Selection Process Difficult for Trump Administration

By Sandra Basu

WASHINGTON — David J. Shulkin, MD, who currently serves as under secretary for health and heads VHA, is the Trump administration’s pick for new VA secretary.

The decision, announced earlier this month, was the culmination of a lengthy – and sometimes byzantine–  search for the head of the second-largest federal agency.

If approved by the Senate, Shulkin would be the first VA secretary who is not a veteran. Prior to his VHA position, he was president of Morristown, NJ,  Medical Center and president and CEO of Beth Israel Medical Center in New York.  

He also is, so far, the only Obama administration holdover in the proposed new Cabinet. Shulkin received unanimous Senate approval when appointed under secretary in June 2015.

President-elect Donald Trump said he and his transition team had interviewed “at least 100 people” in their search. Part of the difficulty was the multitude of campaign promises to improve care for veterans.

“I have no doubt Dr. Shulkin will be able to lead the turnaround our Department of Veterans Affairs needs,” Trump said at his first news conference since his election, calling him an “incredibly gifted doctor.”

“His sole mandate will be to serve our veterans and restore the level of care we owe to our brave men and women in the military,” Trump said about the 57-year-old physician. “Sadly our great veterans have not gotten the level of care they deserve, but Dr. Shulkin has the experience and the vision to ensure we will meet the health-care needs of every veteran.”

Outgoing VA Secretary Robert McDonald, meanwhile, told VA employees, “It has been the privilege of a lifetime to serve as your Secretary of Veterans Affairs, and it has been an honor to call each of you a colleague.”

“David has played a critical role in our MyVA transformation and has substantially increased access to care for veterans,” McDonald said about the appointment of Shulkin. “I am encouraged by this choice, and I look forward to working with him to ensure our veterans continue to receive the high-quality care, benefits and honor they deserve.”

He asked VA employees to “show David the same level of support with which you have blessed me.”  

The VA secretary post was one of the last Cabinet-level positions to be filled by the incoming administration.

The challenges were recognized by a coalition of 20 veterans groups that wrote a letter to Trump and the transition team urging that they consider keeping McDonald, who had a business background and is in the mold of other Trump appointees.

“Transforming an agency as large and diverse as VA will take a continuous commitment from leadership over the course of many years,” stated the group of military and veterans organizations. “As you make your selection for VA Secretary, then, we advocate for an approach that recognizes and builds upon current progress. Given the challenges we face, we cannot afford to start over.”

Two key senators wrote a letter to Vice President-elect Mike Pence, however, hinting that Trump should choose new leadership for the VA.

Sens. Ron Johnson (R-WI), chairman of the Senate Committee on Homeland Security and Governmental Affairs, and Chuck Grassley (R-IA), chairman of the Senate Committee on the Judiciary, insisted that the agency is in desperate need of improvement to fix issues like constant whistleblower retaliation, veteran suicide, overprescription of opioids and poor care.

Ultimately, the Trump administration found a compromise, replacing McDonald with one of his key staff members.

Number of Contenders

A number of contenders for the VA job had been mentioned during the Trump transition, including former House Veterans’ Affairs committee chairman Jeff Miller of Florida; former Alaska governor Sarah Palin; former Massachusetts senator Scott Brown; Pete Hegseth, the former chief executive of Concerned Veterans for America; and Adm. Michelle Howard, the first African-American woman to command a U.S. Navy ship. In the last weeks before a decision was made, Cleveland Clinic CEO Toby Cosgrove was mentioned as a leading contender.

Even before a decision was made, several veterans’ advocacy groups reiterated their position that they oppose any effort to diminish the role of VA.

“Veterans deserve a system that is set up for them, that understands veterans,” said American Legion Executive Director Verna Jones.

Jones, along with representatives from 30 other veterans’ groups, met with President-elect Trump’s transition team in a private meeting last month where they made those views clear.

Vietnam Veterans of America Executive Director Rick Weidman said “tens of thousands of vets will get good to very good and oftentimes excellent care across the nation at VA hospitals.” The problem he said is quality assurance.

“Keep the VA, but let’s make it better,” Weidman emphasized at a press conference after the meeting.

Paralyzed Veterans of America Executive Director Sherman Gillums also underscored that, while some have said that VA should retain its function as a provider of specialized services and outsource the rest, that is not the best system of care for veterans.

“Standalone spinal cord injury and polytrauma units will do just that, stand alone in a fragmented and less-coordinated system of care,” Gillums said. He added that his group was not expecting everything to be fixed in VA over the past two years and, “to his credit, VA Secretary Bob McDonald has set VA on a positive course with a myriad of improvements.”

Gillum said PVA would like to see the VA’s MyVA initiative to continue, noting, “It is our desire to see that momentum continue under the next administration.”

The concern over the direction of VA comes as questions arise over what changes the new administration is likely to make. Questions also have arisen regarding the influence of one advocacy group, Concerned Veterans for America.

CVA put forth a document in 2015 that would give enrolled veterans the choice of purchasing heavily discounted private health coverage by using the funds currently spent on them through the VA healthcare system. Many other veterans service organizations disagree with that.

“They are a small group who has opposing views,” Jones pointed out. “When you look at the … big six congressionally-chartered organizations that represent about 5.6 million members, we all say the same thing. We say that veterans deserve a healthy VA healthcare system, and we oppose privatization. I can’t speak for what CVA has written.”

Weidman suggested that one way to address healthcare access issues for veterans is addressing the shortage of clinicians in the U.S.

“From our point of view, USUHS needs to expand greatly, and you need to create other campuses … because only the federal government has the resources to start a new medical school,” he said.

Moving Forward

The current VA secretary, meanwhile, has been touting progress made by the agency in the last days of the Obama administration. McDonald said at a forum that VA is not only necessary for veterans, but also for American medicine.

He derided ideas that are “ideologically based, not based on what is good for the veteran,” such as giving veterans healthcare vouchers.

Veteran Choice

“What gets lost in the debate is that veterans already have a choice; 78% of veterans have more than one way of getting healthcare,” McDonald said

As VA improves the care it provides, more veterans choose to receive that care, McDonald said, which is why the agency needs budget flexibility.

“The average veteran uses VA for 34% of their care, only 34%. If that 34% goes to 35%, we need a budget increase of 1.4 billion dollars, not small,” he said.

Deputy VA Secretary Sloan Gibson, meanwhile, said at the 2016 AMSUS conference that, in improving access to healthcare, VA has been working to address staffing, space, increased productivity and care in the community.

The time to hire and fill a position for a medical center director has been cut in half, he pointed out, adding, “We are working the same issue and the same process for chiefs of staff, for associate directors and assistant directors.”

When it comes to providing outside care, Gibson said that, over the last few years, there has been an increase in care in the community from about 16 million appointments to 25 million medical appointments.

“Care in the community, and that includes our federal healthcare partners, is a fact of life, is a vital component,” he said. “Today it is going to be a vital component and tomorrow in the delivery of care for veterans. What we want to do is to make it more seamless for the veteran. Not thinking about it in terms of inside [VA care] or outside [VA care].”