VA Secretary David Shulkin has proved to be something unique in President Donald Trump's Washington: an Obama appointee nominated by Trump who is beloved by almost everyone and getting stuff done.

By tweaking regulations, he has managed to fire hundreds of allegedly incompetent employees, publicized waiting times at Veterans Affairs clinics, gotten money to expand vets’ treatment by private doctors, and expanded care for isolated vets through telemedicine and mobile phones, while promising to close 430 vacant VA buildings and speed up benefit awards. Shulkin also made a bold — and risky — decision to bypass contracting rules to buy a $16 billion digital health record system.


“What motivates me and what motivates Dr. Shulkin is the same, to provide the best care to veterans,” said Rep. Phil Roe (R-Tenn.), chairman of the Veterans Affairs Committee. “I don’t know whether he’s a Republican or Democrat, and I could care less.”

But there’s a reason Shulkin was Trump’s fourth choice for the VA job — or possibly the fifth, or the 10th, depending on whom you ask. The VA, with 350,000 employees and 1,250 health care sites, is a political quagmire. Not many people want to clean up others’ messes with hundreds of people looking over their shoulder.

The VA’s conservative critics are holding their fire now that a GOP administration and Congress control the agency. But savaging from both left and right is likely to start up again if Shulkin’s mission flags. That could easily happen.

The administration and Congress must agree on a way to scrap or overcome budget caps to fund an ambitious Shulkin agenda that includes building up the $70 billion VA health system from within while simultaneously enabling veterans to get care outside its doors.

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Shulkin sees his primary mission as reestablishing trust among veterans. After taking office, he got legislation passed that makes it easier to fire poorly performing staff, and he quickly relieved several top officials, including Brian Hawkins, head of the Washington, D.C., VA Center. (The federal Merit Systems Protection Board ordered Hawkins reinstated, but Shulkin sidelined him in an administrative job.)

In a bold stroke for transparency, he made the VA the first health care system in the country to publish waiting times at its clinics. With equal decisiveness, in June, he decided to scrap the VA’s venerable IT system with a one-source contract. He got a Department of Justice ruling to help expand the ability of isolated veterans to see doctors remotely, through telemedicine and mobile apps.

All the while, Shulkin has held at bay libertarian groups like the Concerned Veterans of America, who are inclined to allow vets to freely choose to see doctors outside the VA. Shulkin said recently that privatization of the VA "won't happen while I'm in office."

In a reflection of Shulkin’s determination to bolster the VA's health care services even while expanding veterans’ options, when Trump signed an emergency $2.1 billion measure to continue funding for the 2014 Veterans Choice Act, the bill also included $1.8 billion to strengthen 28 VA hospitals.

But these steps only nibble at the edges of the main issue, which is how to satisfy the health needs of veterans without breaking the VA system, whose costs have been climbing at 5 percent annually. With budget caps near bursting, Congress needs to develop legislation this fall that will keep the faith with veterans while staying under those caps.

“It’s not clear that Shulkin or the Hill have a complete grasp on how big their budget hole is, let alone the willingness to fill it,” says Phillip Carter of the Center for a New American Security, a centrist think tank. “They can’t build two parallel systems with no regard for cost and no guiding principles for how to allocate care. It’s not politically viable or feasible.”

Tough decisions earn respect

Shulkin has managed to get work done under an erratic president by “making sure he is not tapped to make decisions outside of Veterans Affairs,” says one colleague. Shulkin, whose nomination was unanimously approved by the Senate in February, isn’t registered with either party, and no one seems to know whether he leans Democratic or Republican.

Former President Barack Obama appointed him to lead the VA’s health system in 2015, but “my only party is the veteran’s party,” he told POLITICO in an interview at his office.

Trump has had nothing but praise for Shulkin, and he enjoys great popularity in the Senate and House, where Roe says that Shulkin’s medical background gives him insights that his two predecessors, Eric Shinseki and Bob McDonald, didn’t have.

“We think alike — it’s almost scary sometimes,” said Roe, himself an obstetrician. “He’ll say the same thing that I’d been thinking.”

Shulkin’s frankness and accessibility have won fans across the spectrum, even from those who question his actions — an irregularity in polarized Washington.

"He's a very impressive person. He can drill down on the VA's problems, explain them and find solutions that draw on his private-sector knowledge," said Dan Caldwell, policy director for Koch Industries-backed Concerned Veterans of America, which, unlike Shulkin, wants to allow vets to freely seek care at private facilities.

“So far in his tenure, he has shown leadership and ability to focus on veterans, to keep ideology out of the equation and work in a bipartisan way,” said Julia Brownley of California, a senior Democrat on the House Veterans Committee.

Shulkin has yet to nominate several senior deputies — including undersecretaries of health and benefits, and a chief information officer to oversee the acquisition of a new records system. Two VA IT workers who spoke on condition of anonymity said the lack of high-level leadership had left them twiddling their thumbs.

Although many IT specialists in and out of the VA question Shulkin’s decision to ditch the agency’s 40-year-old digital record system, one official who opposed the decision said IT officials had resigned themselves to work on it — largely because they respect Shulkin as a leader.

Welcome to the jungle

Many of the problems Shulkin faces date back decades. The VA has always struggled to handle the demand for health care from veterans. Before 1996, when health undersecretary Ken Kizer began implementing an integrated care system, the VA treated veterans only for service-related conditions.

The classic Catch-22 was the World War II amputee whose wound was frequently infected because of his diabetes. “He could get the stump cared for at the VA, but not his blood sugar problem,” recalled Kizer. “It didn’t make sense.”

Thousands of veterans struggled to get care for years while the Pentagon and VA tussled over whether exposures to the herbicide Agent Orange, during the Vietnam era, or a variety of other toxins used during Mideast wars, were responsible for their ailments.

Since the late 1990s, the VA has alternately rationed and increased care as it sought to do right by veterans while holding down costs. Yet it still can’t meet the demand.

The 2014 Phoenix VA scandal, which resulted from evidence that officials faked appointment calendars to obscure long wait times, prompted Congress to open its checkbook with the Veterans Choice Act, which authorized $10 billion over 3 years to care for veterans in the private sector.

The Choice program, meant to be temporary, allowed vets to go outside the system if their care required more than a 30-day wait, or required them to travel more than 40 miles. Even so, the program ran out of money earlier this year as veteran demand was still surging.

In June, Shulkin testified that 35 percent more veterans were seeking health care outside the VA each week than had done so a year earlier. The Choice program was blowing through cash without a clear idea of how much more would be needed.

President Donald Trump, accompanied by VA Secretary David Shulkin (right), talks with a patient during a Veterans Affairs Department "telehealth" event at the White House. Shulkin has accomplished much in his tenure, including expanding care for isolated vets through telemedicine and mobile phones. | Evan Vucci/AP Photo.

And while the program has improved over three years, some still call it a “train wreck” — as Sen. Jon Tester (D-Mont.) referred to it recently. Montana veterans have had more, not less, trouble getting care because of red tape associated with the program, he said.

It isn’t clear vets are being treated better outside the VA system. Their records often aren’t shared among private and VA doctors, leading to poor coordination. An insprector general report last month, for example, found that patients prescribed opioids in non-VA clinics received conflicting guidelines on how to use them.

The VA also has no clear idea of how much it costs to care for patients within its walls. The agency hired PricewaterhouseCoopers to determine the demand for services at each VA facility, a Senate staffer said, but that report could take years to finish and, in the meantime, “when you don’t know what demand is, it creates a problem for Congress.”

The move to expand veterans care in the private sector comes at a time when the U.S. health care system is moving in the opposite direction, with health care systems seeking ever more tightly integrated care within their facilities.

Shulkin, who as CEO of Morristown Medical Center in 2011 set up one of the country’s first accountable care organizations — in which doctors are rewarded for lowering unnecessary costs — is well aware of this.

“As a hospital administrator, which I [was] for 30 years in the private sector, you want to maximize your current fixed costs,” he said in the interview. “Care in the community is not going to be cheaper.”

Shulkin hopes to create a rational balance of inside and outside care — “adjusting the hot and cold spigots,” he says — that is based on patient need and predicated on good information sharing. Congress will take his ideas as it develops legislation this fall for “Choice 2.0, or whatever we call it,” Roe said.

Shulkin would ditch the “30 days/40 miles” rule in favor of a system based on the veteran’s clinical needs. In his vision, veterans seeking care would first talk to a VA provider — in person, by phone or virtually — leading to a clinical assessment to decide whether their care would be met best within or outside the VA. If a veteran were treated outside the VA, information from the visit would flow back to his or her primary care team.

Sharing that information is a problem, though. The pursuit of an IT system in which records flow smoothly among the VA, military and private health care systems motivated Shulkin’s decision in June to ditch the VA’s digital health record system — built in-house since the late 1970s — in favor of a Cerner Corp. system.

But that transition will take five years at a bare minimum and could cost $16 billion, according to one estimate. “We haven’t figured out how to pay for it yet,” says Roe, who recently hired a staff IT expert to help oversee the undoubtedly difficult transition.

“This is a huge project,” Roe said. “It may be the biggest IT project in the country’s history.”

Small steps

Shulkin isn’t ready to give veterans unfettered choice in health care because, he acknowledges, the VA’s brand has been tattered so badly that free choice could lead to an exodus from the system that he estimates would add $20 billion a year to the VA’s budget.

“On a level field of competition, I do not believe that we would be treated fairly today, because I believe this agency has had years, if not decades, of neglect and failure to modernize,” Shulkin said.

More flight from the VA health care system could eventually lead to its elimination — a disaster for the millions of veterans, many of them with meager means, who rely on services impossible to affordably achieve anywhere else.

“It would put veterans with very difficult problems out into the community with nobody to stand up for them and to coordinate their care,” Shulkin testified in June.

As a first step toward making VA care more focused, Shulkin has ordered administrators to take 5 percent of their budget — $3.5 billion total — away from care cheaply available in the private sector, like eyeglasses and flu shots, and use that money to double down on core VA services, such as treating traumatic brain and spinal cord injury, PTSD and providing orthotics.

David Pittman contributed to this report.

