Why Firing VA Secretary Would Have a Major Impact on Veterans Healthcare

Shulkin opens up to Healthline

The first thing Shulkin did in his hour-long interview with Healthline was apologize for his lapses in judgment.

“I regret the fact that this became a distraction for the VA because it has taken away from our ability to do what is important, and that is to improve the lives of our veterans,” said Shulkin.

“I own that. But in terms of ethics violations, some people think that you should not travel with your wife, when in fact every VA secretary has traveled with his wife. If you’ve received ethics approval from the agency, which she had, there is nothing wrong with that,” he added.

Shulkin said he mailed a $4,312 check last month to reimburse the government for the cost of his wife’s airfare. He also plans to reimburse the official who gave him the tennis tickets.

Shulkin said he did not come to the VA for any personal financial gain.

“I have taken many steps to safeguard against this kind of thing happening again,” he said. “This is about veterans. That is why I came here. People who think there is corruption or unethical behavior, that makes me sad because I do not think it is supported by the facts.”

Shulkin refused to criticize Trump personally during this interview.

But he admitted it has been frustrating at times working in such a politically charged environment.

“I’ll just keep focusing on the work, and on the veterans, as long as I can,” he said. “I’ve been pretty successful in keeping the politics out of the department and trying to do things in a bipartisan way. Now, that’s been more challenging in the last four or five weeks, but I want to continue with the formula we’ve been running. I don’t believe the VA should ever become a political issue. But not everyone agrees with that.”

Despite the drama, Shulkin said progress has been made on each of the five priorities he identified soon after taking the job.

Those priorities are 1) modernizing the agency’s facilities and systems, 2) using the agency’s resources more efficiently, 3) providing quicker responses on veteran appeals and disability claims and improved access to care, 4) reducing veteran suicides, and 5) allowing patients greater choice in when and how they see caregivers.

“I have no idea where this goes from here, but part of me is scared that if I don’t continue to fight, what is the alternative?” Shulkin told Healthline. “I believe so strongly that our veterans deserve better than they were getting when I arrived here. It required a fight to get through all of this, and at times it has not been fair to my family. But there is a plan now that makes sense.”

Privatization is the real issue

Most veterans and veteran advocates say that forging more partnerships between the VA and the private sector would be a good thing for America’s veterans, whose wait times and drives to see doctors are still sometimes longer than they should be.

But the Choice program, which is managed by Health Net Federal Services, is mired in red tape and is now pushing away the very community caregivers it purports to embrace.

Why?

Because these community caregivers are simply not getting paid by the bureaucratic VA.

Many of these caregivers now refuse to see veterans in this program.

Shulkin, along with most veterans and veteran advocates, agree that more and selective privatization is a good idea for veterans.

But he insists that total privatization of veterans healthcare would be a catastrophe for America’s veterans.

“It just would not work. It would be a disaster,” Shulkin said.

Shulkin noted that there are several new studies showing the flaws and limitations in private-sector care for veterans compared with the VHA, the VA’s healthcare wing. The health services range from suicide prevention to overall healthcare.

Shulkin quoted a recent RAND Corporation report titled “Ready or Not?”

In it, researchers looked at whether private-sector health professionals in New York state had the “capacity” and “readiness” to address the needs of the state’s 800,000 veterans.

Such patients, the study explained, are on average older, sicker, poorer, and far more complex than the civilian-sector patient.

The conclusion was that only 2 percent of the state’s providers met RAND’s “final definition as ready to provide timely and quality care to veterans in the community.”

Another new report by the National Academies of Sciences, Engineering, and Medicine on veterans of the Iraq and Afghanistan wars concludes that VHA mental healthcare is “comparable or superior to that in the private sector.”

The majority of veterans in the report said that despite serious shortages of mental health staff and clinical space, and confusion about how to access care, they had “positive experiences” and appreciated VHA staff’s “respect toward patients.”

When the veterans were asked whether needed services were provided in the VHA, 64 percent said they were.

When they were asked about services they’d received in the private sector, only 20 percent said they received needed services.

Late last year, meetings were held by Trump administration officials to discuss the possibility of merging the VA with Tricare, the primary health system for all active duty troops and their families.

Tricare, which enables active duty troops to visit a private doctor, works reasonably well by most accounts.

But efforts by the VA to allow veterans to see a private doctor have been less successful.

Last December, Tammy Duckworth, the Illinois senator and retired army lieutenant colonel, told Healthline that the meetings demonstrated Trump’s desire to privatize the VA.

The White House denied that assertion.

“The VA was specifically designed to provide unique services to meet the total needs of veterans,” Duckworth, who lost both of her legs in 2004 on a combat mission in Iraq, told Healthline.

“Any attempt to privatize VA, to move veterans further away from VA as the primary coordinator of care, or undermine the integrity of VA hospitals and clinics, is unacceptable,” she said.

A conflict of beliefs

Shulkin would not say it outright, but there is clearly a conflict between his philosophy of some privatization and the more aggressive privatization supported by Hegseth and other conservatives.

“Part of the challenge that we have when you think about the Choice bill, can you get there overnight from the system we have today to a system that provides complete choice, or do you need a disciplined path and structure to help us get there?” Shulkin said.

“This is a journey forward, but we need a plan. Others don’t have operational experience to just go there right now and immediately. I know that this kind of change requires multiyear commitments. If one changes too fast, that can be a disaster.”

Shulkin said he wants veterans to have more choices and he wants to cut away the bureaucracy.

“The current VA system is extremely complex to understand. In the Choice program, specifically, we have seven different ways to pay for community care, each one is a different program with different rules,” he said.

“Add the middle business, the third-party administration paying the bills, and you just have too many ways that outside providers get confused. Some send the bills directly to the VA, instead of a third party, and the bill gets lost or delayed,” he said.

It’s hard enough to be a provider of healthcare let alone one not getting paid for what they do, Shulkin said.

“The program has not worked,” he said. “So what I am trying to do is consolidate those seven programs into a single program, pay the providers on time, change this from an administrative system for veterans to a clinically based system. I have never seen a healthcare system that you can only get services 40 miles away, if you need to be seen now you should be seen now, no matter where you live or how long you have been waiting.”

Shulkin said he is working closely with the House and Senate on proposals that eliminate the 40-mile and 30-day wait rules for veterans to seek outside care.

“It is a process, but we are making real progress,” he said.

Shulkin’s accomplishments at VA

Last May, Shulkin spoke at length about the VA’s challenges and how to overcome them during a press briefing at the White House.

While there are many problems at the VA, there also have been accomplishments on Shulkin’s watch.

Almost a year after he listed the VA’s challenges, Shulkin said that while the VA is still mired in bureaucracy and some individual clinics are still in dire need of fixing, there have been improvements in several areas.

Shulkin said that under his leadership, the VA has embarked on the largest transformation and modernization effort in recent history, tackling head-on issues that have lingered for years.

The VA has established an Office of Accountability and Whistleblower Protection. It aims to help protect employees who expose problems and assist authorities with disciplining or terminating any VA manager or employee who has violated the public’s trust and failed to carry out their duties.

Under Shulkin, the VA became the first federal agency to post information on employee disciplinary actions online and is now requiring senior official sign-off on all settlement actions above $5,000.

Under Shulkin, the VA is also now posting online wait times for veterans at every VA medical facility. These are updated on a weekly basis.

“We now publish wait times. We publish opioid prescription rates. We publish quality scores. We show the VA numbers compared to local hospitals and we are moving a month from now to start transparency about where your claims and appeals are in the process rather than leaving the veteran in the dark,” Shulkin said.

Shulkin said the system used by the VA’s 38,000 schedulers has been simplified and an antiquated computer system is being upgraded to one resembling a Microsoft Outlook calendar.

Average wait times for veterans to see a doctor displayed online now should be accurate, he said.

Shulkin also announced the VA would adopt a joint electronic health record integrated across all Department of Defense (DoD) and VA components, using the same system as the Defense department.

Marked improvements

Shulkin said that since the IG’s interim report 11 months ago, which was highly critical of the VA Medical Center in Washington, D.C, a series of major improvements have been implemented.

After the report was released, Shulkin immediately began replacing key members of the leadership team and brought in Larry Connell as the acting medical center director.

In addition to Connell, the facility has a new acting deputy director, acting assistant director, nurse executive, and chief of logistics.

“We appreciate the work of the IG,” Shulkin said recently in a statement. “Their report is a critical step in improving the overall performance of this facility. Further, it is especially valuable as VA strives to markedly improve the care we provide to our veterans and as we move forward in restoring veterans’ confidence in the medical care they receive.”

Shulkin noted that the IG’s interim report demonstrated failures on a number of levels, including medical facilities, hospital networks, and the VA Central Office.

He has pledged to implement several proactive steps to help correct and prevent similar problems, including making unannounced on-site audits at VA facilities, conducting VA-wide staffing reviews, restructuring logistics to centralize accountability, and establishing new oversight for medical center performance, including at the VA Central Office.

At the D.C. facility, Shulkin has also eliminated all pending prosthetics consults greater than 30 days from 9,000 to zero. Additionally, he has established an oversight process that promptly addresses supply shortages.

Waiting is the hardest part

Glenn Bergmann, an attorney at Bergmann & Moore, a law firm whose clients are veterans with a disability claim before the VA, said the agency’s biggest problem is that it still continues to deny disability claims for veterans whose illnesses and ailments are clearly related to their service.

“Some things at the VA still haven’t changed,” said Bergmann.

He noted there are an estimated 500,000 veteran disability claim appeals pending at the Veterans Benefits Administration and the Board of Veterans’ Appeals.

These appeals often languish for years.

“VA’s repeated mistakes and delays deciding claims cause serious problems for our veterans seeking VA treatment,” said Bergmann.

He said if Shulkin stays, he must lead the charge to adopt more “presumptives” to VA’s list.

Presumptives are the various diseases and ailments that are presumed because of scientific evidence to be connected to and caused by a veteran’s time in the military.

Presumptives are a science-based way to expedite the accurate processing of claims so veterans obtain the prompt and quality VA care they need.

Bergmann said veterans who are not getting the care they have earned include those who have brain cancer and were deployed since August 1990.

It also includes Gulf War veterans with Gulf War Illness and Vietnam veterans with glioblastoma who were exposed to toxins such as sarin and deadly herbicides such as Agent Orange.

Shulkin said he agrees the VA needs to change its entire culture and start believing the veterans when they come through VA clinics’ front doors.

“Yes, presumptives are the biggest problem,” he said. “On a very high level, I have introduced my desire to redo the benefit system. It currently doesn’t work. It is set up as a gatekeeper system in which veterans come to VA and receive a yes or no answer. It is adversarial. That has to change. We want to be advocates, we want to help veterans gain independence and health and well-being.”

Shulkin said veterans who come to the VA now are unfairly forced to arrive with all the right paperwork, but then have to be given a prehistoric exam with old equipment.

“And then if you don’t like the answer you are given, you are stuck in multiyear appeals process and often see adjustments to your disability rating,” said Shulkin.

He added he’s worked this past year on getting rid of the idea that the VA and veterans are adversaries.

“VA is currently set up as adversarial, and that above all else has to change,” he explained. “We need to look for an alternative to that system. I’ve gone to business schools to seek their help in finding alternative ways to honor our commitment to the men and women who were injured in service, and to help them get out of the cycle and truly support them in their transition. We need to be not adversarial, but on the side of helping veterans achieve their goals. That is why I came here.”

At present, Shulkin said, the VA assumes the veteran is lying.

“We have cases of apathy where someone does not even look up from his desk and look the veteran in the eye,” he said. “This is a symptom of an unacceptable culture where people do not understand the mission of the VA and the idea that that every organization is responsible to whom they serve. Most call them customers, at VA we call them veterans.”

It’s not going to change with snap of the finger, Shulkin warned.

“We need to set a plan, a direction where we want to go,” he said. “We do need more privatization. That is the path that I have set. But it is hard to be a moderate any more in Washington. No one has learned that more than me in last four to five weeks. But what I did from the beginning when I came in as undersecretary, I wrote that we need a strong VA, but VA can’t do it alone. It needs to be supplemented with high-performing private sector companies.”

“Therefore, I do believe that you can drive this as long as you are committed to fixing and investing in the VA, and at the same time developing a network in private sector. If a veteran has a choice they will pick the best in the VA and the best in the private sector.”

Shulkin’s supporters and critics

Paul Rieckhoff, an Iraq War veteran and founder and chief executive officer of Iraq and Afghanistan Veterans of America, said Shulkin’s unstable leadership is simply not good for veterans.

“It’s a really bad situation and it impacts us all,” he said. “The leadership failure, the infighting, the paralysis, there is no way the secretary can get things done when he is on the phone with reporters. There is a lot to do.”

With regard to the future of the VA and a position on privatization, Rieckhoff said Shulkin is just part of the problem.

“It’s about the White House failure to articulate a position and Secretary Shulkin’s failure to articulate a clear vision and to create stability,” he said. “And that is what our veterans need the most. They want the trains to run on time. There are still wait times. There still are problems. Four negative IG reports. It’s important. The mechanics, the business of the VA. These are life and death issues for veterans and we can’t afford to have unstable leadership. “

But Denise Nichols, BSN, MSN, a retired Air Force major and Desert Storm veteran, disagrees.

Nichols suffers along with hundreds of thousands of her fellow Desert Storm vets from Gulf War Illness, a confounding host of often debilitating and even deadly ailments caused by various toxic exposures to the veterans of that war.

She’s been a pebble in the shoe of the VA for 25 years. And while she has issues with Shulkin, she does not think he should be fired.

“I fear that whoever replaces Shulkin will push for more privatized care, and that is not what we want,” said Nichols.

She added that Trump is “listening to the wrong voices” when it comes to advice on veterans health.

“My advice to President Trump is to not rely on veterans groups that don’t have many members. President Trump does not speak for the overall population of military veterans. He needs to speak with VFW, American Legion, Veterans for Common Sense’s Anthony Hardie, Vietnam Veterans of America’s Rick Weidman. President Trump does not listen to us. He’s never had a meaningful sit-down conference with these groups.”

Nichols said she supported the idea of the Choice program and hopes Shulkin fixes it.

“There is a reason why it was created. We do need physicians in the community that can take the load off, waiting lists are too long,” she said. “But to completely privatize the VA, no. The VA is supposed to be centered on veterans. The VA has dedicated programs for amputation, for example, and for spinal cord, toxic exposures, all kinds of things that they know more about than a hospital outside VA does.”

Meanwhile, a poll released Thursday by the Iraq and Afghanistan Veterans of America (IAVA) did not contain good news for Shulkin.

The group summarized its survey with this statement:

“Today, as reports continue that President Trump is considering replacements for VA Secretary David Shulkin, IAVA released a poll of more than 4,000 members of the post-9/11 veteran and military community.

The poll, which is the only public and current poll of its kind, shows that only 14 percent of IAVA veterans polled trust VA’s national leadership, and only 24 percent approve of Secretary Shulkin’s performance.”

‘Second inning of a nine-inning ballgame’

But for now, at least, Shulkin remains on the job.

He hopes to continue implementing his ambitious plans to change the VA.

“The President has supported us, but we are in the second inning of a nine-inning game, and you just don’t want to stop the ballgame at this point,” he said. “I understand why people want to make changes quickly at the VA, but what I am doing is setting in motion a long-term strategy for the department. We are changing the culture here, but this is a journey, and we’ve set a positive path forward.”

Shulkin concluded the conversation by stating that his “singular focus is the critical work to be done at the VA to improve the lives of veterans. My dedication to better serve the men and women who sacrificed to protect our country is unwavering.”