Dr. Ronny Jackson’s nomination to lead the Department of Veterans Affairs has come under fire, with new allegations that the White House physician drank on the job and improperly prescribed pills to White House staff.

The New York Times reported earlier today that Jackson, who also served under Presidents Obama and George W. Bush, had previously “distributed Ambien, a prescription sleep aid, which is not a narcotic, to White House staff and members of the news media flying on long overseas trips, as well as Provigil, a prescription drug for promoting wakefulness.”

And Democratic Senate aides shared with the Times one account of an incident when Jackson allegedly got drunk while on the job: “On one trip during Barack Obama’s presidency, White House staff needed to reach Dr. Jackson for medical reasons and found him passed out in his hotel room after a night of drinking.”

This is, quite obviously, not the type of résumé you’d want to put forward for any medical job — especially not one in the president’s Cabinet.

But I want to expand a bit on a point that Matt Yglesias made earlier today at Vox: All this scandal swirling around Johnson masks how unqualified he is to run the country’s largest hospital system. Here’s Matt:

The VA employs around 375,000 people with a budget surpassing $185 billion. Only the Defense Department is a bigger US government agency. Jackson was a successful combat surgeon who oversaw a few dozen staffers at the peak of his wartime service and now supervises a small staff of about 70 people in the White House medical office. He appears to struggle with the (modest) management aspects of the job but has succeeded nonetheless due to his strong personal rapport with a series of presidents. Trump likes him, in particular, because of his virtuoso press conference defending Trump’s health (including a height and weight estimate that registered him as officially non-obese), but this has nothing to do with the VA’s work. Even if the charges against Jackson are entirely false, “wasn’t drunk on the job” and “the president likes him” is not an appropriate bar for an important substantive position that requires considerable management skill and subject matter expertise.

As Matt points out, Veterans Affairs is a huge federal bureaucracy. The last person confirmed to this position was David Shulkin, who stepped down from the position in March. Before Shulkin came into office, he held C-suite-level positions in three hospital systems, including working as president of Beth Israel Medical Center, a major hospital in New York City.

Others have come from different parts of the health care system, like Robert McDonald, who served under President Obama and previously ran Procter & Gamble, a company with 95,000 employees.

And still others have come from inside the department, serving, for example, as a deputy administrator before stepping into the top role.

This type of experience is primarily important in running the country’s largest health care system. But even beyond that, whatever happens at the VA can ripple out to the rest of the American health care system.

VA hospitals are big enough to help popularize certain policy approaches and steer other hospitals in similar directions.

A good example of this is the role Veterans Affairs appears to have played in the opioid epidemic, by encouraging doctors to more aggressively question patients about their pain levels at each visit.

In 1999, the VA was one of the first health care systems to start considering pain the “fifth vital sign,” after blood pressure, temperature, respiration rate, and pulse.

Doctors who trained around that time remember hearing that they too should treat pain as a vital sign — after all, the country’s largest health care system had decided this was a good policy to implement.

Looking back, experts I’ve interviewed now worry that this “pain as a vital sign” movement may have only exacerbated the opioid epidemic. It seemed well-intentioned at the time, but it didn’t actually seem to improve pain treatment among veterans. It did, though, appear to increase opioid prescribing — once doctors asked patients about pain, after all, they felt like they needed to offer some sort of solution.

This is one example of Veterans Affairs being a large enough health care system to guide the rest of American hospitals. If it plants a flag and implements a new policy, it doesn’t do so in a vacuum; other health systems take note when the largest one starts doing something differently.

This all means that the future of Veterans Affairs is not just about one large health care system — it’s about the rest of the American health care system too.

This story appears in VoxCare, a newsletter from Vox on the latest twists and turns in America’s health care debate. Sign up to get VoxCare in your inbox along with more health care stats and news.

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