With David Shulkin now ousted from the Veterans Affairs Department, all eyes are on President Trump’s nominated replacement to see where he comes down on the most pressing issue at VA: How large a role should the private sector play in providing health care to veterans?
One problem for observers and stakeholders in the veteran community is Trump’s pick, Dr. Ronny Jackson, has very little experience in public policy or veterans issues. Veterans service organizations and lawmakers were effusive in their praise of Shulkin, while expressing disappointment in his firing and noting the new relationships they would have to now forge.
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“I don’t know if he ever set foot in a VA [facility],” Louis Celli, the national VA director at American Legion, a group that represents more than 2 million veterans, said of Jackson. By the time the secretary designate is fully able to understand all the issues facing the department, Celli said, “this administration could be over.”
As VA secretary, Jackson would be responsible for managing 370,000 employees spread across 3,000 facilities. Administering veterans disability benefits, education subsidies and cemeteries number among the department’s dozens of lines of business. Still, its responsibility to provide health care to veterans is by far its biggest operation—the Veterans Health Administration runs the largest hospital network in the country—and is what led Jackson, a physician, to get the job.
Trump “ultimately decided that his health care experience, his distinguished career in the medical profession was something that would be beneficial at the VA,” Lindsay Walters, a White House spokeswoman, told reporters Thursday. “At the end of the day . . . the status quo was not working. We need somebody who understands the health care system.”
While Jackson has served as White House physician since 2006 and the president’s personal doctor since 2013, his background is atypical for VA secretaries. While Shulkin was the first to helm the department without himself being a veteran, he had served at VA as an undersecretary as head of the Veterans Health Administration. He had previously led multiple private medical centers and health systems. His predecessor was Bob McDonald, who came from the private sector but whose nomination was met with plaudits because of his experience leading the Fortune 50 company Proctor & Gamble. McDonald replaced Eric Shinseki, who had previously served as chief of staff of the Army.
In a New York Times op-ed published after his firing, Shulkin warned that his political enemies from within the Trump administration pushed him out not due to the scandals surrounding him but because of ideological differences about the future of VA.
“I have been falsely accused of things by people who wanted me out of the way,” Shulkin said. “But despite these politically based attacks on me and my family’s character, I am proud of my record and know that I acted with the utmost integrity. Unfortunately, none of that mattered.”
Shulkin added that the environment surrounding him became “so toxic, chaotic, disrespectful and subversive” that he could no longer accomplish his job. He said his opponents within the department, whom he repeatedly vowed to oust, were fighting to privatize VA health care and saw him as a barrier in achieving that goal.
“They saw me as an obstacle to privatization who had to be removed,” Shulkin said. “That is because I am convinced that privatization is a political issue aimed at rewarding select people and companies with profits, even if it undermines care for veterans.”
Opponents of privatization, including Shulkin, nearly all veterans service organizations and key lawmakers on both sides of the aisle on Capitol Hill, could breathe at least a momentary sigh of relief when Trump announced Jackson as his nominee to be the next VA secretary. Jackson is in many ways an unknown, but is not associated with any previous push to minimize the government’s role in providing veterans health care as were some of the other candidates Trump was reportedly considering.
“I am deeply concerned about the nominee,” said Joe Chenelly, executive director of AMVETS, another congressionally chartered veterans service organization. “Veterans’ lives depend on this decision, and the Trump administration needs to substantiate that this active-duty Navy officer is qualified to run a $200 billion bureaucracy, the second largest agency in the government.”
AMVETS added it was pleased Jackson had a medical background, but noted VA is “more than healthcare.”
“What qualifications does the president’s nominee have to address claims, appeals, benefits and cemetery affairs?” the group asked.
Celli noted that even McDonald, a veteran who came to the department with vast managerial experience, took a while to fully “wrap his arms around the entire mission of what VA was” and was therefore only able to make a significant impact in two or three areas of VA’s operation.
President Obama was wise to recognize he needed a veteran who had also run a large company with a big budget and many employees, much like VA itself, McDonald told Government Executive.
"That intersection is very small and I think [Obama] recognized that," McDonald said. "While Adm. Ronny must be a great doctor, the question the Senate will need to address is does he have sufficient management experience."
Even Shulkin seemed to suggest the job requires a large learning curve.
“No one is naturally prepared to take on a task like this,” Shulkin told NPR on Thursday. Jackson would not be met with political leadership at the department to help guide him through the ins and outs of its medical network, as Trump has yet to nominate an undersecretary to head VHA.
"Given the state of the VA today, the most important thing is the leadership experience of a very large organization," McDonald said. Having medical experience would only be the third top priority, McDonald said, after being a veteran.
Several groups expressed concern over the fate of reforms VA had already initiated under Shulkin. The now former secretary was in the process of realigning the department’s regions, or Veterans Integrated Service Networks, and the larger structure of the department. He had worked with oversight committees in Congress on a proposal to consolidate existing programs giving veterans access to private sector care on the government’s dime and easing veterans access to such programs, while maintaining a tight balance with those who tend to have a knee-jerk reaction against any reform that could be construed as VA privatization. The existing Veterans Choice Program is expected to run out of funding this summer. He had won approval for his plan to shutter underutilized facilities and had already help shepherd measures to expedite firing of problematic employees and reform the disability appeals process through Congress and into law.
“I have enjoyed getting to know Secretary Shulkin, and I’m glad to call David a friend,” said Rep. Phil Roe, R-Tenn., who chairs the House Veterans Affairs Committee. “I think he’s done a fantastic job and I hate to see him go.”
Roe pledged to work with Jackson and build “a strong relationship with him also.” Roe’s counterparts in the Senate made clear they would not automatically grant their approval, as will be necessary for his confirmation.
“I look forward to meeting Admiral Jackson and learning more about him,” Sen. Johnny Isakson, chairman of the Senate VA committee, said after praising Shulkin for the “tremendous impact” he made during his tenure.
Sen. Jon Tester, D-Mont., was even more non-committal.
“Moving forward, the VA needs a strong leader at the top who will listen to veterans, strengthen the VA and work with Congress to implement bipartisan reform,” Tester said. “I look forward to meeting Rear Adm. Jackson soon and seeing if he is up to the job.”
McDonald suggested Trump’s selection could mark a departure from the path on which he and Shulkin put the department, which the former secretary said he formulated after hundreds of visits around the country to listen to VA beneficiaries.
“Veterans don’t want the privatization of the VA,” McDonald. “I hope President Trump is listening to veterans.”
The American Legion’s Celli speculated that Trump’s choice of Jackson was a matter of happenstance rather than qualification. His selection was not as “draconian” as he an many had feared, Celli said, but it still appeared as if Jackson got the nod because he was “someone with military experience who [Trump] just happened to know.” Celli was at least pleased that Jackson’s demeanor and medical abilities were “above reproach,” but said he would still have to prove himself beyond that to earn the support of the veteran community.
“Great, he’s a nice guy,” Celli said. “There’s a lot of nice guys out there.”