Trump’s most popular Cabinet secretary is Obama holdover

 In Science

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.

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“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.

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.”

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