Perhaps the most surprising of President Trump’s cabinet appointments is his choice to lead the U.S. Department of Veterans Affairs (VA), Dr. David Shulkin, who was confirmed unanimously last night, 100-0. Dr. Shulkin has served as undersecretary for health at the VA since he was unanimously confirmed for that position in 2015. Given that President Trump routinely trashed the VA while he was on the campaign trail, it was unexpected that he would select someone within the VA to turn it around. Dr. Shulkin also has the distinction of being the sole Obama appointee to be kept on and carried over into the new administration. He is one of the few cabinet appointees to enjoy overwhelming bipartisan support. Finally, his selection is unprecedented in that he is the first non-veteran to lead the VA.
Considering all that, he must truly be a special person to have gotten this job. And by virtually all accounts, he is indeed special. Dr. Shulkin has been lauded as “a man of character” whose service is “respected by the entire veterans community.” Of course, I like that he has deep roots in New York, having served as president and CEO of Beth Israel Medical Center. He has a national reputation as a “turnaround expert” and a guru when it comes to health care quality and safety. Perhaps most important to his success, though, is that “[h]e knows the VA but he is not of the VA.” We’re all counting on him to turn the faltering agency around and ready to support his efforts.
Reforming the VA is a huge and urgent task. Its budget is nearly $177 billion for 2017, which covers everything from disability and education benefits to fighting veteran homelessness, to the largest chunk: providing health care to veterans. Approximately 9 million veterans are enrolled to receive health care through VA providers. The VA system often provides high-quality care, but in recent years has been plagued by unconscionably (sometimes even fatally) long wait times for care. Without a doubt, difficult work lies ahead.
As Dr. Shulkin takes the reins of the VA, I suggest that he include the following principles among his highest priorities:
1. Restore trust and credibility.
Veterans, the public, and lawmakers have diminished confidence in the VA. Last spring, the Government Accountability Office released a damning report regarding the wait times for veterans seeking care at VA facilities. Making matters worse, the VA has been guilty at times of hiding the truth and misleading the public. We had known for years that wait times were a persistent problem, but last year’s report showed that the VA manipulated the data to mask the true extent of the problem. Potential employees and veterans themselves won’t be attracted to the VA if they can’t trust it. Job number one for Dr. Shulkin must be repairing his agency’s reputation and earning the trust and respect of veterans and Congress.
2. Ensure timely access to care.
Despite a relentless focus on the problem, it seems that the VA has still not gotten a handle on wait times. A review released just last month found that 1,100 veterans in Phoenix are still waiting 30 days or longer for appointments. The average wait time for a mental health appointment at the VA is 4.5 days. While the quality of care at the VA is often similar to or better than what other health care systems provide, that doesn’t mean much if veterans can’t even get in the door. Waiting more than a month to get checked out for a physical injury—or multiple days for a mental health concern—is dangerous, and unacceptable.
3. Create more choices for community-based alternatives to care.
Half of veterans say they prefer to see a health care provider in their own communities, rather than at the VA. Like all Americans, veterans want—and should have—choices about where they get their care. Efforts have been made to increase veterans’ options for community-based care, including the 2014 Veterans Choice Act. But that program was set up hastily—Congress gave the VA just 90 days to get it up and running—and left veterans confused by their options and by the maze of cumbersome new protocols for getting care. A new report by the VA Office of Inspector General found that veterans enrolled in the Choice program waited an average of 45 days to see a health care provider. One challenge has been the addition of a third-party administrator that veterans need to deal with to schedule their care, rather than going through a more streamlined process directly with the VA. The report also found inadequate provider networks in the Choice program. As community-based options are developed, it is important not only that providers are available, but also that those providers are well-versed in the unique needs and culture of veterans.
4. Adapt to the realities of the modern military.
Today’s veterans are different from yesterday’s in numerous ways. Women are the fastest-growing segment of the veteran population. An estimated 1 million veterans are lesbian, gay, or bisexual and an estimated 134,000 are transgender. Those in the armed forces who are being deployed today are using new tools of war, including drones, that may have different psychological effects on veterans than we have seen in past conflicts. Burn pits present a new and not fully understood risk to the health of veterans. We are just now understanding more fully the effects of Agent Orange on Vietnam veterans. It is imperative that providers both within and outside of the VA understand the unique challenges facing today’s veterans, which may be different from those of past generations’.
5. Listen to veterans themselves.
This is perhaps the most important principle for anyone, but especially so because Dr. Shulkin is not himself a veteran. We can’t presume to know what veterans need, want, and experience. It’s essential to have the humility and patience to ask questions, to listen carefully, and to ensure veterans’ voices are represented and responded to. Dr. Shulkin has historically exhibited enormous compassion and respect for what his patients themselves are telling him. He “gets it.”
6. Fight for needed human resources.
The Department of Defense has been exempted from the hiring freeze President Trump imposed on federal agencies, but for now that order still applies to many positions in the VA (although certain roles, including those responsible for direct patient care, have been exempted). Dr. Shulkin said last year that he will need each of the 45,000 open personnel slots to turn around the VA and set it on the right path forward. Dr. Shulkin and his team must advocate tirelessly to ensure that the agency has the human capital it needs to provide timely, high-quality care to our nation’s veterans. A severely understaffed agency cannot fulfill its obligations.
Turning around the VA is a tough job to say the least, and we should all be thankful to Dr. Shulkin for his service and his courage. The serious, entrenched problems—both perceived and actual—at the VA threaten the health and well-being of our veterans, who deserve the very best care the United States can offer. We owe it to our veterans to transform the VA into a system that meets veterans’ needs, gives them choices, and delivers excellent, timely care. It seems the President has appointed the right person for the job.