A Case for Optimism at the VA

Shulkin is not much of an insider, of the proverbial D.C. variety or even of the VA, where he has served only since 2015. His prior VA experience consisted of being on the actual hospital floor, as a resident, when rotating through medical centers as part of his physician training. This is unlike many of the senior-level employees at VA on the two most salient points: the majority appear to be VA career administrators who obtained degrees after they had been with VA over several years; the majority of degrees they hold are in public health, public administration, or business. Last year,reporter Luke Rosiak discovered that out of the 300 top VA employees, only six directors and three associate directors were also medical doctors.

One trait Shulkin does share with the majority of other VA doctor-directors is his lack of prior military service. Only two VA medical facilities are run by doctors who also had served in the military (as of January 2016, Adam M. Robinson Jr. at the VA Maryland Health Care System and David Walker in Jackson, Mississippi. This does not count Chicago’s Captain James A. Lovell Federal Health Care Center, which is a partnership between the Department of Defense and VA.). This, however, opens up a different but subset discussion about the Human Resource dynamics within VA that have been a continued source of befuddlement to many a VA Secretary and presidential administration.

VA hires fewer veterans than has the departments of Defense, Transportation, Justice, and Social Security Administration. While VA indicates around 30% of its workforce are veterans, as of a decade ago these vets were mainly in blue-collar jobs doing janitorial work, rather than in positions with any authority. A gargantuan driver of this outcome is the VA practice of limiting job openings to only current federal or agency employees. This is itself driven by a clause in VA’s collective bargaining agreement with its union, the American Federation of Government Employees, that stipulates that union members must be given first consideration in job openings. Currently, the union represents nearly 250,000 out of 350,000 VA employees. Union dynamics regarding the hiring and firing of VA employees, in addition to the Merit Systems Protection Board’s near-stranglehold on the firing/accountability dynamics of senior-level VA employees, have proven to be an Alcatraz against cultural reform in VA.

Shulkin now has experience with these inner dynamics, as well as has been burned by them. At least twice in testimonies on the Hill, Shulkin told lawmakers that employees with a criminal conviction had been let go by VA, only to learn (or have to admit) later that the employees in question had been afterward reinstated in the VA.

The insularity of VA’s employment process is something that Shulkin detected early. Despite VA’s large workforce, it’s struggled deeply with attracting, hiring, and retaining necessary medical staff. Shulkin noticed that VA waits for applicants to answer job ads it posts on USAJOBs.gov. Unlike private hospitals that regularly make or receive recruiting calls from other institutions, VA is simply passive. And the best in the field thus don’t think to come knocking.

This is the type of thing that Shulkin, as an “insider” of the medical profession, notices thanks to his long experience in the private sector. An internist by training, Shulkin has helped to lead several private health care systems, including Beth Israel Medical Center in New York and the University of Pennsylvania Health System. He left a 1.3 million job with the Morristown Medical Center when asked by President Obama to become under secretary, because “it was clear that VA was in need of reform.” In an interview at the time, he said: “I felt I could help and my private sector experience was relevant. Second, that this was my chance to give back to those that had stepped up to serve out country.”

His outsider-VA but insider-private sector medical experience influenced what he initially saw as a root cause of VA’s metastasized problems. He explained to Health Leaders Media that

It’s no secret that VA’s healthcare system has suffered from bad customer service, or that its focus seems to wander often away from its primary constituents, veterans seeking medical care. It’s also no secret that the larger medical profession has been enduring its own upheavals. Shulkin’s stated commitment to reorient VA towards better care of veteran patients is thus important to weigh against his history. In 2008, Shulkin authored “Questions Patients Need to Ask: Getting the best Healthcare“, a book that is meant to help patients better navigate the labyrinth of medical care, in part by providing them with the types of questions to ask when faced with a medical situation. He also founded and acted as CEO of DoctorQuality Inc., a pioneering site to help consumers learn about quality health care.

VA, of course, comprises much more than just a healthcare system—but that healthcare system is the most visibly troubled of its three major administrations. Some of its troubles appear systemic, while others seem influenced by factors of the federal bureaucracy largely outside of its control. Congressional action will thus be essential to the success or failure of any VA secretary moving forward.

But for Shulkin in particular, the elements of his professional background hold promise for his expected tenure as VA Secretary. And, while not a veteran himself, Shulkin has been no stranger to the military or military life: his father was an Army psychiatrist, while his grandfather was a WWI veteran who later worked at a VA facility. Thus the actual optics of Trump’s pick for VA secretary arguably bear up against scrutiny. There’s some substance after all to the promise of tangible reform within VA under Shulkin’s leadership.

Rebecca Burgess is program manager of the Program on American Citizenship at the American Enterprise Institute.