Cattle that controls where, as here, a plaintiff ’s challenge is constitutional and thus not dependent on the APA for a cause of action. control over administrative agencies, Congress concluded, could better be achieved through doctrines such as statutory preclusion, exhaustion, and justiciability, rather than through “the confusing doctrine of sovereign immunity.” Accordingly, § 702 was designed to “eliminate the defense of sovereign immunity as to any action in a Federal court seeking relief other than money damages and stating a claim based on the assertion of unlawful official action by an agency or by an officer or employee of the agency.” Presbyterian Church, 870 F.3d at 524 (internal citations and footnote omitted) (citing H. Rep. No. 1656, 94th Cong., 2d Sess. 5, reprinted in 1976 U.S.C.C.A.N. 6121, 6123-6130). We assumed that the “legal fiction” referred to by Congress was that created by Ex parte Young, 209 U.S. 123 (1908), and its progeny. Presbyterian Church, 870 F.3d at 524 n.7. 20 Gallo Cattle did not cite Presbyterian Church or any other authority for this holding. VETERANS FOR COMMON SENSE v. SHINSEKI 6329 The first and second sentences of § 702 play quite different roles, each one significant. The first sentence entitles aggrieved individuals to “judicial review of federal agency action.” The second sentence, added to the statute decades later, waived sovereign immunity for “[a]n action in a court of the United States seeking relief other than money damages . . . .” One such action, of course, is a suit for “judicial review of federal agency action” of the sort authorized by the first sentence. But other actions exist too. Injunctions may be sought, for example, to enforce the Constitution itself; courts need no statutory authorization to undertake constitutional review. See, e.g., Bell v. Hood, 327 U.S. 678, 684 (1946) (“[I]t is established practice for this Court to sustain the juris- diction of federal courts to issue injunctions to protect rights safeguarded by the Constitution . . . .”). Gallo Cattle considered a challenge to an agency order denying the plaintiffs preliminary relief while they adjudi- cated the merits of their petition before an administrative board — that is, interim relief to which the plaintiffs believed themselves entitled by statute and the agency’s regulations.21 Id. at 1198-1200. The plaintiffs sought “judicial review of agency action” not because it was unconstitutional, but because it violated the rules governing the agency. For that type of suit, the plaintiffs’ cause of action was the APA itself, so we applied § 704’s limitation on what agency action is reviewable — meaning subject to “judicial review” under the first sentence of § 702 — and concluded that because § 704’s terms were not satisfied, the first sentence of § 702 did not authorize judicial review. Consequently, sovereign immunity could not be waived because the plaintiffs failed to bring a 21 The plaintiff ’s claim on the merits before the administrative board concerned a First Amendment challenge. Gallo Cattle, 159 F.3d at 1196. That claim was not before the court, however. The plaintiffs appealed only from the agency’s denial of its request “to pay [the challenged] assess- ments into escrow pending a decision on the merits of the petition” — a matter solely of the agency’s procedure for adjudicating disputes through its administrative process. Id. 6330 VETERANS FOR COMMON SENSE v. SHINSEKI cognizable “action” in court. Id. at 1198 (addressing the “waiver of sovereign immunity in suits seeking judicial review of a federal agency action under [28 U.S.C.] § 1331”) (emphasis added)). [2] As in Presbyterian Church, the plaintiffs here raise a constitutional challenge, which does not depend on the cause of action found in the first sentence of § 702. Section 704’s limitation of that first sentence is thus inapplicable, and the district court’s reliance on Gallo Cattle was incorrect.22 Instead, because Veterans have brought “[a]n action in a court of the United States seeking relief other than money dam- ages” that arises under the Constitution itself, as in Presbyte- rian Church, we find that sovereign immunity has been waived by § 702’s second sentence. We find additional support for this conclusion in a decision of the D.C. Circuit that rejected similar arguments to those made by the government and accepted by the district court here. In Trudeau v. FTC, 456 F.3d 178 (D.C. Cir. 2006), that court declined to adopt the FTC’s position that “(1) the waiver [of sovereign immunity under § 702] applies only to actions arising under the APA; and (2) since review under APA § 704 is limited to ‘final agency action,’ the waiver of sovereign immunity is similarly restricted to conduct that falls within that compass.” Id. at 186. Undertaking an analysis identical to ours in Presbyterian Church, the court determined that “noth- 22 While incorrect, the district court’s confusion was reasonable. The district court cited Gros Ventre Tribe v. United States, 469 F.3d 801 (9th Cir. 2006), a prior decision of this court that discussed both Presbyterian Church and Gallo Cattle and observed in passing that it “saw no way to distinguish” the two cases. Id. at 809. The Gros Ventre Tribe court ulti- mately resolved the case on other grounds. For the reasons just provided, we find Presbyterian Church and Gallo Cattle readily distinguishable: Presbyterian Church concerns § 702’s waiver of sovereign immunity as to constitutional challenges, while Gallo Cattle concerns challenges under the APA itself. Section 704 constrains only the latter situation, and it is the former type that we are presented with here. VETERANS FOR COMMON SENSE v. SHINSEKI 6331 ing in the language of the second sentence of § 702 . . . restricts its waiver to suits brought under the APA,” and thus the waiver applied to the plaintiff ’s First Amendment claim there. Id. Moreover, the court “h[e]ld that the waiver applies regardless of whether the [agency’s challenged conduct] con- stitutes ‘final agency action’ ” under § 704. Id. at 187 (citing Presbyterian Church, 870 F.2d at 525). This is consistent with our holding that § 702’s waiver of sovereign immunity applies more broadly than to actions under the APA itself. We therefore hold that, as to Veterans’s constitutional claims for “relief other than money damages,” § 702 waives sovereign immunity regardless of whether the claims arise from “agency action” as defined by the APA.23 B. The Veterans Judicial Review Act The Veterans Judicial Review Act (“VJRA”) prohibits judi- cial review of “the decision of the Secretary [of Veterans Affairs] as to any” “question[ ] of law and fact necessary to a decision by the Secretary under a law that affects the provi- sion of benefits by the Secretary to veterans or the dependents or survivors of veterans.” 38 U.S.C. § 511(a). The VA argues that this provision precludes us from considering Veterans’s second constitutional challenge, concerning the procedure for the adjudication of claims for disability benefits. The dissent goes even further and suggests that the VJRA forecloses our ability to decide Veterans’s first constitutional challenge, regarding delays in mental health care services, as well. We disagree as to both challenges, and shall explain why below in the context of each claim. 23 We note that even if we did not find a waiver of sovereign immunity here, Veterans’s constitutional challenge could proceed against all individ- ual defendants under Ex Parte Young — precisely the fiction for which Congress sought to eliminate the need in adding the second sentence of § 702. 6332 VETERANS FOR COMMON SENSE v. SHINSEKI II We first address Veterans’s statutory and constitutional claims concerning the delays in VHA’s provision of mental health care. The number of veterans diagnosed as suffering from mental illnesses, and the percentage of those who are awaiting treatment, is simply staggering. As of April 2008, at least 85,450 veterans were languishing on VHA waiting lists for mental health care — a number that may significantly under-represent the scale of the problem both then and now.24 The urgent need to provide veterans with the mental health care to which they are entitled is clear, not least in light of the high suicide rate among this vulnerable population. In the absence of procedures designed specifically to safeguard vet- erans’ rights to timely, effective treatment, veterans are suf- fering and dying, heedlessly and needlessly. Veterans contend that the introduction of a formal appeals process to allow a veteran to contest an administrator’s deci- sion to place him on a waiting list for mental health care, of more transparent clinical appeals procedures, and of a proce- dure permitting veterans with PTSD to seek expedited access to mental health care in acute cases, would save lives. The district court ruled that Veterans have no recourse in the fed- eral courts to contest the VA’s systematic failure to provide veterans with procedures safeguarding their access to the mental health care to which they are statutorily entitled. In some respects, the district court is correct. In others, it erred in so ruling. Although our power is limited under the APA and we cannot grant Veterans the relief they seek as to their statutory challenge, we hold that their constitutional right to due process has been violated, reverse the district court’s rul- ing in this respect, and remand this appeal for further proceed- ings. 24 As noted earlier, supra note 9, some veterans are not even placed on formal waiting lists until they have already waited for a month. VETERANS FOR COMMON SENSE v. SHINSEKI 6333 A. APA Challenge to Mental Health Care Delivery 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 effec- tive 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 Alli- ance, 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 “prop- erly 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 sug- gested 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 com- pelled by a federal court under § 706(1) only if that action is one which is legally required. Id. Quoting the Attorney Gen- eral’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 (quot- ing Attorney General’s Manual on the Administrative Proce- dure 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 eli- gible veterans by failing to implement the Mental Health Stra- tegic 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 implementa- tion 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 Veter- ans seek to compel. In relevant part, 38 U.S.C. § 1710 requires that the VA fur- nish 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 dis- ability 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 sec- VETERANS FOR COMMON SENSE v. SHINSEKI 6335 tion 1710(a)” to prescribe, establish, and operate a system of annual patient enrollment. In designing this “enrollment sys- tem,” the Secretary “shall ensure that the system will be man- aged 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 obliga- tion mandates the implementation of the Mental Health Stra- tegic 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 veter- ans 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 defi- ciencies 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.” Nor- ton, 542 U.S. at 65. Even a less formal agency “plan” may “it- self 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 particu- lar 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 com- munication 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 accept- able mental health care therefore cannot proceed because Vet- erans 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 dis- trict 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 juris- diction to consider this claim. We note at the outset that while the VA argues vigorously that the VJRA forecloses our con- sideration of Veterans’s second due process claim, regarding the disability benefits adjudication process, it does not con- tend 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 “chal- lenges to the medical care or other benefits provided in spe- cific cases.” Gov’t Br. 33 n.7. A potential jurisdictional flaw is not a litigant’s issue to waive, of course, so we must con- sider the issue ourselves notwithstanding the parties’ agree- ment. 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 schedul- ing — violates the Due Process Clause by providing insuffi- cient process. It is debatable whether that question of law is one that is “necessary to a decision by the Secretary” affect- ing 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 constitu- tionally sound, but it has not issued a “decision” on the ques- tion 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 calcu- lating compensatory benefits. See 38 U.S.C. § 1156(b)(1)(B). The dissent argues that “there is simply no way to adjudi- cate the due process claim without ‘determining first’ whether the VA’s administrative staff ‘acted properly in handling’ vet- 25 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 pro- cedural 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 individ- ual veteran, as in the two cases cited by the dissent, where “underlying the claim is an allegation that the VA unjustifi- ably denied him a veterans’ benefit.” Thomas, 394 F.3d at 974 (emphasis added). The relevant “decision[s]” as to “ques- tion[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 “deci- sion[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 under- standing 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 physi- cian identified “about 1,000 suicide attempts per month” among the veterans seen in VHA facilities.27 The precise con- 26 The VA’s statistics do not differentiate between veterans who are sim- ply enrolled with the VA, veterans who are receiving other types of (non- mental 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 investi- gation. 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 depriva- tion 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 veter- ans. 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 enti- tled “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 involv- ing 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 bene- fits 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 abil- ity to hold hearings on the agency’s operations,” and that “[b]ecause Con- gress is already actively involved in the agency’s affairs, programmatic improvements should be made in the offices of the VA or the halls of Con- gress, 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 govern- ment to respond. Had the resulting oversight then yielded actual solutions, this case might have become moot. It is only because the government con- tinued 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 impli- cates 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 bene- fits, 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 Educa- tion 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 common- sense proposition that an unreasonable delay in the delivery of an entitlement can amount to a deprivation of that entitle- VETERANS 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 ill- ness 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 inter- est 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 Dis- senting 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 nonad- versarial 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 adjudica- tion 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 spe- cific 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 depri- vation 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 bur- dens 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 depriva- tion 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 errone- ous deprivation. It similarly erred in its conclusion that the third Mathews factor weighs against imposing additional pro- cedural 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 depri- vation faced by veterans with serious mental illnesses and dis- orders. Veterans did not prove conclusively at trial that veterans seeking mental health care face a high risk of detri- mental delays in the provision of care, but the district court’s factual findings support the conclusion that there is a signifi- cant 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 . . . proce- dural 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 recep- tionist 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 vet- eran 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 super- vising administrator about their need for more immediate care, nor to insist that they be evaluated by a medical profes- sional, 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 pro- fessional — 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 eval- uated 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 auto- matically 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 person- nel (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 safe- guard 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 dis- tinction 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 delete- rious 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 sub- jected. The record contains one story, for example, of a vet- eran 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 diag- nosed with PTSD. All told, over 84,000 veterans are on wait- 31 We have not “misunderst[ood] [the] evidence” of the existing proce- dural 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 adminis- trative 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. Vet- erans 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 alarm- ing in view of the apparent ineffectiveness in the scheduling system. In July 2005, an “Audit of the Veterans Health Administration’s Outpatient Scheduling Procedures” con- ducted 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. Spe- cifically, the 2007 report found: 72 percent of patient appoint- ments 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 Out- 6348 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 imple- mented. [10] This is therefore not a case in which existing proce- dures are sufficient, such that additional process is unlikely to produce significant marginal reductions in the risk of errone- ous 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 pro- duce 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 fac- tor 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 safe- guards were introduced to facilitate veterans’ ability to secure their entitlement to mental health care in a timely and effec- tive 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 addi- tional 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 con- trary, it is embracing delay over effective treatment. If there is any justification for the VA’s interest in main- taining the status quo, it has not told us, and we cannot imag- ine 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 ade- quate 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 con- ceive 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. *** 6350 VETERANS FOR COMMON SENSE v. SHINSEKI [11] We have determined that veterans have a towering interest in avoiding delays in their mental health care, the risk of erroneous deprivation is high given the absence of review procedures, the value of additional procedural safeguards would be great, and the government’s interest does not weigh against additional protections. The current delays therefore constitute a deprivation of Veterans’s mental health care with- out due process, in violation of the Fifth Amendment. [12] We reverse the district court’s judgment to the con- trary, and remand for further proceedings. On remand, the dis- trict court shall conduct hearings in order to determine what additional procedures or other actions would remedy the existing due process violations in three core areas. The district court shall consider what procedural protections are necessary to ensure that: (1) individuals placed on VHA waiting lists for mental health care have the opportunity to appeal the decision in a timely manner and to explain their need for earlier treatment to a qualified individual; (2) individuals determined to be in need of mental health care receive that treatment in a timely manner; and (3) individuals with urgent mental health problems, particularly those at imminent risk of suicide, receive immediate mental health care. Although, as we have noted earlier, the district court may not order the VHA to implement the Mental Health Strategic Plan or institute the recommendations of the Feeley Memorandum, it may consider specific procedures or measures mentioned in both to aid in its determination as to what procedures are nec- essary. The district court’s determination may also draw upon the findings of the 2007 VA Office of Inspector General VETERANS FOR COMMON SENSE v. SHINSEKI 6351 Report, and other evidence already in the record or adduced at a hearing following remand; we recognize that circum- stances may have evolved since the district court last took evi- dence three years ago. We still remain hopeful that at least some of the problems in this case can be resolved by the parties working together. The district court should encourage them to meet and confer to propose a remedial plan that addresses the mental health care delivery problems described above, to be presented to the court for approval. It is within the discretion of the district court to consider obtaining the assistance of a Magistrate Judge or appointing a Special Master to aid the court in any way deemed necessary. In the end, the district court shall either approve a plan agreed upon by the parties or enter an appropriate order instructing the VHA to provide Veterans with the procedural safeguards to which they are entitled. III We next address Veterans’s statutory and constitutional claims concerning the delays in the VBA’s claims adjudica- tion system, particularly in the claims appeals process. On appeal, Veterans challenge the district court’s denial of relief for these claims and contend that relief is warranted under both the APA and the Due Process Clause. Once again, we affirm the district court’s denial of Veterans’s statutory claim, but reverse the district court’s ruling on their constitu- tional claim. We hold that Veterans’s entitlement to service- connected death and disability compensation is a property interest protected by the Due Process Clause, and that the lack of adequate procedures to prevent undue delay in the provi- sion of that property constitutes a deprivation that violates Veterans’s constitutional rights. 6352 VETERANS FOR COMMON SENSE v. SHINSEKI A. APA Challenge to Delays in Compensation Claim Appeals In considering Veterans’s APA claim with respect to bene- fits adjudication, we are, once again, 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. Veterans’s APA claim concerning timely and acceptable adjudication of veterans’ service-connected death and disabil- ity claims cannot proceed because Veterans do not assert that the VA “failed to take a discrete agency action that it is required to take.” Id. at 64. The district court erred in stating: “It is uncontested the adjudication of benefits claims is a discrete agency action that the VA is required to take.” That analysis failed to consider the cornerstone of Veterans’s APA claim. Veterans are chal- lenging pervasive deficiencies in the adjudication process that harm their members, not delays in discrete benefits adjudica- tions that the VA is required to make. As discussed above, agency action to remedy widespread delays is not a discrete, “required” action under § 706(1). On this basis alone, Veter- ans are barred from seeking statutory relief that is dependent upon the VA’s waiver of sovereign immunity under the APA. See Norton, 542 U.S. at 63-65. We therefore affirm the dis- trict court’s dismissal of Veterans’s APA claim, on the basis that it does not meet the APA requirement for reviewability.33 33 Because Veterans are barred from seeking statutory relief under the APA, we need not consider the VA’s alternative arguments that 38 U.S.C. § 502 or § 511 also bar consideration of Veterans’s statutory claims. VETERANS FOR COMMON SENSE v. SHINSEKI 6353 B. Due Process Clause Challenge to Delays in Compen- sation Claim Appeals 1 First we must consider whether we may hear Veterans’s constitutional claim. The VA argues that we lack jurisdiction to do so, because the VJRA divests all federal courts but the Veterans Court and the United States Court of Appeals for the Federal Circuit of jurisdiction to review any question concern- ing veterans benefits. We reject that contention. In our view, the VJRA does not strip district courts of jurisdiction to hear constitutional challenges to the VA’s system-wide conduct, divorced from challenges to individual benefits determina- tions. The VA points to two sections of the VJRA, sections 502 and 511. Neither applies here. a. Section 502. 38 U.S.C. § 502 states, “An action of the Secretary to which [5 U.S.C. §§ 552(a)(1), 553 (the APA pro- vision concerning rulemaking)] refers is subject to judicial review. Such review . . . may be sought only in the United States Court of Appeals for the Federal Circuit.” The district court determined that, given § 502’s grant of exclusive juris- diction to the Federal Circuit, “any challenge by [Veterans] to VA regulations is not reviewable in this Court.” It found that provision relevant because, in its view, granting Veterans the relief they seek “would invariably implicate VA regulations.” Consequently, it held that “any such challenge is reviewable only in the Federal Circuit” under § 502. By its plain text, however, § 502 concerns only “judicial review” of “action[s] of the Secretary” as defined by the APA. We are thus presented with Norton’s complement: for the same reason that the delays Veterans challenge are not “action[s] of the Secretary” that are reviewable under the APA, see supra at 6333-37, they are not actions that may be 6354 VETERANS FOR COMMON SENSE v. SHINSEKI challenged in the Federal Circuit only. Section 502 is clear in its purpose of directing APA-based challenges to the VA’s rules and regulations to a single federal court, in derogation of the APA’s general grant of judicial review in all courts. So we cannot read its jurisdiction-stripping provision any more broadly than the narrow class of actions that may actually be challenged under the APA after Norton. In addition to § 502’s plain text, our precedent dictates this result. In Preminger v. Principi, 422 F.3d 815 (9th Cir. 2005), we held that § 502 bars review outside the Federal Circuit of “direct challenges to VA rules and regulations” only. Id. at 821 (emphasis added). And in Nehmer v. Department of Vet- erans Affairs, 494 F.3d 846 (9th Cir. 2007), we determined that § 502 concerns only suits that “directly challenge either the merits of the VA’s regulation or the VA’s rulemaking authority.” Id. at 857-858 (emphasis added). Veterans chal- lenge neither, but only the VA’s failure to discharge its duty to veterans in a short enough time to avoid depriving them of their property interest without due process. Finally, we find that the district court’s concern that “an order expediting claims adjudications . . . would force the VA to alter or repeal some of [its] regulations,” and thus would violate § 502, was entirely misplaced. As just explained, § 502 limits judicial review of discrete agency actions, not claims of the type asserted here. Veterans’s only surviving claim with regard to benefits is a facial constitutional chal- lenge to the VA’s actual conduct, not its codified rules, so § 502 is not implicated at all. See Nehmer, 494 F.3d at 858-859 (where plaintiffs “challenge[d] the actions of the VA in failing to comply with the terms of” a court order, § 502 did not bar review “irrespective of the existence of the VA regulations” that were adopted in response to the order, because the claim was not a “facial challenge to VA regula- tions”). While the VA may choose to modify its regulations to comply with a remedial order, that future remedy would not convert Veterans’s suit into an action for judicial review VETERANS FOR COMMON SENSE v. SHINSEKI 6355 of an agency action subject to § 502. Thus, § 502 does not affect our ability to review Veterans’s constitutional claims. b. Section 511. The district court understood § 511 to pre- clude “review of individual benefits decisions,” but not “fa- cial constitutional challenges to the VA benefits system.” Nonetheless, the court determined that § 511 barred review, because “the determination of whether the delay is unreason- able may depend on the facts of each particular claim,” which individually may not be reviewed in district court. Section 511 blocks review of “decision[s] of the Secretary” as to any “questions of law and fact necessary to a decision by the Secretary under a law that affects the provision of ben- efits.” 38 U.S.C. § 511(a) (emphasis added). Under the stat- ute’s plain text, there are three problems with the district court’s analysis. First, the conduct Veterans challenge is not a “decision” within the meaning of § 511. While the term “decision” is not expressly defined in the statute, we understand it in the con- text of the statute to mean individual benefits adjudications — the type of individualized decisions Congress sought to keep out of the district courts. See H.R. Rep. No. 100-963, 1988 U.S.C.C.A.N. 5782, 5803-5804. Section 1156, for example, discusses “ratings decision[s]” by the Secreta [Text truncated at 120,000 characters. The full text is on the page linked above.] --- Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/3065770. Public record. Not legal advice.