David Shulkin, the secretary of veterans affairs, looked like the rare Trump cabinet member who was above using his office for personal enrichment. Then, on Valentine’s Day, the VA Office of the Inspector General released an extensive report on Shulkin’s misuse of VA staff and funds to turn a business trip to Europe last July into a sightseeing vacation for him and his wife. “This was time that should have been spent conducting official VA business and not providing personal travel concierge services to Secretary Shulkin and his wife,” the inspector general concluded.
Following the revelation, Shulkin acknowledged making “mistakes” and remarked that “the optics of this are not good.” But he insisted that leaks about his European jaunt were part of an internal White House plot to unseat him because he has tried to put the breaks on the privatization of the VA health care system. Bolstering his argument, last week ProPublica reported that a coterie of White House staff was trying to oust Shulkin in order to promote the interests of the conservative Koch brothers, who favor total privatization of veteran health care. In the face these reports, Democrats and representatives of veterans service organizations (VSOs) have come—albeit somewhat tepidly—to Shulkin’s defense.
If one believes Shulkin, what we are seeing is a classic drama of good against evil, with Shulkin defending veterans’ interests against those who want to outsource care to private sector profiteers. But Shulkin, once a putative defender of government-provided veterans’ care, is no longer the hero he portrays himself to be. The curious case of the European vacation represents instead the latest in a series of bad compromises that may end with the dismantling of the nation’s largest and, as myriad studies confirm, best health care system. This would not only jeopardize the health of some nine million veterans, but would also set back efforts to create a more rational and sustainable health care system for all Americans.
In 2017, when Donald Trump nominated Shulkin as secretary of veterans affairs, many in the veterans community breathed a huge sigh of relief. Shulkin, a physician, had served as VA under secretary for health in the Obama Administration. He was the only Obama holdover in the new Administration and one of the few Trump cabinet members actually qualified for their jobs. He also, unlike so many Trump appointees, seemed supportive of the mission of the agency he was going to administer.
When I interviewed him for a book I was writing on VA health care in 2015, Shulkin told me that, as a former private-sector hospital administrator, he was surprised to discover that the VA was able to achieve great outcomes because it was both a provider and payer of care. He openly admired its delivery of integrated care and the fact that the system addressed not only its patients’ physical and mental health problems, but also their social, economic, occupational, and housing needs.
In March 2016, in the New England Journal of Medicine, Shulkin boasted that the VA outperforms private industry in “lower risk-adjusted mortality rates, better patient-safety statistics, and better performance on a number of other accepted process measures.” As under secretary for health, Shulkin said he did not oppose veterans getting care in the private sector when needed, but wanted the VA to coordinate that care.
Shulkin’s unanimous Senate confirmation in February 2017 represented a victory for the VSOs, who had fended off far worse candidates. As a candidate, Trump had promised the job to Tea Party Republican Jeff Miller, then a congressman from Florida. As chair of the House Veterans Affairs Committee, Miller had barely concealed his hostility to VA health care and his eagerness to privatize it.
After the election, Trump changed his mind about Miller and temporarily flirted with Delos Toby Cosgrove, a veteran and the CEO of the Cleveland Clinic. As co-chair of the congressionally mandated Commission on Care, Cosgrove consistently represented the interests of highly paid hospital CEOs, who would benefit mightily from privatization. Other candidates included Pete Hegseth, the former president of the Koch-funded Concerned Veterans for America, a fake grassroots group devoted to VA health care privatization.
Eventually, under pressure from VSOs and many Democrats, Trump picked Shulkin. Some were surprised that Shulkin would accept the position, but he did so enthusiastically, promising that veterans’ health care would never be privatized on his watch.
Yet Shulkin has since been an unreliable champion of VA health care. His public pronouncements about it have been highly critical. In his first “State of the VA” address at the White House, in May of 2017, Shulkin parroted the conservative narrative of a broken VA, insisting that it was “still in critical condition” and required “intensive care.” As I later wrote, he failed to mention a book that would be released two weeks later entitled Best Care Everywhere—a compilation of clinical case studies hailing the VA’s little-publicized role as an incubator for “real change” in treatment methods. The book’s editor? David Shulkin. Yet neither he nor VA public affairs personnel have promoted it or its message.
Shulkin has insisted that he opposes privatization. Yet that seems true only in the narrow sense that he has not suggested a wholesale transfer of VA care to private operators. As sociologist Paul Starr has written, privatization has a broader meaning. It involves “any shift of activities or functions from the state to the private sector.” Other hallmarks of privatization include attacking public sector unions, blaming system problems on public sector employees, starving the public sector of resources, and insisting that the private sector can provide better and more efficient services than the public.
The secretary consistently checks all these boxes. He has enthusiastically supported denying due process to VA employees and argued for the firing of employees for even minor infractions. He has also tried to starve the system of needed resources. In the fall, he tried to shift almost a billion dollars from programs earmarked for the homeless, mentally ill, and female veterans toward general operations. Only an outcry from patient safety experts and advocates for the homeless prevented the secretary from eliminating over $400 million needed for homeless programs as well as getting rid of the Patient Safety Centers of Inquiry, which help keep VA patients from dying from preventable medical errors and injuries.
In early 2017, Shulkin announced his support for outsourcing audiology and optometry to private sector providers, since, as he put it, “there’s a LensCrafters on every corner.” And in November it was revealed that, without the knowledge of the VSOs or Congress, the secretary had been holding secret talks to explore the possibility of merging the Veterans Health Administration with Tricare, the insurer that pays for private sector care for active duty military personnel and military retirees. Such a move could fundamentally transform VA health care into a mere payer, rather than provider of care. VSOs reacted with outrage.
Shulkin’s support for outsourcing is also evident in discussions of the future of Veterans Choice, a temporary program enacted in 2014 that allows veterans facing long wait times or travel distances to instead receive private-sector care paid for by the VA. Shulkin has long supported some version of a permanent expansion of the Choice program—and his support continues in spite of a an inspector general report documenting $89 million in fraud and abuse. The program has also racked up over $4 billion in cost overruns and diverted almost $15 billion to private sector providers that could have been used to the hire more VA staff.
That’s important, because there are currently over 35,000 unfilled positions at the VHA. A recent report from the National Academies of Science, Engineering, and Medicine revealed that shortages of VA staff, office space, and exam rooms were impeding the delivery of high quality mental health care to veterans of Iraq and Afghanistan. The administration and Shulkin extended eligibility for hundreds of thousands of veterans, without providing funding for any new staff. This will further boost the caseloads of already overburdened VA caregivers. That, in turn, will lead to more staff burnout, higher turnover, and patient complaints about appointment delays.
Shulkin is also promoting the outsourcing of the VA’s highly successful in-house electronic medical record technology, VistA. In spite of many warnings that this move may not produce information sharing between the VA and either the Department of Defense or private sector providers, Shulkin has pushed for the use of a commercial product from Cerner, a for-profit health technology company. According to University of Pennsylvania Professor Ross Koppel, an expert in health care information technology, “the shift from Vista to Cerner will be wrenching and it’s unclear that its advantages are worth the cost.”
Some VSO officials believe that it’s better to have a tarnished Shulkin in charge of the VA than any likely replacement named by Trump. Yet now that his job is jeopardy, with some congressional Republicans calling for his resignation, Shulkin may be less able and willing to protect the agency from those trying to do it the most harm.
Shulkin’s February 15 appearance before the House Committee on Veterans Affairs—a day after the inspector general report became public—was not reassuring. He defended a proposed budget in which half of $4 billion in new health care funding would be diverted to private sector providers. Conveniently, 27 positions in the VA’s Office of the Inspector General would be eliminated—presumably making it more difficult to blow the whistle on any future taxpayer funded junkets, Choice program cost overruns, or VA contractor abuses.
In his testimony, Shulkin went further down the outsourcing road by arguing that the VA should focus only on what he called “foundational services” like primary care, mental health treatment, geriatrics, and extended rehabilitation. A wide range of other services—cardiology, oncology, urology, etc.—would no longer be integrated or comprehensive. Instead, they would be turned over to private doctors and hospitals.
According to Shulkin, this does not represent “the onset of privatizing VA.” However, a narrower government focus is exactly what the private health care industry wants. There is no big money to be made from delivering the labor-intensive services needed to manage the chronic, long-term conditions of many veterans. That’s why private providers are waiting to profit from any episodic, high-cost medical interventions that they can bill to the VA.
Tim Walz, a Democratic congressman, saw the writing on the wall: “I think it’s more and more difficult, Mr. Secretary, to say, ‘I’m not supporting privatization at the VA,’ because it appears like you are.” But Walz’s Republican colleague, committee chair Phil Roe, didn’t seem bothered by the proposed elimination of “non-foundational” services. Instead, he expressed his concern that Shulkin’s foreign travel had created unnecessary “distractions” for the agency.
In reality, the greatest threat to VA health care, at the moment, is the bipartisan push for expanding Veterans Choice. Even before Trump took office, few members of Congress from either party were committed to improving VHA funding and staffing, hiring practices, or management culture. Instead, they were bickering about the pace and scope of outsourcing, with some veterans’ service organizations feeling they had no option but to give up ground just like the Democrats.
Under a president who has publicly stated that he wants to see 90 percent of veterans receive care in the private sector, any VA secretary who serves under him—whether named Shulkin or not—won’t be much of a bureaucratic buffer against dismantling the agency piece by piece. That takes a real opposition party, interested in wooing working-class Trump supporters who are veterans, back to the polls for Democratic candidates in 2018 or 2020, based on broken Republican promises.
Now, more than ever, veterans need a strong voice, on their own behalf, not Democrats who echo GOP rhetoric and co-sponsor bills damaging to the VA. If veterans’ service organizations and Trump’s putative opponents in Congress can’t provide that soon, they will end up being enablers of changes in veterans’ health care that few of its recipients ever asked for or wanted. And nine million patients will not be thanking them when the impact of those changes is more widely felt.